The provision of eye care to these children was very collaborative and very flexible.  The children were accompanied to the eye examination by either their occupational, physical or speech therapist.  The therapists’ presence was very comforting to many of the children, and often they were able to assist during the examination process.  The therapists often made suggestions on how to modify procedures in order to obtain responses or helped prepare the children for the examination experience.  They were also instrumental in facilitating communications between doctor, parents and teachers.  If a child was having a “bad day,” or follow-up care was needed, a 2^nd appointment was scheduled.

Research has shown that children with special needs have a higher incidence of vision problems, and this population was no exception.  More than 10% of the children required glasses; 6% had strabismus, and 3.7% had amblyopia.  An additional 2.5% were referred for additional evaluation for potential ocular health problems.  ALL children with special needs should have comprehensive vision examinations ASAP!  Dr. Bodack’s research has reaffirmed this.

Many children with special needs are unable to express their discomfort or explain their symptoms.  Their comorbidities often require large investments of time and money to manage.  The examination of pre-school children with special needs is often difficult.  Therefore, they do not receive the comprehensive vision care that they desperately need, and their vision problems remain undiagnosed.   This project is an example of what can be accomplished when the services are brought to these children instead of waiting for them to seek care.  The interdisciplinary environment facilitated the diagnosis and management of vision problems at an early age.  Most importantly, communication between optometrist, therapists and teachers created a better understanding of each child’s visual functioning and how to help that child reach his or her full potential.

Read Dr. Bodack’s description of the characteristics of strabismus here.

Read more about autism and vision here.

Fourteen minutes into the interview, Dr. Ciuffreda refers to the 1961 study by Dr. William Ludlam on “The Orthoptic Treatment of Strabismus: A Study of 149 Non-Operated Unselected Concomitant Strabismus Patients Completing Orthoptic Training at the Optometric Center of New York.” In this study of the effectiveness of vision therapy (orthoptics) for the treatment of strabismus, 76% of the patients achieved a “functional cure.”

That rang a bell somewhere in the optometric filing cabinet inside my brain, and I went in search of “Flom’s Criteria.”  Published in 1958 in the American Journal of Optometry, Dr. Merton Flom discusses “The Prognosis in Strabismus.”   He begins that discussion by distinguishing between a functional cure and a cosmetic cure.  After all, how can you determine the prognosis for a certain treatment unless you know what it is you hope to achieve with that treatment.

A functional cure of strabismus restores normal binocular vision to the patient: clear, comfortable single vision at all distances, stereopsis (depth perception), and the ability to maintain binocular vision 95% of the time when moving the eyes through the world in 3 dimensions.  The patient may require lenses and even small amounts of prismatic correction to achieve this functional cure.

Dr. Sue Barry, who achieved a functional cure for her strabismus at age 50 through a vision therapy program, describes her experience:  “For the first time, I could see the volumes of space between different tree branches, and I liked immersing myself in those inviting pockets of space. As I walk about, leaves, pine needles, and flowers, – even light fixtures and ceiling pipes – seem to float on a medium more substantial than air. Snow no longer appears to fall in one plane slightly in front of me. Now, the snowflakes envelope me, floating by in layers and layers of depth. It’s been seven years since I gained stereovision, but ordinary views like these still fill me with a deep sense of wonder and joy.”

The prognosis for a functional cure is dependent upon many factors:  does the eye turn in or out, all the time or intermittently, is there amblyopia or other adaptations to the eye turn, is the magnitude of the eye turn large or small, how motivated is the patient to achieve a functional cure? In some cases, the prognosis for a functional cure is poor, or vision therapy has been unsuccessful.  Then the discussion changes to considering a cosmetic cure.

A cosmetic cure occurs when the strabismus is no longer noticeable.  A functional cure invariably includes a cosmetic cure, but a cosmetic cure does not assure a functional cure.  A cosmetic cure is the goal of strabismus surgery, and more often than not, this can be achieved.  However, without improved function (a functional cure), the cosmetic cure may not last.  The eye turn may return at some point, and a second surgery may be recommended.

When considering the options to “cure” your strabismus, first consider what type of cure you hope to achieve.  Which options are more likely to help you and what is the prognosis for achieving that goal?

Dr. Flom summed it up quite well…..

“When the prognosis is based on good judgement and is tempered with an evaluation of the patient as a human being, it becomes an invaluable aid in recommending the kind of treatment for a strabismus.”

Read more about strabismus here.

Optometry & Vision Development (OVD)

Aurora, OH – The most recent issue of Optometry & Vision Development (OVD), the official journal of the College of Optometrists in Vision Development has research and other articles that may surprise the general population. Did you know that a simple pair of glasses can significantly improve your quality of life? Researcher, Dr. Janis Winters of the Illinois College of Optometry/Illinois Eye Institute, in her paper, Vision Related Quality of Life among Urban Low-Income Black Seniors Participating in an Eye Care Program: Effect after New Spectacle, has shown that poor, elderly, under-represented minorities show a significant and positive change in the individual’s perception of their overall quality of life. When the National Eye Institute Visual Function Questionnaire was given to the participants before and after spectacle wear a significant difference was found with wearing the glasses. The general health, general vision, ocular pain, and distance activities, as well as near activities, social functioning, color vision, peripheral vision, and mental health subscales compared to first administration of the survey were also significantly different when the spectacles were worn. This paper strongly supports how an individual’s quality of life can improve just by wearing glasses. It is unfortunate that so many cannot afford or do not have access to optometric eye and vision care.

In this same issue of OVD an article by Dr. Marie Bodack, Eye and Vision Assessment of Children with Special Needs in an Interdisciplinary School Setting, found that during a three year period of the 273 children with special needs who received eye examinations (about 1/3 of the children had been diagnosed with autism), 3.7% had amblyopia (lazy eye), 6% presented with an eye turn, and 11% had refractive errors (nearsightedness, farsightedness, astigmatism) requiring correction. Approximately 2.5% were also referred for additional care because of ocular health problems. This paper supports the need for all with special needs to have comprehensive eye care by an optometrist.

And finally, Dr. Dominick M. Maino, OVD editor, wrote in his editorial, 3D in the Classroom: See Well, Learn Well, that the American Optometric Association’s (AOA), The 3Ds of 3D Viewing is great advice for the consumer. If you experience the 3Ds of 3D viewing (Discomfort, Dizziness and lack of Depth, when viewing 3D movies, television, video-games and 3D educational content), you should incorporate 2 more Ds – See your Doctor of Optometry, especially one who is a Fellow of the College of Optometrists in Vision Development (COVD). Dr. Maino also emphasized the AOA’s recognition of the vision problems that cause the difficulties often associated with 3D viewing as a major public health issue. Although the research is just now beginning to be conducted in this area, it appears that problems with focusing, eye teaming and eye movement ability all play a role in the discomfort, dizziness and lack of depth experienced by those viewing simulated 3D. These binocular vision dysfunctions often affect not only how we enjoy our free time, but also how well we perform in school. The good news is that if you have these problems, those who belong to the College of Optometrists in Vision Development have vision rehabilitation/therapy programs available so that you can enjoy all that 3D has to offer.

This issue of OVD also has practice management articles, as well as photographs and information about COVD’s annual meeting recently held in Las Vegas.

About Optometry & Vision Development

Optometry & Vision Development (OVD) is a peer-reviewed open access journal indexed in the online Directory of Open Access Journals. The full text of these articles is available free from www.covd.org. OVD is an official publication of the College of Optometrists in Vision Development. Any questions may be addressed to the editor, Dominick M. Maino, OD, MEd, FAAO, FCOVD-A at dmaino@ico.edu or 312-949-7282.

About COVD

The College of Optometrists in Vision Development (COVD) is an international, non-profit optometric membership organization that provides education, evaluation, and board certification programs in behavioral and developmental vision care, optometric vision therapy, and visual rehabilitation. The organization is comprised of doctors of optometry, vision therapists, and other vision specialists. For more information on learning-related vision problems, optometric vision therapy, and COVD please visit www.covd.org or call 888.268.3770. 

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!

“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.

Colt McCoy is the quarterback for the Cleveland Browns.  In a game against the Piittsburgh Steelers on December 8, McCoy took a vicious helmet-to-helmet hit.  McCoy was laid out on the turf and was taken out of the game, but was allowed back in the game after missing 2 plays.  According to the coach, McCoy did not complain of any symptoms of a concussion and the medical staff followed all NFL guidelines.  The concussion was not diagnosed until after the game, when he began to show classic signs and symptoms.  The Browns’ medical and coaching staff had a myriad of excuses for not, at the very least, showing more concern for McCoy’s health and the possibility that he had suffered a concussion.  Anyone witnessing the hit and McCoy lying on the turf should have stepped up and demanded an appropriate evaluation.  Any way you spin it, there is no way McCoy should have been allowed back in the game.

Sidney Crosby plays hockey for the Pittsburgh Penguins.  He is considered by many to be the best player in today’s NHL.  Crosby suffered a concussion in January 2011 and did not play for the rest of the 2011 season and for the first 20 games of the 2011-12 season.  Last week his concussion symptoms returned after being elbowed in the head.  He is out indefinitely.  Some wonder if this is the end of his career.

These events have gotten significant attention,  because they involve professional athletes.  But the risks to young athletes are no less.  Young men and women playing football, soccer, hockey, wrestling, and other sports are suffering from concussions and their aftermath everyday!  High schools and youth athletic programs don’t have the resources available to professional sports.  Parents and coaches must educate themselves about the risks associated with traumatic brain injury and the signs and symptoms of concussions.  They must provide the best equipment to reduce the risk of injury.  Parents and coaches must advocate for rules and policies that put the health and well-being of the student athletes as the highest priority.

Here is a good place to start:  The Centers for Disease Control and Prevention (CDC) has an online training course: Heads Up-Concussion in Youth Sports.

Read more about concussions and traumatic brain injury on the VisionHelp blog.

Read more about the Illinois College of Optometry and the Chicago Concussion Coalition.

More to the point, I love toys that can be used to develop your child’s vision while having tons of fun.  The American Optometric Association recommends toys that will help develop or sharpen your child’s general eye movement skills; eye-hand coordination skills necessary for writing and sports; shape and size discrimination skills needed for reading; and visualization and visual memory skills needed for comprehension and for the ability to visualize abstract things.  I would like to add to that list of skills.  Vision is also about output; the ability to respond in a meaningful way to visual input.  It involves movement and navigation, timing and rhythm, and the ability to make judgements about where things are, not just what things are.  So now lets go back to stick, box, string, tube and dirt.

• Sticks come in a variety of sizes and can be used to dig big holes and little holes (size discrimination); to extend your reach and poke soap bubbles (judgements about where things are);
• Boxes can hold and hide other toys and objects (visual memory); they can be combined with other boxes to build boats, trains, robots, time machines and anything you can imagine (eye-hand coordination and visualization).
• String can be used to drag something from here to there (navigation); throw the string over a stick to make a pulley–pull down on the string to make something move up (visualization); use string to make leashes and take a stuffed animal zoo on parade (movement); heavy-duty string, aka rope, can be a jump rope or a swing (timing and rhythm).
• One cardboard tube is a telescope, and two cardboard tubes are binoculars–what a great way to begin to explore where things are in space.  Tubes are also great for hitting objects and watching them move in the opposite direction (eye movements and eye-hand coordination).
• Dirt and its first cousin, sand, can be poured and molded (shape and size discrimination); you can write in the dirt (visualization); piles of dirt become hills to help understand a 3-D world (where things are).

Of course the possibilities are already endless but why not add a few more “toys,” like assorted bottles, water, and blankets.  The opportunities to improve your child’s visual skills through play are limited only by your imagination.  But play isn’t only about vision.  There is evidence that play, especially free imaginative play, is crucial to normal social, emotional, and cognitive development.  Play helps children learn important social skills such as taking turns and negotiating.  Play requires more sophisticated language in order to communicate about something or someplace that exists only in the child’s imagination.  Play fosters creative thinking and problem solving skills that will enhance a child’s ability to manage an unpredictable and complex adult world.

Please, grab some toys and go play with your children! Then sit back and watch as their imaginations and creative juices take sail.  Take sail…. boats… pirates……buried treasure….. awww, please please let me play too!

Read about toys that you can purchase : The 2011 Easy-on-the-Eyes Holiday Gift List

Read more about activities to help develop your child’s visual skills.

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.