To BV or not to BV

To BV or Not to BV:VT in the

Primary Care Office

23rd Annual Victoria ConferenceDelta Ocean Pointe Resort Victoria, BCPacific University College of Optometry

July 18th-21, 2013

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To BV or Not to BV: That is No Longer

the Question, But Rather the Answer!

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Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor, Pediatrics/Binocular VisionIllinois Eye Institute

Illinois College of OptometryChicago, Il

[email protected]

Lyons Family Eye CareChicago, Il

LyonsFamilyEyeCare.com

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To BV or Not to BV: That is No Longer the Question, But Rather the Answer!

• ..Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous economics, or to take arms against a sea of troubles with binocular vision and optometric vision therapy. To grunt and sweat under a weary life, But that the dread of something unknown....the undiscovered country of BV and VT whose bourn all travelers prosper, doth not puzzle the will and makes us rather bear those joys we have...than those ills of 3rd party payers that we know not of? (With apologies to The Bard). This course reviews the diagnostic and evidence-based therapeutic procedures the primary care optometrist can use to improve patient care while supporting the fiscal stability of their practice.

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Executive Summary

• Binocular vision in the news

• 3D Vision Syndrome in the news

• High incidence of BV problems

• Evidence based medicine/research supports optometric vision therapy

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Executive Summary

• Amblyopia can be treated at any age

• Learning related vision problems optometric intervention supported by research

• Attention and binocular vision problems related

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Executive Summary

• Our patients are in pain

• Proven examination techniques available

• Proven intervention/therapy available

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Executive Summary

• The myths of OVT wrong

• Expand your patient base

• Be unique

• Offer more

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BV Dx & Tx in the News!!

3D In the News: Update!

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Sports Vision !

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Non-strabismic BV disorders

Prevalence/Incidence

• Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5%

• Convergence Excess: ~6%

• Accommodative disorders: 3-5%

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• Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5%

• 309,000,000 people in USA (2010 Census) at 5% = 15 million +

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• Convergence Excess: ~6%

• 18 million +

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• Accommodative disorders: 3-5%

• 15 million +

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If any other disease had this prevalence/incidence, it would be considered an epidemic…if not a pandemic!

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CI on TV

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NIH NEI and CI

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Subjective Complaints of Patients with BV Disorders

• Blur• Headache

• Aesthenopia

• Diplopia

• These complaints are usually associated with near work

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• Blur

• Headache• Aesthenopia

• Diplopia


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• Blur

• Headache

• Aesthenopia

• Diplopia


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• Blur

• Headache

• Aesthenopia

• Diplopia


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Screening for BV Dysfunction

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Effectiveness of computerized oculomotor vision screening in a military population: Pilot study José E. Capó-Aponte, OD, PhD, et al.

The number of warfighters affected by blast induced mild traumatic brain injury (mTBI) has increased considerably in the recent years as a consequence of the current conflicts. Oculomotor (eye movement) vision problems frequently result from mTBI; however, conventional oculomotor examinations are time-consuming and can only be performed by an eye doctor. This limits the number of military personnel that can be evaluated for oculomotor problems before and after deployment. This study showed that computerized oculomotor vision screening performed by non-eye-care providers can be an effective means to expedite the identification and management of oculomotor vision problems in patients with or without mTBI.

Capó-Aponte JE, Tarbett AK, Urosevich TG, Temme LA, Sanghera NK, Kalich ME. Effectiveness of computerized oculomotor vision screening in a military population: Pilot study. J Rehabil Res Dev. 2012;49(9):1377–98. http://dx.doi.org/10.1682/JRRD.2011.07.0128

Comprehensive Eye ExaminationVisual Efficiency Evaluation

Strab/Amblyopia ExaminationVision Information Processing

AssessmentSpecial Testing: Visagraph, TOVA

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PATIENT MAMAGEMENT

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Comprehensive Eye Examination

– History

– VA

– Refraction

– BV (CT, NPC, Stereo, etc)

– Eye Health

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Do enough testing to meet 3rd party requirements AND determine if more testing is needed

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Visual Efficiency Examination: Basic Tests

• History (Academics, Sports, Work, Hobbies)

• COVD Quality of Life Survey/CISS

• Visual Acuity20/97 32


• Refractive Evaluation (Objective/Subjective)

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• Oculomotor –Cover Test, Hirschberg,

–Kappa, Krimsky, Bruckner

–EOMs

–NPC (with red lens)

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• Heterophoria

• Vergences–Sheard’s criteria

• Need twice your phoria in reserve (10 pd exophore at near needs 20 pd BO reserves)

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• Accommodative Tests –Minimum amplitude =

15 - (0.25) age•So a 20 year old should have at least 10 diopters of accommodation

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–NRA/PRA, Minus Lens Amplitudes

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–Push Up/Pull Away Amplitudes, MEM

–Facility

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Basic tests

• Stereopsis

• Random Dot,

• Stereo Fly• Less than

70 seconds of arc

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Basic tests

• Worth 4 Dot

• Fixation Disparity Testing–Wesson Card,

–Bernell Fixation

Disparity (Associated Phoria),

Disparometer40/121

Common BV Syndromes

• Convergence Insufficiency– Most common syndrome

– Symptoms: aesthenopia, headaches, blur, diplopia, loss of concentration• associated with near work

• often occur near the end of the day

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Convergence Insufficiency

• Signs:– An exodeviation at near

• Can even be an intermittent exotropia at near

– Receded NPC value• NPC larger than 10 cm

– Reduced BO vergences at near• Often fail to meet Sheard’s criterion

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Convergence Excess

• Symptoms: Diplopia, headaches, aesthenopia– almost always near related

• Signs:– Esophoria at near

• Use detailed accommodative target or you may miss the esophoria

– Vergences• BI vergences at near may not compensate

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Convergence Excess

• Signs–Dynamic Retinoscopy

• May be the most significant test

• Typically a high lag of accommodation

• Lag may be +1.00 to +2.00 DS at 40 cm

• Lags greater than +2.50 D at 40 cm should suggest uncorrected hyperopia

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Fusional Vergence Dysfunction

• Symptoms: aesthenopia, headaches, blurred vision (Binocular Vision/Visual Discomfort Dx)

– Associated with reading or near work

• Signs: – Phorias: Normal at distance and near

– Reduced BI and BO vergences at distance and/or near

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Accommodative Disorders

• Symptoms: blur, headache, aesthenopia, fatigue when reading, difficulty changing focus from one distance to another

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Accommodative Disorders

• Signs–Accommodative Insufficiency:

• Reduced amplitude of accommodation

• Minimum Accommodation:

15 - (0.25) (age)

–Accommodative Infacility• Failure of monocular facility testing

• Expected value: 11 cpm47

Other BV Disorders

• Divergence Excess–Prevalence of ~0.5 to 4%

–Exophoria greater at distance than near

–Frequently first discovered in grade school

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Other BV Disorders

• Divergence Insufficiency–Very rare!

–Esophoria greater at distance than near

–Be careful to rule out lateral rectus palsy!

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Strabismus & Amblyopia

3-5% of the population

Tx appropriate at all ages

May do out of office VT

and achieve success!

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Amblyopia

Pathological until proven otherwise

Infants/Toddlers

Children

Adults

AmblyogenicFactors

Anisometropia

Bilateral Refractive Error

Strabismus (Constant)

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Amblyopia

Legal Consultant

AmblyopiaMalpractice case was not because of missing

an eye disease…But rather due to alleged inappropriate management/treatment

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Diagnosis & Treatment

for BV Disorders

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Treatment for BV Disorders

Evidence Based Medicine

Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in non-strabismic accommodative and vergence disorders. Optometry.

2002;73(12):735-62

Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optom Vis Sci. 2005 Jul;82(7):583-95.

…vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence.

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Scheimann M et al. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthal2005;89(10):1318-23.

Base-in prism reading glasses were found to be no more effective in alleviating symptoms, improving the near point of convergence, or improving positive fusional vergence at near than placebo reading glasses for the treatment of children aged 9 to <18 years with symptomatic CI.

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Treatment for BV DisordersEvidence Based Medicine

Quaid P, Simpson T.Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls.

Graefes Arch Clin Exp Ophthalmol. 2013 Jan;251(1):169-87. doi: 10.1007/s00417-012-2135-0. Epub 2012 Aug 29.

The IEP group had significantly greater hyperopia compared to the control group on cycloplegic examination. Vergence facility was significantly correlated to (i) reading speed, (ii) number of eye movements made when reading, and (iii) a standardized symptom scoring system. Vergence facility was also significantly reduced in the IEP group versus controls. Significant differences in several other binocular vision related scores were also found.

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Solan H et al. M-cell deficit and reading disability: a preliminary study of the effects of temporal vision-processing therapy. Optometry. 2004 Oct;75(10):640-50.

This research supports the value of rendering temporal vision therapy to children identified as moderately reading disabled (RD). The diagnostic procedures and the dynamic therapeutic techniques discussed in this article have not been previously used for the specific purpose of ameliorating an M-cell deficit. Improved temporal visual-processing skills and enhanced visual motion discrimination appear to have a salutary effect on magnocellular processing and reading comprehension in RD children with M-cell deficits.

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Evidence Based MedicineSolan H et al. Is there a common linkage among reading comprehension, visual attention, and magnocellular processing? J Learn Disabil. 2007 May-Jun;40(3):270-8.

Solan H et al. Role of visual attention in cognitive control of oculomotor readiness in students with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18.

Eye movement therapy improved eye movements and also resulted in significant gains in reading comprehension.

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Cotter S et al. Treatment of strabismic amblyopia with refractive correction. Am J Ophthalmol. 2007 Jun;143(6):1060-3.

These results support the suggestion from a prior study that strabismic amblyopia can improve and even resolve with spectacle correction alone.

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Scheimann M et al. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47.

Amblyopia improves with optical correction alone in about one fourth of patients aged 7 to 17 years, although most patients who are initially treated with optical correction alone will require additional treatment for amblyopia. For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching with near visual activities and atropine can improve visual acuity even if the amblyopia has been previously treated. For patients 13 to 17 years, prescribing patching 2 to 6 hours per day with near visual activities may

improve visual acuity when amblyopia has not been previously treated

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Levi DM. Prentice award lecture 2011: removing the brakes on plasticity in the amblyopic brain.Optom Vis Sci. 2012 Jun;89(6):827-38.

Video-game play induces plasticity in the visual system of adults with amblyopia.Li RW, Ngo C, Nguyen J, Levi DM.PLoS Biol. 2011 Aug;9(8):e1001135. Epub 2011 Aug 30.

Prolonged perceptual learning of positional acuity in adultamblyopia: perceptual template retuning dynamics.Li RW, Klein SA, Levi DM.J Neurosci. 2008 Dec 24;28(52):14223-9.

Adult Amblyopia

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• Treatment modalities– Lenses

– Prisms

– Vision therapy• Traditional therapy

• Computer therapy

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Lenses as TreatmentBest Rx (clarity, comfort, function)

Refractive Error Amblyopia Concern

Binocularity Concerns

Interference with Learning

Rx if….

Myopia >5.00D Under correct eso/Fully correct exo

Depends on child’s age

>5.00D (any age)

>3.00D @>1yr

Hyperopia >2.00D Under correct

exo/Fully correct eso

>2.50D >2.00D

Astigmatism >1.25D Depends on VA

>1.25D

Anisometropia >1.00D Monitor BV/Stereo

>1.00D >1.00D63

Lenses as Treatment

• Best Rx (clarity, comfort, function)

• Accommodative disorders– Can prescribe reading only Rx or an

add (I never give R/O, D/O)

• Exodeviations– Overminusing (DE)

– May not be a first choice. Give add

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Bifocals for Kids

Bifocal Seg Height

Infants/Toddlers

Pre-schoolers

Bi-sect pupil

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Bifocals for Kids

Bifocal Seg Height

3-5 Years

Bottom 1/3 of Pupil

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Bifocals for Kids

Bifocal Seg Height

> 5yrs

Bottom of Pupil

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Bifocals for Myopia Progression

Gwiazda JE, Hyman L, Norton TT, Hussein ME, Marsh-Tootle W, Manny R, Wang Y, Everett D; COMET Grouup.

Accommodation and related risk factors associated with myopia progression and their interaction with treatment in COMET children.Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143-51.

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Bifocals for Myopia Progression

PALs were effective in slowing progression in these children, with statistically significant 3-year treatment effects. The results support the COMET rationale (i.e., a role for retinal defocus in myopia progression). In clinical practice in the United States children with large lags of accommodation and near esophoria often are prescribed PALs or bifocals to improve visual performance. Results of this study suggest that such children, if myopic, may have an additional benefit of slowed progression of myopia.

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Polycarbonate/Trivex Lenses

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Prism as Treatment

• Can be used with CI, CE, DI, DE, Vertical Deviations

• Prescribe the least amount of prism needed– Determine the associated phoria with a Wesson

Card or Bernell Box

• Fresnel Prism trial, then Rx

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Optometric Vision Therapy as Treatment

• The approach of choice for CI, Fusional Vergence Dysfunctions, accommodative disorders, and Amblyopia– High chance of success with these disorders

– Results are typically long lasting

– Often can treat these disorders using primarily home VT with in-office check-ups

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Vision Therapy as Treatment

• Traditional therapy– Hand-eye, Vergence and Accommodative

procedures

• Computer Therapy– Can attack hand-eye, vergence, accommodative

and oculomotor problems (Vision information processing anomalies?)

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Vision Therapy for Amblyopia

• Prescribe Rx

• Implement occlusion therapy

•Implement Atropine therapy

• Active optometric vision therapy

• Monitor

• Change Rx/Tx as needed

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Period of Sensitivityvs

Period of Plasticity

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Atropine

Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, Hertle RW, Holmes JM, Quinn GE, Sala NA, Scheiman MM, Stager DR Sr, Wallace DK; A randomized trial of atropine regimens for treatment of moderate amblyopia in children.Ophthalmology. 2004 Nov;111(11):2076-85.

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Atropine

CONCLUSIONS: Weekend atropine provides an improvement in VA of a magnitude similar to that of the improvement provided by daily atropine in treating moderate amblyopia in children 3 to 7 years old.

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Atropine

Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study.Am J Ophthalmol. 2003 Oct;136(4):630-9.

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Atropine

A beneficial effect of atropine is present throughout the age range of 3 years old to younger than 7 years old, and with an acuity range of 20/40 to 20/100. A shift in near fixation to the amblyopic eye is not essential for atropine to be effective in all cases. Sound eye acuity should be monitored when a planospectacle lens is prescribed for the sound eye to augment the treatment effect of atropine.

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Occlusion TherapyAge (yrs) Per Day Schedule Minimum Exam

Frequency

1 4 60min periods 1 day on/1 day off Weekly

2 3 30min periods 2 day on/1 day off Every 2 wks





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Amblyopia Therapy

What do we know about amblyopia?– More than decreased VA

– Visual-Spatial affects

– Accommodation

– Hand-eye

– Stereopsis

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Active Vision Therapy

Hand-eye

Oculomotor

Accommodation

Have child “Do Stuff”

Interact with environment60/97

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Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic amblyopia. EYE. 2004;18(1):109-10

CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres.

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Phases of Therapy• Monocular (HE, OM, ACC)

• Biocular (HE, OM, ACC, Anti-suppression)

• Binocular (Vergence, Acc)

• Integration/Stabilization

Do it all at the same time!

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Traditional Therapy Procedures

• Hand-Eye Procedures– mazes

– dot to dot

– cutting

– coloring

– filling in O’s

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Traditional Therapy Procedures

• Vergence procedures– Brock String

– Lifesaver card

– Anaglyph Series (BC920, others)

• Accommodative Procedures– Minus lens dips

– Flippers

– Hart Chart90

Vergence Procedures

Brock String

Simple

Inexpensive

Easy

Effective

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Vergence Procedures

Life Saver Cards

BO and BI

Good fusion

Anti-suppression

Inexpensive

Effective

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Vergence Procedures

Fusion Cards

Random dot targets

BC 920, BC 50

Anaglyph series

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Vergence Procedures

Aperture Rule

“Flying W”

Stereoscopes

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Accommodative Procedures

Rock Card

Flippers

Anti-suppression

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Accommodative Procedures

Hart Chart

the old standby

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Computer Vision Therapy

• Can attack vergence, accommodative, and oculomotor problems

• Most programs are set up to record patient’s performance each session– Removes the problem of compliance!

• Different products on the market– Home Therapy System

– Computer Aided Vision Therapy

– Psychological Software Services

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Computer Vision Therapy

• Patient can use at home, work, wherever they have access to computer

• Trains eye movements, vergences, accommodation, and perceptual skills

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Why use Computer Aided VT?

• “I’d like to do VT in my practice, but...”

• Patients who cannot afford office VT

• Patients who cannot make a time commitment for office VT

• Patient compliance problems

• Insurance or Third Party Problems

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How do you incorporate Computer Aided Vision

Therapy in your practice ?

• Diagnose the patient!!!

• Assign a therapy protocol

• Computer aided VT in the office

• Schedule follow-up appointments

• Evaluate the patient’s progress/Follow-up

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Computer Aided VT Resources

Neuroscience Center of

Indianapolis

http://www.neuroscience.cnter.c

om/

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http://www.jofcr.com/stcds/stcds.html

Soft Tools


Computer Orthoptics

HTS (Home Therapy System)

http://www.homevisiontherapy.com/

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Computerized Aided Vision Therapy

Gary Vogel, OD, FAAOAvailable from Bernell

800-348-2225http://www.bernell.com/

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Brainware Safari

http://www.brainwareforyou.com/

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Brainware Safari

Helms D, Sawtelle SM. A study of the effectiveness of cognitive therapy delivered in a video game format. Optom Vis Dev 2007;38(1):19-26.

Students in the study group showed an average of 4 years and 3 months improvement on tests of cognitive skills, compared to 4 months improvement for the control group and showed an average of 1 year and 11 months improvement on tests of achievement compared to 1 month for the control group.

http://www.brainwareforyou.com/

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Conclusions

• Easy way to incorporate VT for BV disorders into your practice

• Monitor the output to check for compliance and tricks!

• Remember that the key is in diagnosing patients and follow-up

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VT Equipment

Use the tools discussed

You do not need a whole room of

VT “stuff”

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WWW Sites for BV/VT

Gemstonevision.Org

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BV Organizations

COVD http://www.covd.org/

OEP http://www.oep.org/

949-250-8070

AAO BV Sectionhttp://www.aaopt.org/sections/bvppo/aaobvp.html 301-984-1441 109

BV Organizations

PAVE/Parents Active

for Vision Education

http://www.pave-eye.com/

Neuro-Optometric

Rehabilitation Association

http://www.noravc.com/

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Patient WWW Sites

3 D Pictures

http://www.vision3d.com/optical/

index.shtml#stereogram

How Does Binocular Vision Work?

http://www.vision3d.com/stereo.html

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Patient WWW Sites

• http://www.children-special-needs.org/vision_therapy/what_is_vision_therapy.html

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Position Statement on VTAOA, AAO, COVD many others:

Position Statement on

Optometric Vision Therapy

“The American Optometric Association affirms its long standing position that

optometric vision therapy is effective in the treatment of physiological, neuromuscular and

perceptual dysfunctions of the vision system……..”

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Practice Management

Myths

VT is Too Expensive!

You Can’t Make Money Doing VT!

Which is it? Can’t have it both ways!

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Practice Management

FirstComprehensive Examination

ThenVisual EfficiencyStrab/Amblyopia

Follow-up

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Practice Management

All BV Disorders are a Medical Condition

CI, CE, DI, DE, Pursuit/Saccade Dysfunction

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Practice Management

Accommodative disorders tend to be refractive

Accommodative insufficiency, excess, infacility, instability, etc

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Practice Management

Visual Discomfort

is a medical diagnosis

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All Ages Can Benefit….

More PatientsBetter Patient CareEvidenced Based

Do it! 120

Questions? Contact:

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor, Pediatric/Binocular Vision ServiceIllinois Eye Institute/Illinois College of Optometry

3241 S. Michigan Ave. Chicago, Il. 60610312-949-7280 voice 312-949-7668 fax

Private Practice 773-935-2020

[email protected]

www.LyonsFamilyEyeCare.comwww.ico.edu 121

To BV or not to BV

Health & Medicine

Transcript of To BV or not to BV