In Search of Hyperopes

Last week I brought a group of 1st year optometry students to an elementary school in Brooklyn .  We performed a vision screening on roughly 80 pre-kindergarten, kindergarten and 1st grade students.  I really enjoy taking 1st year students on vision screenings.  It’s their first real clinical experiences.  They get to practice what they have been taught on patients other than their classmates.  There are so many “teachable moments.”  It never takes more than 5 minutes before one of them notices something worthy of a referral for a comprehensive vision examination.  They begin to see the connections between various measurements and visual function in a classroom (and beyond!).  And who can resist smiling when you watch a 5 year old try to take apart a student’s  ophthalmoscope.

The purpose of a vision screening is to identify children with vision problems requiring intervention.  Sometimes these vision problems are easily overlooked.  A classic example is hyperopia (farsightedness).

When children are farsighted, they are able to compensate for the hyperopia by focusing their eyes.  They have to focus even more when reading or performing other near vision tasks.  The greater the hyperopia, the greater the focusing effort.  All that focusing can cause eye fatigue, intermittent blur, headaches, and inefficiency when using the eyes to gather information.  But it also allows the young hyperope to avoid blurry vision.  These children will pass the vision screening unless you search for the hyperopes.  That is one of the tests that we perform during a vision screening.  We include a certain procedure to look specifically for hyperopes with good visual acuity.

But a little bit of hyperopia is expected in children…….. so when do you refer?  How much hyperopia warrants a comprehensive eye exam and the possibility of an eyeglass prescription?

When discussing referring or prescribing for uncorrected hyperopia, I often point to an article written by Dr. Jerome Rosner in 1997:  The relationship between moderate hyperopia and academic achievement.  Rosner looked at the correlations between refractive error and performance on reading tests in a group of 782 elementary school children.  He found that the children with uncorrected hyperopia greater than +1.25 diopters were more likely to have lower reading scores.

Dr. Rosner drew a line in the sand — for children with hyperopia greater than +1.25, a comprehensive vision examination is indicated to determine if that child would benefit from lenses.  That was the number we used at the vision screening.  We referred many children for a variety of reasons;  that included several children who were able to read the letters on the chart 10 feet away, despite uncorrected hyperopia of greater than +1.25.

But identifying these children is only the first step in the battle against learning related vision problems.  These children need comprehensive vision examinations.  Hopefully that will happen and these children will be well on their way to successful performance in and out of the classroom.

Read more about vision screenings here and here.

This is Autism

Robert Nurisio is a vision therapist blogging about his patient care experiences here at VT Works.   I discovered his blog recently and I am hooked!  His insights into patient care and providing vision therapy are incredible and inspiring.

In honor of Autism Awareness month, he posted this video of a 6 year old boy with autism.  It makes my heart soar.

Ethan, you are very special.  Thank you for this gift.

Sing Together!  (Here are the lyrics:)

It’s nine o’clock on a Saturday
The regular crowd shuffles in
There’s an old man sitting next to me
Making love to his tonic and gin

He says, “Son can you play me a memory
I’m not really sure how it goes
But it’s sad and it’s sweet
And I knew it complete
When I wore a younger man’s clothes”

Sing us a song you’re the piano man
Sing us a song tonight
Well we’re all in the mood for a melody
And you’ve got us feeling alright

Now John at the bar is a friend of mine
He gets me my drinks for free
And he’s quick with a joke or to light up your smoke
But there’s someplace that he’d rather be

He says, “Bill, I believe this is killing me”
As a smile ran away from his face
“Well, I’m sure that I could be a movie star
If I could get out of this place”

Now Paul is a real estate novelist
Who never had time for a wife
And he’s talking with Davy, who’s still in the Navy
And probably will be for life

And the waitress is practicing politics
As the businessmen slowly get stoned
Yes they’re sharing a drink they call loneliness
But it’s better than drinking alone

Sing us a song you’re the piano man
Sing us a song tonight
Well we’re all in the mood for a melody
And you’ve got us feeling alright

It’s a pretty good crowd for a Saturday
And the manager gives me a smile
‘Cause he knows that it’s me they’ve been coming to see
To forget about life for a while

And the piano sounds like a carnival
And the microphone smells like a beer
And they sit at the bar and put bread in my jar
And say “Man what are you doing here?”

Sing us a song you’re the piano man
Sing us a song tonight
Well we’re all in the mood for a melody
And you’ve got us feeling alright

Signs of Autism: April is Autism Awareness Month

Lack of eye contact, staring at spinning objects or light, fleeting peripheral glances, side viewing, and difficulty attending visually are behaviors typically associated with autism.  Yet these can also be signs that there is a visual component to your child’s challenges.  This April, the College of Optometrists in Vision Development (COVD) is participating in Autism Awareness Month and releasing a Public Service Announcement to help educate parents on the visual component to Autism.

As COVD President, Dr. David Damari notes, “Visual problems are very common in individuals with autism. Children on the autism spectrum often have eye coordination and eye movement disorders. For example, when asked to follow an object with their eyes, they usually do not look directly at the object. Instead, they will scan or look off to the side of the object. They might also have difficulty maintaining visual attention. At least one study suggests that more than 20% of those with autism have strabismus (eye turn) and 10% have amblyopia (lazy eye). Other studies support this high incidence of functional vision problems as well.”

Most people don’t realize our eyes are actually part of the brain. So it stands to reason that if someone has a neurological disorder that impacts the brain, their vision would be compromised in some way.  Children with ASD and other neurological disorders don’t complain verbally when their world doesn’t look right; they show us with their behavior.  When vision disorders are treated, one can see improvement in the child’s behavior and how he interacts with the world.

Here is one example of how a child’s behavior changed dramatically once the vision problem was treated.  As a pediatrician, Zach’s mother was aware of the symptoms of autism. While he had many symptoms of autism, he did not meet enough criteria for that diagnosis.  It wasn’t until she took him to a developmental optometrist that she understood how an undiagnosed vision problem could impact his quality of life.

Dr. Janna Jennings shares, “Zach begged me to bring him a loaded gun so he could shoot himself in the head … Since he started wearing the bifocals prescribed by the developmental optometrist a little over two years ago, he has never said another suicidal thing again. After a few months of vision therapy, he stopped saying he was stupid.”  While it took more than bifocals and vision therapy to help Zach fully recover, you can see the impact bifocals and vision therapy can make when there is a visual component to a child’s challenges.

To learn more about how vision disorders can impact a child with ASD or to find a developmental optometrist near you, visit COVD’s website:  www.covd.org.

“For this April’s observance of Autism Awareness month,” Damari continues, “we invite everyone to take a few minutes to view our Public Service Announcements and share them with your friends and relatives.”  The Autism and Vision PSA is airing on Insider Exclusive and can also be seen on COVD’s YouTube channel.

Weekend Reading #6

For your consideration……..

Have a great weekend!

The relationship between increasing sugar consumption and the risk of developing diabetes.   It’s the Sugar, Folks.

One in 12 people has the same vision problems as Bobby.  Vision therapy is the solution.  What 3-D Movies can tell you about your vision

“What price do you put on your child being able to read correctly?”  Double Trouble– Why a Family Pursued Vision Therapy for Both Daughters

Optometry student Ben Emer explains the significance of this ground-breaking federal policy.  Pediatric Eye Care Essential Benefit has now been officially recognized!

Dr. Barry’s realization that vision therapy is about much more than vision, it’s about waking up your brain!  Vision Music and Waking Up the Brain

Dr. Fortenbacher explains  the new treatment paradigm of developing binocular vision to treat amblyopia.  Listen to Emily’s story.    Advanced Amblyopia Treatment for Faster and Better Outcomes

Be Careful What You Wish For

Over a year ago, Dr. Samantha Slotnick , a guest blogger, wrote about strabismus surgery.  She emphasized the point that strabismus is not only an eye muscle problem, it’s a brain problem.  Even if the eyes are aligned surgically, the brain has to learn how to overcome adaptations in order to put those two images together,  into something meaningful.

That blog post has generated more comments than any other!  People around the world are asking for advice and help locating developmental optometrists.  This is one of the goals of this blog– to provide information and perhaps a different perspective on vision, vision problems and treatment for those problems.  The number of views, questions, and comments that were initiated by that blog post made it very clear that we were successful– we got what we wished for!

Dr. Slotnick has replied to every single comment that was generated by that blog post.  In most cases, she was able to help find developmental optometrists around the world to get these patients and their parents the help they are seeking.  But in a few cases, there are no developmental optometrists nearby.  Most recently, Maria from Chile  requested a referral to see if she might benefit from vision therapy.  But there are no doctors in Chile that provide vision therapy.  Be careful what you wish for…… yes, we achieved our goal of raising awareness of the power of vision therapy, but we don’t have the manpower to provide these services to everyone requiring them.  I can only hope that the law of supply and demand will be applicable here– the greater the need, the greater the number of doctors who will provide developmental optometric services.  Developmental optometrists are also finding innovative ways to help patients in far away places.  For example, providing vision therapy via Skype might not be ideal, but it is becoming an option that some doctors are starting to explore.

The take-away message is,  keep those cards and letters coming!  Keep asking questions, let us know what is important to you, what do you want to know and understand.  Let’s keep increasing the DEMAND for developmental optometry and vision therapy, then we can watch the SUPPLY grow across the globe.  And don’t forget to use the locate-a-doctor function on covd.org, maybe there is a developmental optometrist around the corner.

I’m the Data

Today Jillian and Robin Benoit visited with students at SUNY Optometry via Skype.  Together they told Jillian’s story…… how it was discovered that she had severe amblyopia; how an ophthalmologist treated her amblyopia; how her vision problems persisted even when the ophthalmologists said there was nothing more that could be done to help her; and ultimately how optometric vision therapy changed her life.

There were a few moments in their presentation today that I found particularly thought-provoking:

1.  Vision therapy changed, not only Jillian’s life, but the lives of her family and friends.  If Jillian had never learned to read music and play the clarinet, she and her family would not have traveled to see her play with her school band.  They never would have experienced the myriad of opportunities associated with writing and marketing, not 1 book, but soon to be 2 books!  And they will never have to wonder, what if I had taken her to see an optometrist when she was a baby.

2.  Jillian received an email from an ophthalmologist who seemed intent on using the never-changing defensive strategy to bash optometric vision therapy:  where is the evidence, where is the data to prove that vision therapy works.  Jillian took on the ophthalmologist by telling him, “I’m the data!  VT is for people and the people can tell if it works.”  Bravo, Jillian!

Jillian, I would like to give you another perspective on “show me the evidence, show me the data.”  The results of the Amblyopia Treatment Study 2-A were published in the journal Ophthalmology in 2003.  In that study, children between 3 and 7 years of age with severe amblyopia were randomized to 2 treatment groups: full-time or 6 hours/day of patching.  The results: visual acuity in the amblyopic eye improved a similar amount in both groups.  The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hr group and 4.7 lines in the full-time group.

Despite this evidence that was published in an ophthalmological journal, Jillian was patched for 11 hours/day for 3 years.  What good is the evidence if you don’t put it into practice!

Thanks Jillian  and Robin Benoit for encouraging my students to be Superheroes.  You are developmental optometry’s Rock Stars…… Rock On!  

Learning From My Special Needs Patients

Today’s guest blogger is Jessica Stevenson.  Jessi graduated from Capital University with Presidential Honors in Biology and Chemistry in 1998. She is the Clinical Director of Vision Therapy at Professional VisionCare, where she has been integral in the developmental of treatment programs for autism, traumatic brain injuries, and athletes for the past 14 years.  In 2001, she became a Certified Optometric Vision Therapist (COVT).  Jessi lives in Westerville with her husband Preston and her children, Lincoln and Lola.  This originally appeared in Visions, the newsletter of COVD.  

I am so grateful for the opportunity to work with the special needs community.  Here is what they have taught me:

Lesson #1—Listen and look at everything. Keep your ears, eyes, heart and mind open at all times. Watch how the parent interacts with the child for cues on your own interaction. For example, if mom uses short, specific directions, then your poetic (yet long-winded and abstract) ways to describe activities can be distracting.

Lesson #2—Always use person first language. The word “autistic” focuses on the disorder and not the child. “Child with autism” is a verbal reminder you are caring for a child, not a disorder. Parents will notice and appreciate this shift in your language.

Lesson #3—Make modification your new mantra. During a standard vision therapy session, I plan 3 activities. With a child with special needs, I plan dozens. Be willing to try lots of things, if something works, stick with it. If it doesn’t work, don’t take it personally, just move on and try something different. Be flexible even with your equipment. A child with Down Syndrome once refused to wear red and green glasses. Her mom transferred the lenses to a pair of Dora sunglasses and the child loved them. When working with a child with tactile issues, try holding red and green acetate in front of his/her face instead of fighting to get the child to wear the red/green glasses. This idea turned a “challenging case” to an “underwater explorer” as the colored acetates transformed his world.  Imagine the creatures we discovered!

Lesson #4—Parents aren’t allowed to apologize for their child’s behavior and don’t apologize to other patients (within reason). So often, these parents are burdened by explaining their child’s behaviors and justifying them. Taking away this obstacle allows therapy to flow more smoothly and goals to be reached faster.

Lesson #5—Play. Be silly. Play some more.

Lesson #6—Be humble. No matter how smart you are, none of us can claim to be an expert about the patient in front of us. The parent can. Let them. Ask for input, listen to their ideas. When a parent tells you about a procedure, disease, side effect or characteristic that you don’t know about, don’t claim to know if you don’t. Early in her practice, my mentor Dr. Carole Burns, FCOVD, had a mom ask, “What do you know about autism?” Dr. Burns truthfully responded “not much.” This excited the mom because she knew Dr. Burns wouldn’t have preconceived notions or prejudices about her child. Dr. Burns is now sought out in the autism community, but still looks at every child as a unique individual and a chance to learn.

Lesson #7—Be aware of triggers that could cause a behavior or be distracting. When a new patient with special needs schedules an examination in our office, we invite the parents for a walk through before the appointment. We ask them to evaluate smells, sights, noises and overall atmosphere of the office. We invite the child into the exam rooms to touch the equipment with the emphasis that nothing is made to hurt them.

Lesson #8—When communicating with a child with special needs, realize your inability to understand them is not because they are unable to communicate. I learned this lesson with Brandon who was age 4 and non-verbal. While working on parquetry blocks in which two triangles were connecting at the points, Brandon “signed” what I believed to be butterfly. I assured him it was a butterfly, but he needed to build the blocks. Brandon continued signing. I continued prompting him to build the figure. This continued for several minutes, with Brandon’s signs getting more animated. Finally a fellow therapist informed me he was trying to say bird. With that, Brandon jumped up to hug her and then quickly built the blocks. I have learned that whether it is a speech impediment, a toddler’s rambling, or a non-verbal communication, it is my responsibility to figure out the puzzle.

Lesson #9—Count your blessings. Whether I am struggling to get my two children into bed, to eat their peas, or to not use each other as punching bags, I am often struck by how much stronger I would have to be to have a child with special needs. It is then that I am most grateful, not only for my children’s health, but for parents who trust me to work with their children and learn these amazing lessons. I have truly been given a gift and I will never forget that, no matter how many years I am in this profession.