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Vision Therapy Services in a

Primary Care Practice Graham Erickson, OD, FAAO, FCOVD

Pacific University College of Optometry

Incorporation of Vision Therapy into Daily Practice

•  Adequate data •  Consultation

–  Explanation of problems –  Presenting treatment options –  Estimation of vision therapy duration and

prognosis for success –  Establishing goals

•  Establishing goals for the patient •  Determining realistic endpoints for therapy

Considerations •  Patients may prefer home-based VT

due to: –  Cost –  Time –  Distance

•  OD may prefer home-based VT due to: –  Space –  Staffing –  Patient base –  Equipment needs

Management Considerations •  Patient motivation •  Frequency of office visits •  Length of office visits •  Office visit records •  Maximizing home-based activities

and establishing short-term goals •  Monitoring patient progress •  Finishing a vision therapy program

Home-Based VT Management

•  “Rent” or Sell VT equipment set –  Factor in staff time for equipment

acquisition and kit creation –  If renting, factor in replacement costs

•  Prepare written instructions for each of the procedures prescribed

•  Follow-up and Maintenance Therapy –  Monthly Progress Evaluations –  Post - VT Progress Eval’s at 3 mo. and 6 mo.

CONVERGENCE INSUFFICIENCY

•  Review of key problems: – Symptoms on Case History

• Give the patient a C.I.S.S. – Convergence Insufficiency Symptom Survey – Validated for 9-18 y.o.’s – Score >16 suggests abnormal symptoms – Beware of overlap w/accommodative symptoms

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Copyright restrictions may apply."

Scheiman, M. et al. Arch Ophthalmol 2005;123:14-24.

Convergence Insufficiency Symptom Survey

•  Review of key data: –  Phorias: Normal at far, abnormally high exo at near –  Low AC/A –  Decreased Positive Relative Vergence (BO)at near

•  Not uncommon to find reduced BI at near also •  Poor Vergence Facility (more difficulty with BO)

–  Decreased (receded) NPC or Capobianco method •  Worsens with repetition

CONVERGENCE INSUFFICIENCY

•  Review of key data: •  Effects on Accommodative Testing

–  Decreased “plus acceptance” on FCC •  MEM?

–  Decreased NRA –  Reduced Binocular Accommodative Facility

•  More difficulty with plus •  Normal monocular facility results

CONVERGENCE INSUFFICIENCY

Role of the AC/A

Blur “Neuro-optical”

Phasic Accommodation

AccommodativeAdaptation

Tonic Accommodation

Accommodative Response

Fixation Disparity

Phasic Vergence

Vergence Adaptation

Tonic Vergence

Vergence Response

AC/A

CA/C

•  If target is at 40cm and PD = 60mm, convergence demand is 15Δ

•  If Normal AC/A ~4/1 and accommodative response = 2.5D, the patient must exert slightly more than 5Δ of fusional and/or proximal vergence to achieve target fusion

•  If AC/A ~2/1, the patient must now exert almost 10Δ of fusional/proximal vergence to achieve fusion

Role of the AC/A

•  Vision Therapy (ETT:8-15 visits) – Home-Based Pencil Pushups? – Home-Based Computerized Therapy? – Office-Based Therapy?

•  Base-In prism at near •  Lenses (???)

Review of Treatment Prioritization

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General VT Considerations for CI

•  Relative ease or difficulty: •  Primary objectives and goals:

–  Normalize gross convergence –  Develop voluntary convergence –  Normalize positive fusional vergence amplitudes –  Normalize binoc. accom. amplitude and facility –  Normalize negative fusional vergence amplitudes –  Normalize positive & neg fusional vergence facility

•  Typical length of therapy: 8-12 weeks • Home-Based = 4-5 sessions

VT Procedures for CI

•  PHASE I: Gross Convergence – NPC Procedures –  Brock String –  3-Dot/Barrel Card

•  Brock String –  Monitors suppression –  Monitors vergence “posture” –  Modifiable

•  Distances •  Ramp vs Step/Jump •  Lenses •  Prisms •  Voluntary

Phase 1 •  Brock String: Step 1

–  NPC (bead pushup) •  Work in the break/recovery zone •  Emphasize clarity and fusion •  Can add plus lenses •  Can add “look-aways” at recovery point

Phase 1

•  Brock String: Step 2 –  Bead Jumps

•  Set near bead at NPC recovery point •  Other 2 beads spaced at intermediate distances •  Emphasize clarity and fusion •  Can add Plus lenses •  Can add BO prisms •  Can add “look-aways” •  Can add target movement

and non-primary gazes

Phase 1

•  Brock String: Step 3 –  Bug-on-a-String

•  Set near bead at ~40 cm •  Imaginary bug walking up the string •  Emphasize slow movement of “X” •  Can add “look-aways” •  Why is this step important?

Phase 1

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•  Allbee 3-Dot (Barrel) Card –  “Extreme” NPC procedure –  Assist with “cut” card and pushup –  Assist with minus lenses –  Add “look-aways” –  Challenge with plus lenses

Phase 1 Phase 1 & Phase 2

•  Accommodative Activities (Binocular) –  Start with monocular therapy as needed – Move to binocular distance rock and flippers

when ready • Near-Far vs Flippers

–  Emphasize clarity –  Emphasize speed

PHASE II: Relative Vergence •  Computer-Based Vergence Training

–  Step vergence demands –  Works in break/recovery zone –  Random dot and multiple choice formats –  Jump vergence format

Phase 2 VT Procedures for CI

•  PHASE III: Open Space Vergence –  Eccentric Circles/"Lifesaver" Cards –  BIM/BOP Activities

•  Eccentric Circles/"Lifesaver" Cards 1.  Smooth/Step vergence

•  Use pointer to help achieve fusion • Monitor suppression/fusion •  Pushups

2.  Jump vergence •  Look-aways •  Pursuits

3.  BIM/BOP therapy

Phase 3 BIM / BOP

•  BIM: Base-In prism and Minus lenses •  BOP: Base-Out prism and Plus lenses •  For Convergence Activities (and Exo’s):

–  BIM assists fusion –  BOP challenges fusion –  Example: Opaque Lifesaver Card thru +1.00

•  Opposite for Divergence Activities

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Issues for Office-Based Therapy

•  Follow-up and Maintenance Therapy –  3 mo/6 mo

•  Equipment needs/cost: –  Barrel Cards $ –  Brock Strings $ –  Lifesaver Cards $ –  Flippers $$ –  Computer Vergence Program $$$

MANAGEMENT OF AMBLYOPIA

OCCLUSION THERAPY FOR AMBLYOPIA

•  Occlusion methods –  Total occlusion –  Partial occlusion

TOTAL OCCLUSION

•  Adhesive bandage (Opticlude, Coverlet) •  Light Perception occlusion foil

(Bangerter) or clear contact paper •  Patch (Pirate-style or patchworks) •  Opaque contact lens

PARTIAL OCCLUSION •  Bangerter occlusion foils (graded) •  Over-plussed optical lens

–  spectacle or contact lens •  Atropine penalization

Atropine Protocols

•  Sound eye gets 1% atropine –  Daily vs “weekend” –  ung vs. gtts

•  Amblyopic eye optically corrected –  Sound eye +/- Rx

•  Duration of cycloplegia may not be as long as we think

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Atropine Protocols

•  Give handout regarding dilated pupil (sun effects, ER, etc.)

•  Best for moderate-high hyperopia with shallow-moderate amblyopia –  Issues of binocularity

•  ATS1 & ATS4

Considerations for occlusion method

•  Cosmesis •  Compliance •  Age •  VA and performance needs •  Binocularity issues •  Amount: 2 hours/day

–  Increase up to 6 h/day as needed

ACTIVE VISION THERAPY

•  Rationale –  Increase efficacy of occlusion therapy –  Reduce treatment time –  Improve visual deficits –  Better results with older amblyopes

ACTIVE VISION THERAPY

•  Common Visual Deficits –  Poor form discrimination –  Deficient accommodative skills

(amplitude, accuracy & facility) –  Deficient eye movement skills –  Central suppression –  Deficient vergence skills

ACTIVE VISION THERAPY

•  P1: Monocular Activities •  P2: Monocular in Binocular Field Activities •  P3: Binocular Activities •  Caveats:

–  Fast-Pointing Activities –  Resolution vs. Spatial localization activities –  Computer therapy options

Experimental Game May Benefit Kids With Amblyopia •  1/23/15 JAMA Ophthalmology:

research suggests that youngsters with amblyopia who underwent treatment with an experimental video game on an iPad not only had improved vision similar to using a patch, but also retained their vision improvements for a whole year.

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Monocular Therapy Activities

•  Eye-hand coordination (throwing, hitting, tracing, picking up, etc.)

•  Resolution activities (hidden pictures, letter searches, card games, etc.)

•  Accommodative amplitude and facility (monocular) – Near-Far vs Flippers

Monocular in Binocular Field Activities

•  Anaglyphic or Polarized TV Trainer and Bar Reader

•  Anaglyphic tracing books, playing cards, workbooks

•  Anaglyphic computer therapy programs

Binocular Therapy

•  Accommodative amplitude and facility (binocular)

•  Computer programs for vergence amplitude and facility

COMPLIANCE ISSUES •  Education of parents, patient,

teacher, etc. •  Parents need to champion this cause •  Decorate patches & Eye Patch Club •  Home activity kits with instructions •  Track and demonstrate improvements

in-office

Issues for Office-Based Therapy •  Follow-up and Maintenance Therapy

–  3 mo/6 mo •  Equipment needs/cost:

– Monocular activities $ –  Anaglyphic materials $$ –  Flippers $$ –  Computer Program $$$