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.

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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!  

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Epigenetics

Did you happen to see this article in the New York Times: Why Fathers Really Matter.  This article introduces the concept of epigenetics.  Epigenetics can be defined as “the set of modifications to our genetic material that change the way genes are switched on or off, but which don’t alter the genes themselves.” ¹ Epigenetics helps to explain the relationship between a person’s genotype (the genetic makeup as defined by DNA) and phenotype (physical appearance and traits).  The classic example of this is identical twins.  Identical twins have identical genotypes but different phenotypes.  Their differences become more apparent as they age, because the environment plays an important role in epigenetic modifications.  Research in this field is exploding, because herein lies a key to the relationship between an individual’s genetic code, the environment, aging and disease.

It is now known that epigenetic modifications or marks consist of chemical groups that are stuck onto DNA without changing the DNA.  They sit on top of the genetic code and control the activation and deactivation of genes.  This explains why neurons are so different from skin cells, even though they all contain the same genetic code.  If skin cells divide, they become new skin cells.  All the genes are deactivated except for the ones needed for the skin cells to look and behave like skin cells.

But epigenetic modification can also be very fluid.  These chemical switches on DNA govern protein production—which ones will be produced, when, for how long, how much, etc.

• Think enzymes that control metabolic processes and their impact on health.
• Think hormones and their profound influence on child development.
• Think neurotransmitters that impact learning and the growth of synapses.

In the New York Times article, the author, Judith Shulevitz, describes why she has become obsessed with epigenetics:  “because it strikes me as both game-changing and terrifying.”  Here are two reasons why:

• Epigenetic mechanisms of gene expression and suppression are influenced by the environment.  Our phenotype is not written in the stone of our DNA.  Physical traits, mental status, and the development of disease can be shaped by environmental factors such as the food we eat, the air we breathe, our exposure to traumatic events, and our age.
• Epigenetic modifications are heritable.  A recent journal article cited over 100 examples of epigenetic inheritance, in both animals and humans.

One of the best known example of both of these principles of epigenetics in humans is an epidemiological study of the people living through the “Dutch Hunger Winter” of 1944-45, during which  over 20,000 people died of starvation.  Scientists were able to evaluate the long-term effects of the famine among the survivors, including pregnant women and their children.  If a woman was well nourished during the first portion of her pregnancy but malnourished for the last few months, her baby was likely to have a lower birth weight.  On the other hand, if the baby was conceived towards the end of the famine and the mother was malnourished only during the first trimester, she was likely to have a normal birth weight baby.  This is not surprising, because babies do most of their growing during the last months of a pregnancy.  But long-term effects were very surprising.  The babies that were born small stayed small for the rest of their lives, with lower obesity rates than the general population (Audrey Hepburn was one of these babies).  The normal birth weight babies who were poorly nourished during the first trimester were more likely to become obese as adults.  A major environmental event (the famine) changed the epigenetic programming of the developing fetus.  The epigenetic modifications of the babies that were malnourished during the first trimester enabled them to survive by making the most of a bad situation.  But this reprogramming remained in effect long after the famine that caused it.  It is thought that epigenetic modifications to the genes regulating metabolism resulted in a greater likelihood of becoming obese.  Even more extraordinary was the presence of these effects in future generations.  The grandchildren were more likely to be skinny or obese.  Something that happened to a population of pregnant women affected their children and their children’s children!

While Shulevitz has chosen to describe epigenetics as “game-changing and terrifying,” others view epigenetics as the new frontier in fighting disease.  Epigenetic therapies are already being used to fight various cancers.  The role of epigenetics in depression, autism, Alzheimer’s disease and addiction are being explored.   An understanding of epigenetics may prepare us to face the global obesity epidemic.  The epigenetics revolution is underway, and the implications for patient care today and tomorrow are profound.

1.  Carey N. The Epigenetics Revolution: How Modern Biology is Rewriting Our Understanding of Genetics, Disease and Inheritance.  Columbia University Press: 2012.

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[i] Carey N.  The Epigenetics Revolution. 2012

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It’s All About the Blur

A shout out to COVD members Jeffrey Cooper and Erica Schulman!  Drs. Cooper, Schulman and Jamal just published a review of the development and treatment of myopia.  This evidence-based review of over 200 articles has really got me thinking about the options in treating myopia (nearsightedness).

New theories on the development of myopia are evaluating the role of peripheral retina.  When lenses are prescribed for any type of refractive error (myopia, hyperopia, astigmatism), those lenses put a clear and focused image on the fovea, which is essentially the “bullseye” on the retina.  Whenever we want to see something clearly, we aim our eyes so the image falls on the fovea.  The lenses allow us to see clearly precisely because the image is focused on the fovea.  But those lenses (especially spectacles) have a different curvature than the retina.  The result is a slight defocus on the peripheral retina.  The further away from the central retina you are, the greater the amount of defocus.  This is not something noticeable by the average patient, because the amount of blur is small, and because we don’t notice blur as well in the periphery.  But it seems that our retinas DO notice, because there is significant evidence that this peripheral defocus drives the eye to elongate, and that elongation results in myopia.

Consideration of this body of evidence has resulted in renewed interest in the clinical use of orthokeratology – Ortho-K  (aka corneal reshaping therapy or CRT) to reduce myopia progression.  In addition to putting a clear and focused image on the fovea, orthokeratology fitted contact lenses flatten the central cornea which results in a steepening of the peripheral cornea.  The end result is a reduction in the peripheral defocus on the retina, and therefore a reduction in the drive toward elongation of the eyeball.

After reviewing all the studies investigating Ortho-K and the progression of myopia conducted in the last 12 years, the authors conclude:  “Ortho-K results in an approximately 40% reduction in the progression of myopia.  Its advantages are that it both eliminates the need for daytime contact lens wear and reduces the progression of myopia.  Its disadvantages include cost, risk of infection, discomfort, problems with insertion and removal, and reduced visual acuity as compared to glasses or daily wear contact lenses.  In addition it is difficult to determine which subjects will demonstrate slowing of their myopia and by how much.”

Once again, the science is catching up to clinical practice.  Many developmental optometrists have been aggressively using Ortho-K as one of the possible treatments to slow the progression of myopia.  Renewed interest in the role of peripheral retina in the progression of myopia will lead to more research and more research will lead to better clinical guidelines in the use of Ortho-K.  Developmental optometrists are sure to be at the forefront when putting the evidence into clinical practice.

Read more about Ortho-K here.

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Amblyopia Therapy — It’s No Longer Just For Kids

Amblyopia therapy –” it’s no longer just for kids.”   These are the words used by Dr. Michael DePaolis in a recent editorial in Primary Care Optometry News.  He describes a big moment in optometry, a paradigm shift in patient care.  New research has made it very clear that neuroplasticity in the adult brain is alive and well, and the implications reach far beyond the treatment of amblyopia.  But let’s start with amblyopia.

Dr. Dennis Levi explored the use of action video games to treat adults with amblyopia.  Why would playing action video games be an effective treatment of amblyopia?  “Action game play is extremely varied in its demands and rich in the set of visual experiences it offers.  Thus…. the very act of action game playing seems to train the brain to learn, on the fly, how to make the best use of the available information in the display, independent of the specifics of this display, allowing for the broad transfer of learning.”  Levi had 20 amblyopic adults play action video games with only their amblyopic eye.  All 20 subjects improved.  Levi speculates that video game playing is “arousing and rewarding.” Neurotransmitters such as acetylcholine and dopamine are released, and these neurotransmitters are associated with enhanced neuroplasticity.   Compliance is also enhanced, because action video games are more interesting and fun to play than many traditional vision therapy activities.

Now consider some incredible research by Dr. Elizabeth Quinlan.   Dr. Quinlan’s presentation at COVD’s annual meeting focused on the treatment of amblyopia, specifically on possible mechanisms to enhance neuroplasticity.  She has been recording the electrical response of the part of the brain associated with vision (aka the visual cortex) resulting from different types of visual stimulation.  In one series of experiments, she created amblyopic animals (in this case, amblyopic rats) by occluding one eye for an extended period of time.  The resulting pattern of visually evoked potentials from portions of the visual cortex was significantly altered in a pattern that reflected the lack of visual input from the occluded eye.  When the occlusion was ended and the animals had a chance to receive normal visual experience, this pattern of altered electrical activity in the brains of the rats did not improve.  In other words, there was no neurophysiological recovery when normal visual experience was restored.   That is, there was no neurophysiological recovery until she put these animals in the dark.  After placing these animals in total darkness for 3-10 days, and then providing a short period of “rat vision therapy,” these rats had a complete neurophysiological recovery.  The visual evoked responses from the visual cortex demonstrated a more balanced input from each eye.  The dark exposure enhanced the neuroplasticity of the visual cortex which is the basis for successful treatment of amblyopia.

Are we ready for another paradigm shift in the treatment of amblyopia?  Of course, this research was done with rats and involved recording electrical activity from electrodes placed into their visual cortex.  That is a very long way from clinical trials that might provide evidence of more effective treatment of amblyopia by enhancing neuroplasticity in the human brain after dark exposure.  But I cannot help but wonder …… can we provide a safe environment of total darkness for adult patients to enhance their neuroplasticity and then provide vision therapy programs that utilize action video games?  who will open the first Hotel Amblyopia?

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The Need (part 2)

Dr. Eric Borsting and colleagues are still investigating the diagnosis, treatment and consequences of convergence insufficiency.  The most current research from the Convergence Insufficiency Treatment Trial (CITT) which was presented at COVD’s annual meeting considers the behavioral and emotional problems associated with convergence insufficiency (CI).

Fifty-three children with symptomatic CI were enrolled in the study.  For each child, the parents completed the Child Behavior Checklist (CBCL) and the teachers completed the Connors 3 ADHD Index.  The children were then enrolled in office-based vision therapy programs, and 44 of them completed 16 weeks of treatment.  The parents and teachers then completed the surveys again.

When scores at baseline (pre-therapy) were compared to normative data, the children with CI had more symptoms on both surveys.  On the Connors 3 ADHD Index, the symptoms most frequently reported by teachers were inattentiveness, distractability and giving up easily.  On the CBCL, the symptoms most frequently reported by parents were somatic, such as headaches and eye discomfort.  Children with CI exhibited more symptoms and behaviors associated with ADHD than children with no visual problems.  Following vision therapy, the children showed significant improvement on both scales.  Treatment of convergence insufficiency resulted in a reduction in the behavioral and emotional problems reported by both parents and teachers.

Here’s the take-home message:  if your child has been diagnosed with ADHD or exhibits many of the behaviors associated with ADHD, your child needs a comprehensive vision examination.  If vision deficits are revealed, then vision therapy might be the most appropriate treatment option.  This study is another contribution to evidence documenting the power of vision therapy in the treatment of learning-related vision problems.

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The Need (part 1)

Research presented this morning at COVD’s annual meeting had an uber important message:  we need more vision therapy!  Drs. Lisa Christian, Angela Peddle, and 4th year students Shannon Pennifeod and Beth Schellenberg presented the preliminary results of a very important study.

The doctors and students from Waterloo School of Optometry reviewed the records of young patients, all of whom  had been identified as learning disabled by the district school board.  Before writing an individual education plan (IEP) for each, the school board advised that each student have a comprehensive vision examination performed by the pediatric service of Waterloo School of Optometry.

The records of 68 students ranging in age from 6-12 years were reviewed.  None of them had ever had a previous eye exam.  Children requiring spectacles were not included in the study.  The number of vision problems discovered in this population was astounding.

• 43% had reduced stereo vision
• 67% had binocular dysfunction at near
• 36% had signs of convergence insufficiency
• 38% had deficient accommodative skills

Six measurements of binocularity were obtained; 60% of patients failed two or more of those tests.

Children with reading problems who require individual education plans are at high risk for vision problems. What would have happened if these children were not referred for a comprehensive vision examination?  They would have continued to struggle with undiagnosed vision problems.  We need comprehensive vision examinations for ALL children entering school.  Many of theses children will also require vision therapy.

Does your child have a reading or learning disability?  Please make sure that child has a comprehensive vision examination.  Make it happen.

Find a doctor in your area.

Read more about comprehensive eye examinations here.

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We Can Get Better at Everything

Dr. Sue Barry was recently interviewed by NPR for their NOVA web series called “The Secret Life of Scientists and Engineers.”  Her experiences with vision therapy and learning to see in 3-D were life-changing.  Neuroplasticity is the mechanism through which we CAN get better at everything.  Anyone. Any age.

Watch Dr. Sue Barry: The Secret Life of Scientists

Read more about neuroplasticity here and here.

 

Then watch Dr. Barry tell a joke.

 

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The Science: Performance-Related Symptoms

Convergence insufficiency (CI) is a common visual disorder that is characterized by great difficulty maintaining binocular eye alignment when looking at something close up (such as a book or a writing assignment).  This landmark study, funded by the National Eye Institute, provides strong evidence that office-based vision therapy is the most effective treatment for CI.  Treatment success can and should be measured 2 ways: objectively (looking at changes in measurements used in the diagnosis of CI) and subjectively (looking at changes in symptomology associated with CI).

The Convergence Insufficiency Symptom Survey (CISS) was developed to quantify the frequency and severity of symptoms reported by patients with CI.  The 15 symptoms on the CISS can be divided into 2 categories: performance- related and eye-related.  There are 6 performance-related symptoms evaluating visual efficiency when reading and/or performing near work:

• Loss of place
• Loss of concentration
• Having to re-read
• Reading slowly
• Trouble remembering what you read
• Getting sleepy when reading

The 9 eye-related symptoms include blur, headaches, double vision, tired, sore, uncomfortable eyes, words that move and jump, and pulling sensations around the eyes.

This study evaluated the symptomology of children with Convergence Insufficiency before and after optometric vision therapy.   Before vision therapy, the six most frequently reported symptoms were the six performance -related items. Fifty percent of all the children in the study responded “fairly often or always” when asked if they lose their place when reading.  Similarly, 45% of the children reported loss of concentration and having to re-read; 40% read slowly; 38% have trouble remembering what they read; and 37% get sleepy when they read.

Children with parent-reported ADHD (attention-deficit hyperactivity disorder) had significantly higher symptom scores on the CISS and the higher score was almost entirely attributed to an increase in the frequency and severity of these performance-related symptoms.

The good news is that ALL the children who responded to treatment reported a decrease in ALL their symptoms.  And while this study did not look at academic performance, the authors do note this relationship when they state: “the treatment of symptomatic CI may have a positive impact on reading performance and attention.”

What is the take home message?  If your child has a convergence insufficiency, it is important to consider both eye-related and performance-related symptoms.  Your child may not be complaining of blurred or double vision, but they still might have performance-related symptoms.  Loss of place, re-reading, poor reading comprehension, slow reading, sleepiness, poor concentration….. am I describing your child’s symptoms?  Have you considered a vision problem as a possible explanation?

Read more about convergence insufficiency here.

Reading more about vision and ADHD here.

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Dr. Harold Solan — Visual Attention and Reading

Dr. Harold Solan received the Skeffington Award in 1990.  At that point, his body of work was quite impressive.  But he was only getting started!  He continued his research, writing and scholarship for many more years.  In many ways, his post-Skeffington Award work was even more influential.  It is very difficult to choose one “topic” or article to highlight his contributions to developmental optometry.  I suppose I shall have to write more about Dr. Solan’s work. 

Dr. Harold Solan

Attention is often defined as the ability to focus on relevant stimuli as well as a decrease in responsiveness to irrelevant information.  In reading, visual attention increases the ability to read efficiently across a line of text.  Readers must learn to use the oculo-motor system to move their eyes accurately.  First they must focus on the first word on the line, then they must shift their attention to the right as they prepare to move their eyes to the next fixation point, then they must sustain their attention in order to allow for processing of the text.  These three principal elements of attention–focus, shift and sustain—are the link between perception and cognition.  Perception makes the visual information available but not necessarily recognizable.  Cognitive processes allow the reader to use the visual information in order to gain meaning.  In other words, reading comprehension is dependent upon visual attention as expressed by accurate oculo-motor control.  Therefore, vision therapy that is directed at improving focus on relevant stimuli, shifting attentional focus within a complex visual environment, and sustaining attention for an appreciable interval might be expected to improve reading comprehension.

Dr. Solan and colleagues investigated this relationship in a group of 6^th graders with moderate reading disabilities.  These students attended public school in New York City.  On a standardized reading test, their reading comprehension scores averaged 2.2 years below their grade level.  The students’ attention skills were assessed using a standardized testing battery.  Then they received 12 one-hour sessions of vision therapy.  The therapy consisted of specific procedures which were aimed at improving or enhancing focusing, shifting and sustaining visual attention during oculo-motor (eye movement) activities.  After completing the 12 hour therapy program, the students were retested with both the standardized reading and attention tests.  Their scores improved significantly on both measures.  After 12 hours of vision therapy over 5 months, their average reading scores jumped an entire grade level, from the 4^th to 5^th grade level.  This is in sharp contrast to the first 5 years of schooling, when their reading scores improved from a 1^st grade to a 4^th grade level.

Dr. Solan’s research supports the notion “that a link exists between visual attention, oculomotor readiness, and reading comprehension…”  He acknowledged that uncertainties still exist.  For example, the therapy also incorporated memory, speed of processing and executive functions.  How does the engagement of this triad influence cognitive performance and reading comprehension?  Dr. Solan’s research always answered BIG questions but at the same time, left more questions to consider.  That way, he never ran out of ideas for his next research project.  Now, he has left these unanswered questions for others to consider.

Read more about eye movements here.

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