Vision Screening: What’s It Missing?

Today’s guest blogger is Dr. Michael Gallaway.  Dr. Gallaway practices in metro Philadelphia (Marlton NJ).  In addition to his private practice, he has been teaching at Pennsylvania College of Optometry at Salus University since he graduated from the New England College of Optometry.

Most children receive a vision screening in the pediatrician’s office prior to starting school, and later receive some form of vision screening once in school. That’s because vision is so important for learning – up to 80% of what children learn comes through vision.  You would think that screening for vision problems that affect a child’s development or their school performance would be technologically up to date and accurate, but the truth will surprise you!

Most vision screenings use only the Snellen chart, the same letter chart you were probably screened with as a child and which your grandparents were probably screened with when they were children.  The Snellen chart has been used since Civil War times in one room schoolhouses so teachers could know which children should sit closest to the blackboard.  One hundred and fifty years later, and it’s still the only test that most vision screening relies on, even with studies documenting that Snellen charts can miss up to 75% of vision problems. This is because seeing the board clearly is only one of many things children need to do with their eyes in school.  To read and learn, they need the skills to easily focus, move and coordinate their two eyes all day long or else reading becomes a chore…or over time – a learning, behavioral or attention problem.

Another irony is that children who fail the Snellen test are most likely to be nearsighted (or myopic).  But eighty years of research has shown that nearsighted children are more likely to be better readers. The reason?  Children who read more sometimes become nearsighted as their eye muscles adapt to lots of close vision so that their reading requires less focusing effort.  Of course, that can make their distance vision blurry, and so our efforts at vision screening do the best job of finding the children who are the best readers!  Those who are most at risk for a learning related vision problem have eye teaming (binocular), focusing (accommodative), tracking (oculo-motor) and visual processing disorders – and the vast majority have 20/20 vision or already wear eyeglasses!  They see the board easily but struggle using their eyes during reading and writing activities.

When children pass a vision screening by a pediatrician or school nurse, parents, teachers and even the children themselves think their “vision” is fine.  But too many of these children still complain of headaches, double vision or loss of place  when they read or do homework, despite having 20/20 vision.

Recent research has pointed to a potential answer to this dilemma.  VERA is a computer program that screens for both visual acuity (20/20 etc) problems and a range of visual problems that affect reading and homework. This study found that VERA was very effective in finding eye teaming, focusing and tracking problems when compared to standard eye exam tests. One school district that has been using VERA has the lowest special education rate in their county – in part because the school identifies vision problems that are affecting school performance. When these problems are treated with vision therapy or reading glasses, many of the children learn better, and some can even avoid needing special education services…a win-win for children and their schools.  Learn more about VERA at www.visualscreening.com.

So don’t assume because your child can read the small letters on the Snellen chart that their vision is fine. Ask your school about how they screen your child’s vision, and whether they know about VERA.  And inquire as to whether your eye doctor checks for the full range of vision issues that affect reading and learning. 20/20 and healthy eyes are important, but they’re not nearly enough.

Dr. Gallaway has no financial interest in VERA or visualscreening.com.

Read more about vision screenings :

Evidence Supporting the Benefits of Treatment

The Price Tag

Ready For School

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What is Amblyopia? What is NOT Amblyopia

This blog post was inspired by a presentation by Dr. Matthew Walsh.  Dr. Walsh is a Resident in Vision Therapy at SUNY Optometry.  All the residents are required to present a 1 hr. continuing education lecture on a topic of their choice.  Dr. Walsh’s presentation was entitled: Visual Pathway Pathology  Masquerading as Amblyopia in Children.

What is amblyopia?  What is not amblyopia?  Let’s consider the definition of amblyopia from the American Optometric Association and its clinical application.

Amblyopia is a unilateral or infrequently bilateral condition in which the best corrected visual acuity is poorer than 20/20 in the absence of any obvious structural anomalies or ocular disease.

In other words, amblyopia can only be diagnosed when ocular disease has been ruled out.  The optometrist must perform a comprehensive examination including a full evaluation of ocular health.  This is likely to include the use of dilating drops in order to examine the retina.  The doctor will also perform additional procedures to rule out specific causes of vision loss.

Functional amblyopia occurs before the age of 6-8 years and is attributable to deprivation, strabismus or anisometropic, although it may persist for life once established.

When other causes of the vision loss are ruled out, amblyopia must be ruled IN, by the presence of an identified amblyogenic condition: strabismus, anisometropia/isometropia, or deprivation.  Strabismus is an eye turn, and amblyopia is more likely to develop if the eye turn is constant and unilateral.  Anisometropia is a a large difference in refractive error between the two eyes; isometropia is very high refractive error in both eyes.  Several physical conditions may cause deprivation of visual stimulation to one eye, such as a congenital cataract or a ptosis (droopy eyelid).  These amblyogenic factors must be present during the “critical period” of visual development, which is considered the first 8 years of life.  The visual system is far less susceptible to disruption after this time period.  Although the condition MAY persist for life once established, the visual system is amenable to treatment at almost any age.  The critical period applies only to the development of amblyopia, and not to its treatment and resolution.

Amblyopia represents a syndrome of compromising deficits, rather than simply reduced visual acuity, including:

• Increased sensitivity to contour interaction effects
• Abnormal spatial distortions and uncertainty
• Poor eye tracking ability
• Reduced contrast sensitivity
• Inaccurate accommodative responses

Amblyopia is not an eye problem, it is a brain problem.  The brain has great difficulty not only recognizing small letters, but also processing and responding to all types of visual information: words printed on a page, faces in a crowd, cars moving down the road, reflections in a mirror, moguls on the ski slope, etc.  That’s why treatment of amblyopia involves more than just patching.  The brain learns how to process visual information in much the same way humans learn most skills… by starting with a relatively easy task, practicing, and then making the task more difficult as competency increases.  Amblyopic brains have to learn many new skills and this is best accomplished in a structured learning environment.  A vision therapy program will also emphasize the integration of vision with other sensory inputs and the ability to use vision to guide motor outputs.

One more point to be considered:  amblyopia is ruled in when ocular disease is ruled out, except in rare instances when amblyopia AND ocular disease coexist.  In addition to performing a comprehensive examination, the optometrist will consider the degree of vision loss and monitor progress during treatment.  Only when all the causes of vision loss are considered can the prognosis be determined and the best treatment plan be put into action.

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Been There, Done That

These comments are based on this article, Neuroplasticity as a proposed mechanism for the efficacy of optometric vision therapy and rehabilitation, written by Dr. Julia Huang.

In the past 10 years, constraint-induced (CI) movement therapy  has become the treatment of choice for patients with an upper-extremity hemiparesis after a stroke.  CI therapy involves forcing the patient to use the paretic arm by restraining the non-impaired arm for several hours everyday.  The patient must be actively engaged in various task-oriented activities which are made more difficult as improvement is noted.  These patients make marked improvements in motor function AND quality-of-life.  These improvements in function correlate with changes in the brain.   Research studies have shown increases in gray matter in both sensory and motor areas, on both sides of the brain.  CI therapy is based on reversing “learned non-use,” which was first described in animal studies.  Monkeys are able to recover function of affected limbs following surgical destruction of selected nerves, when the non-affected limb is tied down.

More traditional occupational and physical therapy focus on teaching the use of the unaffected limb to do all the work.  These studies demonstrate why this approach is ineffective at enabling a patient to RECOVER movement and function of the affected limb. The need for assistive devices, braces, and wheelchairs is lessening because  CI therapy induces changes in brain structure that result in improvements in movement and function.

These principles of CI therapy are now finding their way into other rehabilitative modalities, such as speech therapy.  By preventing patients from using compensatory strategies such as pointing and gesturing, and condensing 30 hours of  therapy into an intensive 2 week program, patients are making significant improvements in language functions.  The scientific community is beginning to embrace the concept that rehabilitation of motor, sensory and cognitive impairments can ALTER brain STRUCTURE and result in the recovery of FUNCTION.  The neuroplasticity of the human brain can be invoked without regard to the age of the patient, or the severity or duration of the loss of function.

Developmental optometrists have been using these same principles for ages, most notably in the treatment of amblyopia.  By patching the non-affected eye for several hours per day, the patient is forced to learn to use the amblyopic eye.  Therapy includes the addition of a series of task-oriented activities which are made more difficult as improvements are noted.  Reversing “learned non-use” occurs in patients of all ages, by strengthening synaptic connections and inducing cortical reorganization.  The induction of neuroplasticity in the treatment of amblyopia uses the same principles as other rehabilitation specialists:  repetition, motivation, loading, multi-sensory integration and feedback.  The only difference is that developmental optometrists were utilizing these principles clinically before they were validated by recent research. Yes I’ve been there and done that!

Recent research from the Pediatric Eye Disease Investigator Group (PEDIG) has provided the evidence of the benefits of patching or pharmacological penalization with atropine in the treatment of amblyopia.  The addition of near activities to a patching regimen has also been shown to be effective.  Now, in addition to having been there and done that, I am here, as the research proves that the clinical practices  I use every day are evidence-based.  As a result, I will continue to think beyond the limitations imposed by current research and  push the envelope to do more to help my patients improve their quality of life.  I will wait patiently for the science to catch up to my clinical practice.   I love my job.

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A Blessing in Disguise

The American Optometric Association and the 3-D@Home Consortium have signed a Memorandum of Understanding to improve the understanding of stereoscopic/3-D viewing as a safe and appropriate technology for children and adults of all ages.  The two organizations hope to collaborate on clinical research and develop strategies for promoting an enhanced 3-D experience through thoughtful consideration of human vision development and perceptual processes.

The 3-D@Home Consortium is working to accelerate the adoption of 3-D technology in the home.  Through conversations with the AOA, the Consortium has come to understand that vision and eye health are a large component of the consumers’ ability to view 3-D images and to ultimately increase their use of 3-D technology.  And through conversations with the Consortium, the AOA has come to understand that the adoption of 3-D technology is a new opportunity to screen children for undetected vision problems such as strabismus and amblyopia.  These vision disorders, if left undiagnosed, not only interfere with the 3-D viewing experience, but also have the potential to cause the “3-Ds of 3-D viewing”: discomfort, dizziness and lack of depth.

At a symposium on 3-D technology presented at the State College of Optometry in NYC, Dr. Michael Duenas* explained the deficiencies of the current system of providing eyecare to America’s children.  Vision screenings do not do a very good job of identifying children with vision problems.  Even when identified, very few children receive the comprehensive eye exam that is required to diagnose the condition and initiate treatment.  Too many students are sitting in classrooms without the visual skills required for learning.  Often, the results are poor academic performance, a diagnosis of a learning disability or ADHD, or even behavioral issues that could lead to juvenile deliquency.  What if those children could be identified by giving them the opportunity to view a 3-D movie in the school auditorium?

3-D technology is not only about entertainment.  There is a new world evolving, and it is based on the application of 3-D technology in new and exciting ways.  Education is using 3-D content in classrooms.  Imagine an astronomy lesson presented in 3-D, with the planets orbiting the sun.  The use of 3-D technology is becoming so integral to surgery that medical students without the required visual skills may have to consider other specialties.  Optometrists and optometry students understand the importance of 3-D viewing when using the biomicroscope or binocular ophthalmoscope to evaluate ocular structures.  Nanotechnology, fluid dynamics, biochemistry, engineering, aviation, architecture, the military…… all these professions and fields of study are using 3-D technology in design, simulations, research, production, and education.  This list is likely to expand as the technology improves and more creative applications are developed.  As Chris Haws** explained at the symposium, society will be enhanced by the application of 3-D technology far beyond entertainment.  It makes sense to identify those individuals who cannot perceive 3-D images due to undetected visual problems as early as possible.  Treatment will enable them to take full advantage of these applications which are becoming more embedded in their daily lives.

What can we expect as a result of this new partnership?  Educational materials are being developed by both organizations to improve public health and vision and eye health.  In the not too distant future, this partnership may develop public service announcements to be viewed before or after 3-D movies and TV shows.  The public needs more education concerning the importance of 3-D vision to a comfortable and enjoyable experience, the visual problems that can disrupt this experience and the importance of comprehensive vision examinations for children and adults of all ages.

In the meantime, take your children to see a 3-D movie.  If any of them experience any of the Ds of 3-D viewing, consider this a ‘blessing in disguise.”  He or she may have an undiagnosed vision problem which has the potential to negatively impact their lives, in and out of the classroom.  Make sure that child has a comprehensive vision examination.  The sooner these vision problems are diagnosed and treatment is initiated, the better the outcomes.

Here is more information about 3-D viewing:

AOA Press Release on this new partnership

3-D Vision and Eye Health

3-D University

3-D Vision Syndrome or ADHD?

*Michael R. Duenas, O.D. is the Associate Director Health Sciences and Policy for the American Optometric Association, Washington, D.C.

**Mr. Chris Law is a psychologist, filmmaker, and producer with significant 3-D experience.  He is an advisor to the 3D@Home Consortium’s  Human Factors Steering Committee.

 

 

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Eye Movements

Today’s guest blogger is Dr. Ron Berger.  Dr. Berger practices in Ellicott City, MD.  He loves working with children, athletes and individuals with special needs.  When he is not providing vision care, Dr. Berger can be found on the ski slopes and the golf course.  He is also a private pilot and and participates in a volunteer program flying pets to locations in which they can be adopted into new homes.

We don’t often think about eye movements, mainly because as parents we look at our children’s eyes only for appearance and to be certain that we have their attention when speaking to them.  The only time that we look critically at the movement of the eyes is when there is an obvious problem such as turning of one eye outward or inward with respect to the other eye (strabismus) or when “jiggling” (nystagmus) is readily apparent.

However, when examined by a professional, eye movements have much different meanings and consequences.  For example, pediatricians ask children to follow a penlight in all directions of gaze to ensure the existence of neurological integrity, and police officers perform the same test to gauge the loss of reaction time of a driver who has been drinking.

Developmental optometrists view eye movements as insights into how and what a person is thinking.  While reflex eye movements do exist, voluntary eye movements are determined by the brain or the mind of the person.  We do not move our eyes randomly; rather, we move them to that place where we expect to get the most information from whatever we are attending to at the moment.   We might be following the flight of a ball and attempting to determine where it will land so that we may put ourselves into the proper position to catch it.  We might be viewing the landscape before we venture out into the street (look both ways, please).  We might be trying to read and determining where our eyes should land within the line on the page, or where the next line of print begins.

The examiner of eye movements may use tests of performance such as tracking moving objects while watching the actual movements of the eyes, tracking non-moving objects (such as numbers on a printed page) for speed and accuracy, and eye-hand coordination tasks to evaluate how well the person is matching eye movements with hand and finger actions.  In addition, some developmental optometrists may use infrared tracking technology to obtain a graphic record of eye movements during different tasks such as reading.

When eye movements are determined to be less than optimal, noted symptoms such as poor general coordination, poor athletic skills, skipping words and lines during reading, not recognizing the same word even on the same page, and similar behaviors become easier to understand.  Depending upon each individual and the relationship of eye movements to one’s brain and mind, vision therapy may be appropriate.   Vision therapy has a long history of successfully treating such disorders.

Here’s more about eye movements:

Eye movements are linked to academic success

Reading eye movements improve with vision therapy

Watch a video pre-vision therapy and post- vision therapy

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In the News…… 3-D Vision and Health Symposium

There has been a lot of news about the effects of 3D viewing devices on the eyes, especially the eyes of young children.

Through a joint effort of the American Optometric Association and the 3D@Home Consortium, prominent filmmakers and vision researchers will hold a first-of-its-kind symposium on the topic at SUNY College of Optometry, next Tuesday, March 15.

As a practitioner, you may find the symposium interesting and have some compelling questions for the panelists about how the optometric profession can help patients better enjoy 3D viewing, and discuss those eye conditions that can compromise the viewing experience.

The event is free. Find further details and register at http://www.3dathome.org/clinical-symposium-20110315-registration.aspx

More information about 3-D Media and Vision:

Why some people cannot appreciate 3-D movies

Alice in Wonderland and stereoblindness

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The Growing Epidemic of Adult Convergence Insufficiency

Today’s guest blogger is Dr. Mary VanHoy.  Dr. VanHoy practices in Indianapolis, Indiana. Her practice is limited to behavioral/developmental and neuro-rehabilitative optometric care.  She has been practicing for over 30 years and hopes to practice for another 30 years!

This summer I became acutely aware of a growing number of adult patients, predominately female, either self-referred or referred by other health care offices, with complaints of blurred vision, dizziness, disorientation, double vision, and difficulties adjusting to their bifocals or reading lenses.  A careful health history did not reveal any remarkable clues such as a change in medication or recent health challenges.  Some noticed an increase in myopia (nearsightedness) along with the need for a bifocal yet they could not adjust to the bifocal portion.  Another interesting observation was that their ages ranged from the early 40s to early 50s.

Clinical testing usually revealed unaided or correctable 20/20 visual acuities and good ocular health but in carefully evaluating their ability to maintain convergence, it became clear that this particular population had been relying primarily upon their accommodative convergence rather than utilizing fusional convergence to maintain clear, single, binocular (two-eyed) function.

When accommodative convergence is used, the extraocular muscles are being stimulated to point inward by a neurological link to the muscles that control the crystalline lens of the eye in order to change of focus from far to near.  When fusional convergence is used, the extraocular muscles are being stimulated to point inward in order to avoid double vision. Perhaps these patients have relied upon their accommodative systems all their lives and this may account in part for their myopia.  However, their difficulties and symptoms arose when they began to lose the flexibility of their crystalline lens due to aging (presbyopia) and their ability to call upon their focusing system to maintain clear, single, binocular vision began to fail them.

Clinical evaluation of these patients will show that while their eye muscles are certainly strong enough to converge, they do not fully utilize their fusional convergence system but instead rely upon their accommodative convergence system.  Paradoxical findings such as the ability to pass the convergence range tests but difficulties with divergence (relaxing eyes outward) range and the inability to look through plus lenses and still maintain single, binocular vision are definite indicators of this syndrome.  These findings clearly indicate their reliance upon their focusing system rather than their eye teaming system or fusional convergence system.   Using this ineffective response to try to maintain single vision would explain blurred vision, double vision, and dizziness.  They are straining their poor eyes but the over-exertion no longer works for them due to normal aging processes of the eyes.

The good news is that even as adults in their 40s and 50s, the ability to learn how to utilize their fusional convergence system is still viable.  Specific guided visual activities and procedures through optometric vision therapy will allow this population to learn to become aware of where their eyes are pointing and how to aim them closer for near viewing without over-focusing to accomplish this.  So, it is not a matter of building stronger eye muscles but of improved eye muscle coordination and the use of the proper visual system to maintain clear, single, binocular vision for all their visual needs.

Read more about convergence insufficiency:

NEI Video about convergence insufficiency

Important research on the treatment of convergence insufficiency

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Spotlight On…. The Autism College

This post also appears on the VisionHelp Blog.  Help spread the word about the Autism College and Dr. Hillier’s webinar on April 9th.

Chantal Sicile-Kira is a dynamic and fierec advocate for individuals who are on the autistic spectrum.  She has a vested interest in exploring which therapies have proven to be beneficial for autism, and which have not.  Why is Chantal so passionate about giving voice to these issues?  Because she was told when he was little that her son, Jeremy, was severely autistic and to find a good institution for him.  After providing him with the benefit of developmental therapies in California and abroad, Chantal did find an institution well-suited to Jeremy’s needs at age 21.  It’s called “College”.

It is likely this set of experiences moved Chantal to form a different type of college, one that educates parents, families and professionals about therapies making a difference in the lives of individuals with Autism and Asperger’s Syndrome.

I was delighted, therefore, to receive word from our optometric colleague Dr. Carl Hillier that he was invited to be part of the Autism College Faculty.  Chantal has assembled an impressive array of individuals to present continuing education lectures.  They include Joshua Feder, MD, who specializes in  Child and Family Psychiatry and  Neurobehavioral Medicine; Nancy Brady, a special education authority who specializes in the use of Assistive Technology in the general education classroom for those clients with limited communication abilities; and ASD icon Temple Grandin.

On April 9th at 9:00 AM Dr. Hillier will be presenting an invited lecture on-line for the college on the topic of developmental vision issues for individuals who are on the Autistic Spectrum.  Please share this information widely with other professionals and families who will be enriched by what Optometry can offer.

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

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Orthokeratology

Today’s guest blogger is Dr. Stuart Rothman.  Dr. Rothman practices in Livingston, N.J.  He has been a member of the clinical faculty at SUNY State College of Optometry for 30 years.

Orthokeratolgy (also known as ortho k, corneal refractive therapy, corneal reshaping, and accelerated orthokeratology),  is a nonsurgical procedure using specially designed rigid contact lenses to gently reshape the curvature of the eye to improve vision.  Patients wear the lenses while they sleep and remove them in the morning.  Ortho K has long shown promise for allowing myopic (nearsighted) patients to function without contact lenses or spectacles during the day.

Patients active in sports such as swimming, skiing, and contact sports such as football, basketball and hockey all find that being able to perform these sports while seeing well has distinct advantages.  Ortho K doesn’t carry the risks of refractive surgery, can be adjusted if and when the nearsightedness changes, can be stopped or reversed if the patient is not happy with the results, and can be performed on pediatric patients as well as patient considered unsuitable for refractive surgery.  This group includes patients with dry eye or those whose prescription has been changing.

In fact it is this latter group of patient’s who present the greatest promise for orthokeratology.  It seems that patients fit with orthokeratology lenses show myopia progression that is much less than patients fit with either spectacle lenses or soft contact lenses.  Recent research has attributed this to the effect that the lenses have on peripheral retinal focus.  By focusing the peripheral image more than the central image, the lenses seem to be effective on retinal shapes that are most susceptible to continued myopic change.

It is the myopia control potential that drives new patients into offices that do orthokeratology.  Nearsighted children as young as 7 or 8 can be fit, as long as they will allow someone to put the lenses in their eyes.  Since the lenses are worn at night only, parents can be taught insertion and removal techniques as well as the regimen required to care for the lenses.  Parent don’t have to worry about their children wearing lenses on their own and not being able to remove the lenses if a problem develops.

Currently, most lens designs are approved for myopia up to 5 diopters.  The development of new designs may expand the potential for orthokeratology to an even greater population.

Read more from Dr. Rothman about ortho k here.

Watch this news report about  corneal reshaping.

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