The Science and Splash are Back

So today, let’s talk science.  I recently had a conversation with a well-known pediatric neuropsychologist in my area. She is a very caring and competent practitioner by all counts.  She expressed some concerns about referring patients to me.  She said while she felt the science would validate vision therapy in the future, she did not feel that there was enough scientific evidence currently demonstrating the relationship between the vision problems we treat, such as Convergence Insufficiency, and academic performance.  She felt that the science certainly shows that functional vision problems exist and that vision therapy would help alleviate discomfort associated with these vision problems, but that the science did not yet show that treating these vision problems would impact school performance.

I was happy to report to her that the future is here.  In fact, I would like to dedicate the next several “Science” posts to the great research being done showing the correlation between vision and academic performance.

The article I would like to focus on today was written by the same authors of the Convergence Insufficiency Treatment Trial.  In this original research article sponsored by the National Institute of Health these scientists validated what so many of us have known for a long time.  Convergence Insufficiency and many other functional vision problems not only exist but cause a host of problems such as double vision, headaches, eye fatigue, slow reading and poor reading comprehension.   The treatment trial found that in-office Optometric vision therapy is by far the best treatment to alleviate these symptoms.  After completing this research, I am sure they must have encountered some of the same skepticism elicited by my colleague.

Their latest research article found in the journal of Optometry and Vision Science demonstrated that children with symptomatic Convergence Insufficiency showed significant improvements in reading comprehension after being treated with vision therapy. To see  the article click here.  Sounds like an academic performance link to me.   However, their research is by no means the only research out there.  I am happy to report I was able to send many other research articles as well to the practitioner in my area and have to say that she responded very favorably.  I am excited to share more of these research articles with you in the coming weeks.  Stay tuned…

For more information on vision problems that affect school performance, learning, and reading please visit the COVD website at www.covd.org.  To find a developmental optometrist near follow this link.

I hope to be blogging here more often.  I want to give a shout out to all of the COVD blog authors who put in so much time to getting the word out about how vision can impact the lives of so many.  Especially a thank you to Dr. Rochelle Mozlin whose dedication to this blog has helped the lives of many seeking to learn more about these critical and often silent vision problems.

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Another Approach to Treatment of Refractive Amblyopia — The Science

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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100,000 Saccades per Day

Saccades are eye movements from one object of regard to another.  These “jump” eye movements allow us to fixate objects with the fovea, which is the part of the retina that we use to discriminate details and determine, “what is this.” Reading across a line of printed words requires a series of saccades and fixations. First we make a saccades to bring our eyes to the first word in the sentence, then we fixate to allow our brains to process what we are seeing, then we make another saccade to a point a little further along in the sentence and once again fixate to allow our brains to process the visual information.  Saccade-fixate-saccade-fixate.  This pattern continues for as long as it takes to complete the reading .  But saccades aren’t only about reading.  They are the basis for using vision in everyday life.  Every time we want to “look” at something, we have to make a saccade to bring that something onto our fovea.  Saccade-fixate-saccade-fixate.  This happy dance continues all day long.  On average, we make 100,000 saccades per day.

What if you had difficulty with saccadic eye movements?  What if it took you a little longer to make that saccade?  Or you were inaccurate and your eyes landed in the wrong place? Or this put additional stress on your binocular system because you had difficulty coordinating the eyes during saccades?  And now imagine making these errors 100,000 times a day.  The happy dance is no longer very happy.  Welcome to the world of the learning disabled child.

At the annual meeting of COVD, Dr. Zoi Kapoula presented a distillation of her years of work studying saccadic eye movements.  This included the evaluation of the saccadic eye movements of a group of dyslexic children during “real text reading;” recording eye movements as their eyes moved in a sequence of fixations across the text.  The dyslexic children made more saccades, more regressions (moving their eyes backward along the line of text instead of forward), and it took them longer.  In addition, they had more difficulty keeping their eyes properly aligned during the reading task.  This resulted in greater stress on their binocular systems in an attempt to prevent the words from going double.  Dr. Kapoula concluded that these inefficiencies might complicate letter or word recognition processes and “supports the suggestion that besides impaired phonological processes, a visual/oculomotor deficit exists in dyslexics that might perturb the fusional process. “  That’s the double whammy.  Poor eye movements not only make it difficult to read, but make it more difficult to maintain binocular vision while reading which also makes it hard to read.  It’s the proverbial downward spiral.

But there is hope.  Research has shown that vision therapy can be effective at improving both eye movement and binocular skills.  These improvements in visual skills can translate to better academic performance.  It’s time to get your child’s visual “happy dance” back on track.

Percy has great dance moves and eye moves!

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The Science – Vision problem or ADHD?

I have just spent sometime venturing through the blogosphere of mothers with children with ADHD.  I was so impressed with these brave women that write about their experiences, triumphs, and challenges in raising their children with ADHD.  Many of their accounts truly broke my heart.  This is an excerpt from Penny Williams blog “A Mom’s View of ADHD” where she describes her experience of trying to find a good fit for educating her son with ADHD:

“I live in search mode these days, ever since my son Luke, age nine, was diagnosed with ADHD in 2008. I am searching for the medication, therapy, classroom accommodation, product that will make his life with learning disabilities a little easier. I guess you could say I’m searching for the magic bullet, but I don’t think that’s really accurate anymore. It was true the first year or two — I was looking for an “answer,” something to erase his ADHD symptoms. Then I realized that that “something” doesn’t exist. I didn’t think I was looking for a cure for ADHD because I knew that’s not possible, but that’s exactly what I was searching for nonetheless.

My focus in my search now is different, more refined. I am searching for tools to help him compensate for his differences, for environments where he can learn and prosper, parenting methods best suited to his needs, treatments that teach him the skills necessary to have a happy, successful life despite ADHD (and dysgraphia, SPD, Executive Functioning Deficits, and a gifted intelligence). This search is intense and stressful for me, his parent. There’s a lot of {self-inflicted} pressure to be diligent to find all opportunities and to make choices that will only have positive outcomes. In the area of making appropriate choices that lead to positive outcomes, I have failed miserably this year.Luke has struggled in school since the day he walked into kindergarten. Yes, the very first day. While it should improve each year with treatment, maturity, growing self-awareness and a diligent advocacy for accommodations and resources in school, it has not improved for Luke. I feel like we have been standing in the same place for three years, paralyzed, while the world continues to move on all around us. In our minds, we’re moving and working, but we’re getting nowhere.

That feeling of helplessness became overwhelming to me earlier this year. I fought hard with the school but mostly we just received lip service. I watched Luke struggle to fit in an environment that was clearly the opposite of what he needed. I knew he needed more help. I had to find that for him. ”

I think Penny encapsulates the very real struggle that many parents go through that have children with ADHD.  As a developmental optometrist I work everyday with children that have been diagnosed with ADHD.  I see in their parents’ eyes the same sentiments shared by Penny.  While I do not claim to have a magic bullet, I do have tools that have helped many of of my patients that have vision problems that can often mimic or complicate ADHD.

Dr. David Damari, Developmental Optometrist and Fellow of the College of Optometrists in Vision Development wrote a great research article, “Visual Disorders Misdiagnosed as ADHD,” that gives several great case studies of patients with ADHD  who had developmental vision problems. He speaks in the article of how similar the symptoms are for children with common developmental vision problems and those of children with ADHD.  He also describes in detail case studies of children that were misdiagnosed with ADHD and instead suffered from vision problems that affected their ability to perform well in school, learn, read, and maintain their attention.  He also references other research that shows the correlation between ADHD and Convergence Insufficiency, one of the leading developmental vision problems in children.

Probably, though most compelling are the stories from parents whose children were misdiagnosed with ADHD.  Here is a story from the parent of a child from the website, “Vision Therapy Success Stories”:

“Recently, “Sarah” came into the office just to talk to Dr. X. She was so excited .she was no longer struggling with reading and schoolwork and couldn’t wait to thank him. She is no longer taking Ritalin and is doing well in school.

Prior to seeing Dr. X, Sarah struggled to do the work required of her in high school. She found reading burdensome, was unable to finish her homework in a reasonable amount of time, and was unable to keep up with all her assignments. She was feeling frustrated and discouraged. Sarah had been put on Ritalin in order to help her focus on her work, but she continued to struggle.”

Bottom line, if your child is stuggling with attention in school, check to be sure there is not a vision problem.  To find a Developmental Optometrist near you that can diagnose and treat these types of vision problems, please follow this link.

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An Ounce of Prevention

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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The Science – A Glimpse into our Children’s Vision

As I go out and speak with parents, teachers, and doctors, I am almost invariably asked one question.  How can we do a better job of detecting vision problems in our children?  It really is a great question when you consider the following grim statistics:

• One in four children have a vision problem that can affect learning¹
• 60% of students identified as problem learners have undetected vision problems²
• 64% of children ages five and younger have never had their vision screened by a healthcare professional³
• 32-63% of vision problems identified by comprehensive eye examinations were missed in school screenings⁴

Looking at the scope of the problem, anyone can see that this issue is not going to be solved overnight.  Enhanced vision screenings in our schools, more children receiving comprehensive vision exams before entering school, and educating the public on how vision can affect school performance; these are large-scale efforts currently underway by many of COVD’s members throughout the country.  However, there are things each of us can do to help those children we work with everyday.

One great tool we have is the Convergence Insufficiency Treatment Trial (CITT) Symptom Survey.  Other than being a mouthful, this checklist represents one of the great accomplishments of evidence-based medicine.  In 2008, the Archives of Ophthalmology published the results of research sponsored by the National Institute of Health on the treatment of  Convergence Insufficiency, one of the leading vision problems in children.  This condition is often associated with headaches, double vision, and eyestrain.  The study concluded that for an overwhelming majority of these children, the condition is very treatable.

From that study, we have gleaned the CITT Symptom Survey.  In a matter of a few minutes we can now screen children with a tool that is highly predictive for both convergence insufficiency and other functional vision problems⁵.  This one-page symptom survey can easily be filled out as part of the intake process in any office or can be sent home with parents.  It is quick, easy to score, and communicates to parents the types of vision struggles their child is having.   Here is a copy of the CITT Symptom Survey.

Unfortunately, we can’t see through a child’s eyes.  The CITT symptom survey at least gives us a glimpse.

1. Comprehensive Eye Exams Particularly Important for Classroom Success. (2008, August 4). American Optometric Association.

2. ADD/ADHD and Vision. (2011).  College of Optometrists in Vision Development

3. Cotch, M. (2002). Visual Impairment and Use of Eyecare Services and Protective Eyewear Among Children. USA Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 425-429.

4. Danahuse, S. P., Johnson, T. M., & Leonard-Martin, T. C. (2000). Screening for Amblyogenic Factors Using a Volunteer Lay Network and the MTI Photoscreener: Initial results from 15,000 Preschool Children in a Statwide Effort. Ophthalmology, 1637-1644.

5. Rouse, M., Borsting, E., Mitchell, G., Cotter, S., Kulp, M., Scheiman, M., et al. (2009). Validity of the Convergence Insufficiency Symptom Survey: A Confirmatory Study. Optometry and Vision Science, 357-363.

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Congratulations, Dr. Super

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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Congratulations, Dr. Shin

Congratulations to Dr. Hoy Sun Shin, on becoming an FCOVD-A; Academic Fellow of the College of Optometrists in Vision Development.  Dr. Shin is a full-time member of the faculty at Yangsan College in Yangsan City, South Korea.  She has been conducting research investigating the efficacy of vision therapy for children with binocular and accommodative dysfunctions.  Most of her research began with a screening process to identify children with  visual dysfunctions by using a “quality of life” questionnaire.  Parents were asked to describe the degree to which their children exhibited certain symptoms associated with vision problems, such as difficulty copying, headaches when reading, and/or poor reading comprehension.  Children with more symptoms, either in frequency or intensity, were then given comprehensive vision examinations to determine if there is a vision problem contributing to these symptoms.  Dr. Shin has conducted numerous investigations with these results:

• A large percentage of the children with symptoms of vision problems did indeed have binocular and accommodative dysfunctions.
• The children with visual dysfunctions did not perform as well on academic achievement tests when compared to visual “normal” children.
• Vision therapy was effective at improving visual function and reducing symptoms in these children.
• A year after completing vision therapy, the children retained these improvements in their visual skills as well as the reduction in symptoms.

Thank you, Dr. Shin for this valuable research.  Here is more evidence that children with poor visual skills are at a disadvantage in the classroom (and in life!) and that vision therapy is an effective treatment modality.

Dr. Shin is looking forward to further research to expand the evidence-base.  She is already evaluating the visual skills of a popuation of children diagnosed with ADHD.  We know that she is going to be a highly valued and contributing member of COVD with influence in Asia and around the world.

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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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There’s More to Concussions than Meets the Eye

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

*double vision

*eye pain

*poor reading comprehension

*light sensitivity

*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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