Patching Requires Tough Love

On Monday I examined 2 children, both of whom are amblyopic.  Amblyopia  (also called lazy eye) is a condition where one eye sees poorly, even with eyeglasses or contact lenses. Amblyopia can develop in childhood due to:

• An obstruction of vision within one eye due to injury or disease; (deprivation amblyopia)
• Significant differences between the clearness of the images seen by each eye due to farsightedness, nearsightedness or astigmatism; (refractive amblyopia)
• Misaligned eyes or crossed eyes (Strabismus) (strabismic amblyopia).

Both children have refractive amblyopia.  M is a 12 year old boy who had been diagnosed with amblyopia many years ago.  Treatment consisted of the prescription of glasses for full-time wear and a patching regimen.  Patching the better seeing eye for 2 hours per day would force him to use the amblyopic eye while performing visually-guided activities.  M’s amblyopia is not too severe.  Wearing the patch and performing activities with only the amblyopic eye is probably a little uncomfortable and inconvenient (the cost), but  improvements in vision and visual function are likely to be achieved.  As the vision in his amblyopic eye improves, so will his binocular skills and depth perception  (the benefits).
M was reluctant to wear his glasses, and even more reluctant to comply with the patching regimen.  As a result, the vision in his amblyopic eye has improved very little.    When I questioned his mother about why he was not wearing the glasses or complying with the patching therapy, she simply said, “he doesn’t like to do it.”

C is a 4 year old boy who failed the vision screening at the pediatrician’s office.  As soon as I attempted to cover his better seeing eye to measure his visual acuity, his behaviors and demeanor changed.  He tried “peeking” under the patch and when that didn’t work, he tried to take the patch off, and when that didn’t work, he tried to leave the exam room! This child is very myopic in one eye only, and as a result, has severe amblyopia.  Even with lenses, he had to be 3 feet away from the Biggest E to see it.  The treatment plan for C is the same–the prescription of glasses for full-time wear and patching.  However, when he is patched and forced to use only his amblyopic eye, C is very impaired.  He will have great difficulty accomplishing any visual tasks when he wears the patch.  Using the same analysis, the cost of treatment from the perspective of this 4 year old boy is very high.  The severe amblyopia is much more difficult to treat and the prognosis is poor.  So while the cost of treatment is high, the expected benefits are low.  When I explained this to C’s mother, she began to cry.  She understood that although the expected outcomes of treatment are more limited, there are no alternatives.  If C’s vision is going to improve at all, he must wear the glasses full-time and wear the patch for several hours every day.

Patching therapy can be very difficult for a family.  Young children may not understand why they need to wear the patch and will be reluctant to comply with treatment.  They take off the patch as soon as mom or dad turns around.  They tilt their heads to try to peek under the patch and use the better eye.  They whine. They cry.  Patching therapy becomes an ordeal and the parent backs down.  As a result, vision does not improve and the amblyopia lingers.

Poor compliance with medical treatment is not unique to the treatment of amblyopia.  Patching is a form of medical treatment no different than taking medication or receiving immunizations. I do my best to educate my patients and their parents.  I try to be honest about the cost/benefit ratio.  But it is up to the parents to make sure the patching therapy is done.  Patching requires tough love.

For more information about the treatment of amblyopia, read the Clinical Practice Guidelines published by the American Optometric Association.

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It Takes A Village

“It Takes a Village.”  That is the title of the book, written by Hillary Rodham Clinton in 1996, when she was the First Lady.  This title refers to an African proverb, “It takes a village to raise a child.” How appropriate to introduce this post from Dr. Leonard Press.  This post also appears on VisionHelp Blog.  Dr. Press has been building a strong village to support the needs of the children (and grown-ups) he serves.  He knows he can’t do it alone.  The more we interact with like-minded professionals, the more we will learn about how to help our patients.

I’ve had a fabulous time, twice over the past two weeks,  giving a day long seminar to occupational therapists, physical therapists and speech-language pathologists.  Our field has been blessed with colleagues who do a marvelous job of this, in particular Drs. Appelbaum, Hellerstein, Hillier and Scheiman.  Although I’ve been asked to put seminars like this together before, I’ve shied away due to time constraints.

Venturing first up the Hudson River along the Palisades Parkway to do the seminar in Spring Valley, and then down the New Jersey Turnpike for a gathering in Princeton, I had a blast.  One of the best things about having an interactive seminar with “the big three” therapies of OT, PT and Speech,  the ones who are part and parcel of early intervention services, is that they get it.  There’s no need to  convince any of the attendees of the importance of VT, only to work out a framework in which they can feel comfortable collaborating.

Here is what we covered:

seminar-visual-processing-and-therapy-oct-2010

I’m happy to share this information, though it isn’t as much the facts that makes the seminar special as it is the interaction.  In contrast with some professions who don’t grasp the science and substance of optometric vision therapy, those in attendance at these seminars grasped the concepts almost intuitively.  Ideas about the balance between structure and function, between reductionist disease models and holistic developmental models, and between the senses and the senseless resonated with each of the attendees.

My seminars are highly interactive, and though the PowerPoint slides in the hyperlink above will give you a feel for what we covered, it really is the interaction that is priceless.  Though I’m referring principally to hands-on workshop demonstrations, a subject that comes up frequently is how best to advise parents to obtain a consult with a developmental optometrist.  To steer clear of school system and health care politics, I suggest that therapists simply guide parents to the wealth of information at http://www.covd.org, http://www.oep.org, http://www.aoa.org and http://www.visionhelp.com.

Build it, and they will come.  Interact, and they will process the facts – with the public as the ultimate beneficiaries.

- Leonard J. Press, O.D., FCOVD, FAAO

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The Price Tag

What is the most effective way to identify children with vision problems?  The American Optometric Association and the American Public Health Association support comprehensive vision examinations for all children.  The American Academy of Ophthalmology and the American Academy of Pediatrics favor vision screenings.  The latter organizations use an economic argument in support of vision screenings.  It is far less expensive to perform a vision screening vs. comprehensive vision examinations on the entire 1st grade of your local elementary school……… or is it?

The economic view of this debate considers only direct costs.  In the same amount of time it takes to examine a 6 year old child, a vision screening could be performed on 4 or 5 children.  If the screening is performed during the child’s annual visit to the pediatrician, then the cost of an “unnecessary” vision examination is eliminated.  Manpower and equipment costs are easily calculated.  Using this approach, vision screenings are less expensive.  But this type of economic analysis does not consider the INDIRECT costs.  Vision screenings fail to identify many children with vision disorders.  How do you calculate the cost of an undiagnosed vision problem on the quality of life of a school-aged child?

If every child is going to be given the opportunity to learn, then every child must have a comprehensive vision examination when they enter school. The emphasis must be on maximizing our resources, and not on minimizing the need because it translates to a lower price tag.

For more information about the limitations of vision screenings, see Volume 14, Issue 5, article by Zaba et al in the Journal of Behavioral Optometry, 2003.

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“His Eyes Are Fine”

Today’s guest blogger is Dr. Leonard Press, from Fairlawn NJ.  This post also appears on  The VisionHelp Blog.

I saw a young boy as a patient in the office this morning who is almost five years of age.  His history is amazing, and suffice it to say that he had a rough start in life.  In the NICU for the first six days after birth, neonatologists recognized that he had severe motor weaknesses.  He doesn’t really fit into any pattern of a known syndrome, and currently bears the diagnostic entity of “neuromuscular problems of unknown origin”.  Sociable and articulate, he’s been talking since 9 months of age, and has received significant amounts of occupational and physical therapy.  As the early intervention period came to a close at age three, someone decided it would be a good time for him to have an eye examination.  His parents took him to an ophthalmologist, and here is a copy of the report sent to his other physician providers:

OPHTHALMOLOGY – Minimalist Repor t 2010

Now that’s what I call “ophthalmo-minimalism”.  20/20 visual acuity.  Eye exam normal.  See you in two years, and don’t let the door hit you on the way out.

As was the case with this young man, we get many referrals from OTs and PTs who understand how the eyes are interconnected with the rest of the body’s motor systems.  Both the OT and PT recognized that this child had difficulty with copying, switching focus from near to far, and with visual motor testing relative to gross motor testing.  They suggested to mom that her son be examined by a developmental optometrist, and impressed upon her that although “his eyes are fine”, that’s not where the visual system begins or ends.  And when mom brought in her son’s report from the ophthalmologist, I was reminded of the extent to which we miss more by not looking than by not seeing.

So we looked deeper into Jonathan’s visual system, as closely as one can look without peering directly into the rest of his brain.  He showed a low amount of hyperopia on manifest retinoscopy but +2.50-0.75 cx 180 OU after just 15 minutes of one drop of  1% cylopentolate having been instilled.  His Keystone Visual Skills showed a high dergee of binocular instability, with eso at distance compatible with latent hyperopia, and exo at near compatible with accommodative stress and lag.  He also exhibited a small but significant variable vertical drift, compatible with his overall motor history, and his strereopsis was reduced.  The WACS (Wachs Analysis of Cognitive Structures) Test showed that his visual cognition was substantially lagging behind his superior verbal intellect and reasoning skills.

I’ll be meeting with his parents on Monday to gain a bigger picture, and will stay in touch with his developmental pediatrician, physical therapist, and occupational therapist.  Though I haven’t decided as yet what course of action we’ll take, I do know one thing for sure.  His eyes may be fine, but his vision isn’t “normal”.

Leonard J. Press, O.D., FCOVD, FAAO

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More About Reading: Improvements Following Vision Therapy

The Visagraph Eye Movement System (Visagraph) records and analyzes a student’s eye movements while reading.  The analysis provides grade level equivalents for various measurements such as fixations and regressions per 100 words and reading speed in words per minute.  The Visagraph provides objective information which typically correlates with a student’s subjective symptoms, such as loss of place when reading, skipping lines and poor reading comprehension.  The optometric diagnosis is usually “oculomotor dysfunction.”  Recent research by Dr. Barry Tannen and student Noah Tannen evaluated the impact of vision therapy on Visagraph measurements and symptoms in patient’s diagnosed with oculomotor dysfunction.

Forty six children between the ages of 8 and 17 years had Visagraph measurements completed at 2 levels:  first, at their independent reading level and then at 2 years below their independent reading level.  The hallmark of an oculomotor dysfunction is poor eye movements at both levels.  The eye movement dysfunction is evident even when the reading material is “easy” or below grade level.  The 46 children received optometric vision therapy (VT), according to their individual needs.  Visagraph measurements were obtained post-VT, again at 2 reading levels.  All Visagraph measurements at both reading levels showed a significant improvement from pre-VT levels.  For example, reading speed improved by more than 50% following VT. The improvements in Visagraph meaurements correlated with a reduction in symptoms that occurred in 93% of the patients.

Eye movements are an important visual skill, so integral to the reading process. Dr. Tannen’s research provides evidence of the impact of VT on eye movements, reading performance and associated symptoms.  Take the time to consider whether your child has any symptoms associated with a visual dysfunction.

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Visual Skills and Reading

What happens to your reading performance if you have poor visual skills?  Dr. Maureen Powers investigated this very question by artificially creating a visual skills deficit in otherwise “normal” readers.  A group of patients with an average age of 11.5 years was asked to read while wearing increasing amounts of prism.  The prism creates a demand on the visual system which simulates a visual skills deficit.  As the amount of prism was increased, reading performance (measured as reading rate in words per minute) decreased.  Many of the patients showed a “rebound” effect.  At a certain point, the amount of prism was too great and the patients reported double vision.   The patients were no longer expending energy to compensate for the visual problem!  They just read one of the double images, and their reading rates increased.  Dr. Powers concluded that visual deficits can have an impact on reading performance.

Sometimes, it is not the most obvious vision problems that are causing poor academic performance.  In this case, it was the effort required to overcome the visual deficit that was to blame.  Don’t wait until your child has double vision!  If your child is struggling in school, find a developmental optometrist today.

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