gaining independence through vision therapy, bioptics, and...
TRANSCRIPT
RESEARCH POSTER PRESENTATION DESIGN © 2015
www.PosterPresentations.com
BACKGROUND
Assessment:
1. Bilateral Strabismic Amblyopia
2. Constant Alternating Esotropia
3. Suppression of Binocular Vision (dense)
4. Stereopsis Defective with Fusion
5. Saccadic Dysfunction
6. Nystagmus
7. Pseudophakia OU
8. RE: Mild Hyperopia OU, Mild Astigmatism OU
Plan:
1. Begin 32 session vision therapy program
2. Vision therapy program to emphasize fixation, saccadic accuracy and speed,
pursuits, reaction time, span of recognition, dynamic acuity, binocular pairing,
scanning, central-peripheral integration to build driving and reading skills.
3. Prescribed Bioptics to be used for driving.
4. Recommended Adaptive Driving Program
DIAGNOSES
REFERENCES
1. Maino, Dominick. (2009). Neuroplasticity: Teaching an Old Brain New Tricks. Review of Optometry, Web. 07 Feb.
2017.
2. Astle, A. T., Webb, B. S., & McGraw, P. V. (2011). Can perceptual learning be used to treat amblyopia beyond the
critical period of visual development? Ophthalmic & Physiological Optics : The Journal of the British College of
Ophthalmic Opticians (Optometrists), 31(6), 564–573. http://doi.org/10.1111/j.1475-1313.2011.00873.x
3. Astle, A. T., Webb, B. S., & McGraw, P. V. (2011). The Pattern of Learned Visual Improvements in Adult Amblyopia.
Investigative Ophthalmology & Visual Science, 52(10), 7195–7204. http://doi.org/10.1167/iovs.11-7584
4. Levi, D. M., & Li, R. W. (2009). Perceptual Learning as a potential treatment for amblyopia: a mini-review. Vision
Research, 49(21), 2535–2549. http://doi.org/10.1016/j.visres.2009.02.010
5. Li, R. W., Klein, S. A., & Levi, D. M. (2008). Prolonged Perceptual Learning of Positional Acuity in Adult Amblyopia:
Perceptual Template Retuning Dynamics. The Journal of Neuroscience : The Official Journal of the Society for
Neuroscience, 28(52), 14223–14229. http://doi.org/10.1523/JNEUROSCI.4271-08.2008
6. Wolpaw, J. R. (2012). Harnessing Neuroplasticity for Clinical Applications." Brain 135.4. pag. Web.
7. http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y
8. Marottoli, R. A., de Leon, C. F. M., Glass, T. A., Williams, C. S., Cooney, L. M., Berkman, L. F. and Tinetti, M. E.
(1997), Driving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New Haven EPESE.
Journal of the American Geriatrics Society, 45: 202–206. doi:10.1111/j.1532-5415.1997.tb04508.x
9. Kamino, Lisa. (2016). Bioptic Telescope Driving and Low Vision Rehabilitation: A Review. Optometry & Visual
Performance 4.2: 57-61. Print.
10. Gary S. Rubin, Edmond S. W. Ng, Karen Bandeen-Roche, Penelope M. Keyl, Ellen E. Freeman, Sheila K. West, the
SEE Project Team. (2007). A Prospective, Population-Based Study of the Role of Visual Impairment in Motor Vehicle
Crashes among Older Drivers: The SEE Study. Invest. Ophthalmol. Vis. Sci. 2007;48(4):1483-1491. doi:
10.1167/iovs.06-0474.
11. http://www.stdavidsrehab.com/programs-services/outpatient-rehabilitation-services/driving-program.aspx
12. https://www.ocutech.com/product/ocutech-sightscope-flip/
13. Singh, Neeraj K., Ritika James, Avdhesh Yadav, and Divya Jyoti. (2016). Vision and Driving Difficulties with Nystagmus: Finding New Pathways. Optometry & Visual Performance 4.4: 146-51. Print.
VISION THERAPY PROGRAM
Program Length: 32 weekly in-office sessions
• 55-year-old Caucasian Female
• Main concern: “Improve vision and day to day living, improve acuity. I'd like to
drive again.” Wore bifocals from her 30's. Left eye turned in more after surgeries
(DSEK in 2014)
• Ocular History
– Last Eye Exam: 10/3/2015 with Primary OD
– Currently wears Scleral contact lenses
– Fuch's Dystrophy, Nystagmus, cataracts, h/o DSEK and RK
– Signs and Symptoms: eye turn, lazy eye, halos around lights,
clumsy/bump into things, floaters, reduced night vision, bothered by
glare
• Occupation: Psychotherapist, Priest
• Lifestyle: fitness training, gym, yoga, running/jogging, walking, cooking, knitting,
birding
• Medical History:
– Daily Medications: Wellbutrin XL, Armour Thyroid, Prednisolone
– Allergies: seasonal allergies,
– Last Medical Exam: September 2015
– Systemic review: Thyroid dysfunction
– Family history: Hypertension, heart disease, cancer, learning problems
The Optometry Center for Vision Therapy; San Antonio and Austin, Texas
UIW Rosenberg School of Optometry; San Antonio, Texas
Alisa Nola, OD; Briana Larson, OD, FCOVD, FAAO, FNORA; Annie Ramirez, COVT
Gaining Independence Through Vision Therapy, Bioptics, and an Adaptive Driving Program
Pertinent Exam Findings
RESULTS
DISCUSSION
-The prescribed vision therapy program included transferring
visual skills to driving: scanning, central-peripheral integration,
figure ground, reaction speed, processing speed, discrimination,
and in-office training with bioptics.
-Bioptic telescopes and an adaptive driving program should be
considered for a patient with moderate low vision and motivation
to improve driving skills.
-There is substantial evidence that residual plasticity is present in
the adult brain, allowing for the treatment of visual dysfunctions
past the critical period.
-Neuroplasticity is often experience dependent, time-sensitive and
strongly influenced by the environment. Attention and motivation
are also critical factors for plasticity 6 .
-Perceptual learning techniques have been proven to demonstrate
enduring effects on the visual system and transfer to new visual
skills 2-5.
-Visual discomfort, glare, driving difficulties, and reduction in near
tasks have been reported to decrease quality of life in those with
nystagmus. Yoked prisms, vision therapy, and occupational therapy
training were effective in relieving visual discomfort. With further
training and potential vision, a person with nystagmus can improve
driving skills 13.
HISTORY
Initial Exam Progress Evaluation
(at 6 months)
VA's cc Habitual
DVA 20/80- OD; 20/80 OS NVA 20/200 OD; 20/80 OS
DVA: 20/70+ OD, 20/60- OSNVA: 20/70 OD, 20/60 OS
Lensometry PALs
+5.00-2.25x077 OD+3.75-1.50x179 OSAdd +2.25
Cover Test D: CRET 45pdN: CAET 40pd
D: CRET ~35pd N: CRET 45pd
Pursuits +nystagmus horizontal beat, more in left gaze
Same
Saccades Gross overshoots to the right 100% Accurate
Stereopsis (-) Random Dot Stereopsis, 70" Wirt Circles
(-) Random Dot Stereopsis, 140" Wirt Circles
NPC Break 1", Recovery 3", OS out x3, (+) diplopia
Break 2-3", (-) diplopia, able to diverge eyes together
Worth 4 Dot D: constant OD suppression I: constant OD suppressionN: at 4" intermittent 4 to OD suppression; and at 2" reported fusion (no movement with cover UCT).
D: constant OD suppression I: constant OD suppressionN: alternated suppression; intermittent fusion at 12" with 25BO
Developmental Eye Movement
Test
Speed: 25%Accuracy: >55% (graded on 13-year-old scale)
Speed: 45%Accuracy: >55% (graded on 13-year-old scale)
Patient Comments
• Can see more in the periphery in the shower now.
• She is more centered when parking her car.
• Graduated adapted driving course with bioptics.
Final Progress Evaluation Summary (30/32 weeks):
VA cc: DVA: 20/50 OD; 20/40 OS
NVA: 20/60 OD; 20/40 OS
Cover Test: Distance: 35pd CRET
Near: 25pd CRET
Saccades: Accurate
NPC: TTN x3, (-) diplopia
Worth Four Dot:
• Distance: Constant alternating suppression
• Intermediate: Constant alternating suppression
• Near: fusion at 3 feet; uncrossed diplopia closer than 3 feet
Developmental Eye Movement Test: 35% Speed, 33% accuracy
Subjective improvements: Driving with bioptic and loves it. Better at
parking her car. She now reads for pleasure without fighting to see
clearly. Can paint toe nails now (never been able to do).
Plan: Recommended an extension of program to continue developing
visual skills.
Bioptics
The SightScope Flip (Ocutech), Galilean telescope, is available in 1.7x and
2.2x powers, and is helpful for those with mild vision loss (20/100).
Bioptic Fitting and Follow Up
VA cc and 2.2x SightScope:
DVA: 20/50 OD
20/30 OS
Recent studies have confirmed that residual plasticity is present in the adult visual
brain with amblyopia 1-5. Neuroplasticity has been broadly defined as the ability of
the central nervous system to reorganize its structure, function, and connections in
response to external or internal stimuli 6. Historically, amblyopia was believed to be
untreatable past the critical period of visual development (7-9 years of age) 1.
Through stimulation of the afferent pathways of the visual system utilizing vision
therapy, or perceptual learning as referred to in some studies, visual skills can be
improved in an adult. Substantial plasticity in adults has been found with prolonged
visual perceptual learning 5. Importantly, the effects are long-lasting and can be
transferred to new visual tasks 2-5. Vision therapy was used to improve the function
and quality of life in an adult patient with long-standing amblyopia, strabismus,
nystagmus, and binocular vision disorders. This case involved using occlusion
therapy, vision therapy, bioptic telescopes, and an adaptive driving program to
improve visual function and transfer skills to driving.
Moderate low vision is classified as having best corrected vision between 20/70 to
20/160 7. Bioptic telescopes were prescribed in this case to meet the patient’s goal for
driving. Driving is often a goal for those with low vision. For many individuals,
driving is associated with a sense of independence, personal identity, and life
satisfaction 8. A bioptic telescope system, telescope mounted on the superior portion
of the spectacle lenses, has been found to be useful by those who have low vision
(see Figure 1). During the majority of the driving time, patients view through the
carrier lenses and for brief moments (approximately 2 seconds, or 5% of the time)
view through the telescope to view street signs, traffic lights, and other distant
objects 9. Generally, bioptic telescopes provide 2x and 4x magnification and a field of
view between 6 and 16 degrees 9. Although visual acuity is the only visual factor that
is required in all states for a driver's license, it has been shown to have a weak
association with motor vehicle collision rates 9,10. Bioptic driving safety includes
being adequately trained on using the telescope, as well as with other visual
functions. Good candidates for bioptic driving includes congenital, stable visual
impairments, with full peripheral visual fields 9.
After an appropriate bioptic telescope has been determined (dependent on state
bioptic telescope laws and patient characteristics), the patient must receive training to
be proficient with using the bioptic while driving. Occupational therapists, vision
rehabilitation specialists, and certified low vision therapists usually provide this
specialized training. The adaptive driving program determines driving ability by
assessing different areas in vision, cognitive processing, physical ability, and driving
assessment (see Figure 2) 11. The driving assessment generally begins in a stationary
environment (parking lot), then in the car, next in slower or suburban areas, and
finally in highways and/or faster paced environments. Once an individual has proven
to be proficient in driving with the telescope, they are evaluated by the state licensing
agency to determine if a license will be issued.
https://www.ocutech.com/product/ocutech-sightscope-flip/Figure 1: Bioptic telescope
Vision Assessment
• Spatial
• Depth
• Peripheral vision
• Visual Acuity
• Glare
• Visual attention
• Scanning
Cognitive Processing
• Reaction speed
• Memory
• Divided Attention
Physical Ability
Driving Assessment
• Start in parking lot
• Familiarize with vehicle
• Assessment in slower/suburban areas, then highways/city
Figure 2: Adaptive driving program
Specific Skills Therapy
Oculomotor
Fixation, Saccades,
Pursuits
• Hart Chart with Rotator
Board for Dynamic Acuity
• SVI Eye-Hand Proactive and
Reactive
• CPT Scan with Processing
Speed
• Track and Read: Words with
Cognitive and Timed Loading
• Distance Hart Chart with
Bioptics
Central-Peripheral
Integration
• SVI Rotator with Central
Fixation
• MacDonald Card with
Dynamic Acuity
• Track and Read: Span of
Recognition with Central
Fixation
Binocular
Vision
Anti-Suppression
Phase 1: MBF
• Red Transparency with
Red/Green Glasses
• MBF CPT Search with Timed
Component
• MBF Number Saccades with
Metronome Beat
• MBF SVI Letter Chart Motion
Phase 2: Bi-Ocular
• Red/Green Bar Reader over Hart
Chart
• Red/Blue SVI Saccades 1
• Polarized Glasses and Mirror
• Rotating Red/Green Chart
Functional Pairing
• Penlight Fusion with
Red/Green Glasses
• Bead and String Stationary
with Red/Green Glasses
• Gross Divergence Targets
Visual
Processing
Discrimination
• VIPS: Discrimination: Color
Grids
• Tumbling U Chart
• Multi-Matrix
Figure Ground
• VIPS: Figure Ground: Hidden
Pictures
• Red and Green Chart Search
and Scan
• Focus Flexibility
Processing Speed
• Perceptual Speed Timed
• SVI Tachistoscope
• CPT Search Timed