Children with refractive amblyopia often go undetected because their eyes are straight and they don’t have much difficulty with the “activities of daily living.” When told that they need to wear glasses full-time, this is often quite a shock. Add in the need to wear a patch for several hours a day, and not surprisingly, compliance with this treatment protocol is poor. But wearing the lenses and patching is the “backbone” of amblyopia treatment and little or no improvement can be expected if this is not done…… at least that is what “conventional wisdom” has told us to expect. What this traditional approach to amblyopia treatment fails to recognize is that amblyopia is a BRAIN problem and not an eye problem. If a child’s binocular (eye teaming) skills can be improved, this is often accompanied by an increase in visual acuity and other monocular visual skills of the amblyopic eye. In some cases, these improvements also lead to a reduction in the anisometropia (or difference in lens power between the two eyes) and an associated reduction in the lens power required in spectacles to maximize visual acuity. Press and Press have termed this treatment “reverse engineering of hyperopic anisometropic amblyopia.” Everyone is a winner if this can be accomplished. The amblyopia is successfully treated, the need for eyeglasses is reduced, the cosmesis of the eyeglass prescription is enhanced, and the patient is more compliant during the therapy process.
In the article recently published in Optometry and Vision Development, Drs. Press and Press present a case report that includes the use of Visual Evoked Potentials (VEPs) to measure the brain’s response to visual stimuli under different conditions. They were able to compare the VEPs with and without glasses, with different prescriptions, and before and after completion of an optometric vision therapy program. As the visual skills of this 4 year old girl improved and her reliance on the glasses was reduced, her brain’s responses to visual stimuli was significantly enhanced. The average increase in the amplitude of the VEPs increased by 103% post-vision therapy!! The VEPs also demonstrated that when presented with smaller, more detailed visual targets, her brain’s response was increased when she wore a minor prescription. Therefore, at the end of vision therapy, it was decided that it would be in her best interest to wear the glasses when engaged in extended reading and other near activities, but not during outdoor play or watching TV.
Kudos to Drs. Press and Press for using science to demonstrate what we know to be true in clincal practice. Not only were they able to measure changes in brain activity with optometric vision therapy, but they were also able to determine the best prescription for this young child. The reverse engineering of the hyperopic anisometropic amblyopia was a documented success!
Read more about amblyopia here.
Here is another article about approaches to amblyopia therapy.
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Thank you to Dr. W.C. Maples — who quoted mama during his presentation at COVD’s annual meeting to remind us of the importance of prevention in health care. Dr. Maples was discussing infantile esotropia: an eye that turns inward that presents at a very early age, usually at about 4-6 months of age. When the eye turns in, the young child begins to make significant adaptations and changes in the way he or she processes visual information. Often the child is diagnosed with a triad of clinical conditions: esotropia (inward turning eye), anisometropia (difference in the refractive status between the eyes) and amblyopia (reduced visual acuity and visual skills in the turned eye). Treatment of this triad of visual dysfunctions is based on the development of binocularity: teaching the child to use both eyes together. The development of binocularity will create a cascade that also reduces the anisometropia and amblyopia.
But what if we could prevent the development of the esotropia and the associated amblyopia and anisometropia? Dr. Maples conducted research that reviewed the medical records of children with infantile esotropia. He and his colleagues were able to identify 26 risk factors that predispose children to develop esotropia at this early age. These risk factors include premature birth, a family history of esotropia, cardiac or other systemic disease, low birth weight and maternal high blood pressure during the pregnancy. If your baby has any of these risk factors, you can provide visual stimulation to your baby and reduce the likelihood that your baby will develop an esotropia.
What types of activities should you be doing with your baby? Engage in face-to-face activities with your baby, and make sure you do these activities in all different directions. Babies love human faces. Talk to your baby and move slowly to one side and then the other. Make a mobile to hang over the baby’s crib with black and white photographs of faces. Move the baby’s crib to different parts of the room. Find a crib bumper with checkerboard or other high contrast patterns. Movement should be a big component of playtime with baby. Even if your baby cannot yet sit up or roll, make sure the baby has plenty of room to move arms and legs. As the baby matures, be sure to provide enough room to freely move about and explore the environment. Take field trips to the mall, the park, grandma’s house and down the city streets to provide a diversity of visual stimulation from all directions: over, under, in front, behind, left and right. At home (or at the beach), place your baby on top of a beach ball and gently roll the beach ball, to get the vestibular and visual systems talking to each other. Basically, play with your baby and keep things moving! In fact, this is good advice for all parents, not just those with babies with a higher risk of developing infantile esotropia. Visual experience is a critical component of every baby’s development.
Dr. Maples pointed out that there are three components to child development: genetics, maturation, and experience. There is little that can be done to change genetics and maturation. By focusing on the experience, we can shape a child’s development and perhaps prevent the onset or lessen the impact of many dysfunctions and disorders. Mama is right – an ounce of prevention is worth a pound of cure.
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Congratulations to Dr. Selwyn Super, on becoming an FCOVD-A; Academic Fellow of the College of Optometrists in Vision Development. Dr. Super began his optometric career in South Africa. He has been a key player in advancing the profession of optometry world-wide. He has traveled extensively to both learn more and share his knowledge about optometry, vision, and its interface with other disciplines and professions.
Dr. Super has a deep appreciation for the importance of collaboration and research for any profession to “develop and thrive in a world of continuous and accelerating change and demands.” For example, how do certain visual functions change with age? This clinical question has become more emergent with the aging of the “baby boomer generation” and the increasing prevalence of degenerative processes, such as Alzheimer’s Disease. By using technology, it is easier than ever for clinicians to collectively gather normative information. Only then can the clinician make well-informed decisions about treatments and their expected outcomes.
I just re-read Dr. Super’s publication on the “spiral curriculum in optometric education.” Although it was written more than 20 years ago, it still rings true today, especially as the schools and colleges of optometry are faced with an ever-expanding knowledge base, new technologies, and an unfathomable need for eye and healthcare around the world. “Optometric education should set out to integrate knowledge, skills, intentions, and attitudes from the inception and should make excellence in human relations as well as in clinical and practice skills, its major goal. The philosophy of optometry and optometric education should encompass a willingness and commitment to change so as to adapt to new knowledge, scientific discovery, technologic advances, a changing environment and changing human needs.” Well said, Selwyn.
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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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Posted in Brain Plasticity, In The News, Research, Sports, Traumatic Brain Injury, Vision Therapy, tagged "vision therapy", concussions, Eye Movements, football, King-Devick Test, sports, trauamtic brain injury on February 17, 2011 |
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Today’s guest blogger is Dr. Robert Fox. Dr. Fox graduated fromSUNY-State College of Optometry in 1985, after which he completed a residency in Rehabilitative Optometry at the Northport VA Medical Center. He is in private practice in Schenectady, NY, and also consults on brain injury related vision problems at the Sunnyview Rehabilitation Hospital in Schenectady. When not busy at his practice Dr. Fox likes to snowboard, play hockey, and golf.
A recent article in USA Today, highlighted the use of a simple eye test in the detection of concussions. The test, known as the King-Devick test, is a test for eye movement speed and accuracy. The goal of the test is to read lines of numbers off a page as quickly as you can. Research conducted at the University of Pennsylvania School of Medicine has shown that poor performance is a confident indicator that a concussion has occurred.
Awareness of concussions has grown rapidly over the past few years. Professional and scholastic athletes are now being required to sit out much longer than in the past to recover from severe blows to the head. Blows to the head are not limited to football. As an optometrist who consults with a local bring injury rehab center, I have seen injuries in activities such as hockey, lacrosse, gymnastics, dance (yes, dance), and soccer. One of the most important aspects of this new article is the connection between vision function and brain injury. Even mild concussions can cause major visual function problems. These can include:
*blurred vision – especially when reading
*headaches associated with reading
*poor reading comprehension
*frequent loss of place when reading
For the student athlete, these symptoms can have a huge effect on learning and school performance. These vision problems can also linger months after the initial pain and headaches associated with the concussion have gone away. The most common causes of these problems are a convergence insufficiency (eyes that don’t work well together at near) and/or accommodative (focusing) insufficiency following the injury.
The good news is that these vision problems respond well to optometric intervention. The King-Devick test is just one of a larger battery of tests designed to evaluate eye function and the integrity of the vision system. Treatment usually consists of a combination of glasses for reading and optometric vision therapy. These treatments allow the student to return to their academic activities much sooner than just waiting for things to clear up on their own.
Further information on vision therapy and brain injury is available from the College of Optometrists in Vision Development and the Neuro-Optometric Rehabilitation Association.
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