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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Dr. Don Getz — Strabismus and Amblyopia

Developmental optometry has lost another giant.  Dr. Donald Getz has died.  His dear friend and colleague, Dr. Robert Sanet had this to say:  “Don loved many things…. he  especially loved COVD, where he served as President and Master of Ceremonies at the Awards Banquet, and he loved mentoring optometry students.  Don and Lynn opened their home, and Don freely gave enormous amounts of his time and energy to hundreds and hundreds of students who visited him over the years.  Don was a great clinician and a tireless champion of behavioral optometry.  The impact of his generosity, friendship, and knowledge will be carried on through the lives of the patients whose lives were enriched because of his clinical expertise, and through the amazing optometric knowledge he shared with us.”

Dr. Getz received the Skeffington Award in 1988.  I happily re-read his monograph on Strabismus and Amblyopia, which was first published in 1974 by the Optometric Extension Program.  In the acknowledgements, he recognizes his vision therapist, Lora McGraw.  “She did not have the disadvantage of an optometric education, and, consequently, did not know that certain things were impossible.”  Dr. Getz and Lora McGraw were always pushing the envelope and thinking outside the box.

A strabismus is a condition in which the eyes are not aligned. One eye may be turned in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia) relative to the fixating eye.  When the eyes are not aligned, this can cause patients to see double.  Even worse, overlapping images will cause 2 different objects to appear superimposed on the same location in space.   Brains find this “visual confusion” intolerable.  In fact, brains will go to great lengths to avoid double vision and visual confusion.  Having a strabismus will often cause a series of adaptations to avoid double vision, and perhaps permit the visual system to make the most of a bad situation. These adaptations include amblyopia (reduction in visual acuity and other visual functions), suppression (turning off the visual input from the turned eye), eccentric fixation (using an off- center point on the retina to denote straight ahead) and even anomalous correspondence (remapping the processing of spatial coordinates when both eyes are attempting to work together).  It is these adaptations that often make the treatment of a strabismus a difficult task.  These adaptations must be eliminated if a patient is going to learn how to straighten their eyes and keep them straight.

In his book, Strabismus and Amblyopia, Dr. Getz explains the importance of tackling these adaptations and then offers many different activities that can be incorporated into a vision therapy program.  He places great emphasis on the monocular phase of treatment. If monocular skills are not developed and equalized, binocular therapy will be very difficult;   or stated another way, if monocular skills are developed and equalized, binocular therapy will be much easier.

In addition to amblyopia, strabismic eyes have poor spatial localization skills.  The brain has learned to interpret straight ahead while the eye is actually turned.  This process of locating where objects are, and how far away they are, must be relearned, under monocular conditions.  If equal spatial localization exists under monocular conditions, it is almost impossible for the patient to have eccdentric fixation; and if equal spatial localization exists under binocular conditions, it is almost impossible for the patient to have anomalous correspondence.

I have prescribed many of the activities listed in his book as part of a treatment program for amblyopia, but re-reading his book has forced me to reconsider what I am attempting to accomplish.  Dr. Getz has reminded me not to overemphasize the visual acuity of the amblyopic eye.  Instead, attempt to improve and EQUALIZE the performance of each eye during these activities.  The visual acuity will improve along with the improvements in spatial localization and performance.  Even if visual acuity is never equalized, the patient may be capable of binocular function.  Equalizing the behavior and performance of each eye separately should not be overlooked or rushed in the therapy program for a strabismic patient.  The patient will now be ready to match the 2 “ocular circuits” and proceed to the binocular phase of therapy with greater likelihood of success.

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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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The Splash – Persistent Parents

Our guest blogger this month, Carrie Hall,  is one of the very talented vision therapists at my practice. She brings a unique perspective to the blog since she works with patients every week often times for many months.  Because of this,  she often gets to know the patients and their families on a very personal level and truly gets to know the struggles, trials, and triumphs patients go through.  At the conclusion of COVD’s National Vision and Learning month, I think her perspective into one of our patients is a perfect addition to what has been a great highlight of many inspiring vision therapy success stories.

As a vision therapist, I often see a theme among the parents that I encounter. Though they are of various ages, personalities, beliefs and styles, they often share one certain characteristic that sets them apart as vision therapy parents. They are incredibly persistent. They have been told many times in their lives that their children may not be capable of certain things. Perhaps by a doctor intending to give them a realistic expectation of the future, or perhaps by a teacher who is frustrated by a lack of success in their child. Whatever the source, I encounter parent after parent who has been informed that their child will not be capable of a certain level of ability, be it athletic,  academic, or just general life skill development.

Lynn was one such parent. Her daughter Shelby was simply not blooming in school like her older sister had. Reading was inexplicably difficult for this 8 year-old. Always a fight, often involving tears, Shelby simply would not take to reading. Lynn was baffled. Shelby was obviously bright and determined, a spunky and enthusiastic girl. It just didn’t add up. The pieces did not fit. Her eye doctors confirmed that Shelby’s vision was fine. She had 20/20 acuity, so the only reason why she shouldn’t be learning to read was if she simply wasn’t as smart as Lynn thought.
Perhaps some parents are more inclined to take the words of professionals at face value than others. Perhaps some parents simply refuse to be satisfied with an underwhelming determination of their children’s potential. Whatever is the mitigating factor, Lynn could not and would not be satisfied with this evaluation of her daughter. She persisted in her search. When she eventually found Washington Vision Therapy Center whose symptom checklist of vision-related learning problems read like a specific description of Shelby’s struggles, Lynn knew she had found her answer. When confronted with the financial strain that therapy would mean for her family, her persistence did not waiver. She would make whatever sacrifices were necessary: she would ensure her daughter’s chances for success in school and life no matter what.
Maybe persistence is a genetic trait as well. I certainly saw the same attributes in little Shelby that her mother demonstrated. Months after beginning therapy, after countless lifesaver cards and hart charts, Shelby was burnt out with it all. Who can blame her though? When the goal of all the work is just to get better at doing homework, it hardly seems a fair thing to ask of a girl of 8 who would rather be playing outside than getting better at reading any day of the week.
But like I said, maybe persistence is a genetic trait. Or perhaps it’s more nurture than nature. Whatever the case, Shelby persevered. Not only did she make it through therapy, she did great at it. She learned to be able to coordinate the use her two eyes like the best of them by the time it was all said and done. She and her mother developed a balanced working relationship in regards to this specific area in order to attack vision therapy head-on and accomplish every last bit of what Dr. Winters wanted to see from her clinically. Neither one of them would quit. Lynn pushed Shelby, and Shelby pushed right back in order to finish well. That little girl was the definition of persistence.
It’s the characteristic that marks out the parents, and the patients as well, for success. They are all up against diagnoses and school evaluations that make the future look bleak. They have been told repeatedly that they can’t, that they won’t. But they refuse to listen. Little fighters, they are, coming in and out of our offices defying the odds stacked up against them.
The other day, Shelby came up to her mother after doing some reading and said, “You know Mom, I think I like this reading thing.”  She is now at grade level in reading.  That is the payoff for any persistent mother.  Lynn has continue to fight to get Shelby’s story of hard work and persistence out to the public and she is now being featured on COVD for National Children’s Vision and Learning month. http://www.cisionwire.com/college-of-optometrists-in-vision-development/r/mom-of-struggling-reader-finds-help-and-speaks-out-for-college-of-optometrists-in-vision-development,c9283372 Imagine that. A homeshooling mom from Yakima, Washington who believed her child’s struggles with reading were more than a resistant attitude or just that her daughter wasn’t smart enough. Persistence is a powerful thing.

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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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See Well Learn Well

Don’t miss this public health report, 3-D in the Classroom.  3-D imagery is becoming more commonplace, especially in classrooms.  These new 3-D displays are quickly becoming an exciting new tool for teachers and learners across the learning spectrum–from kindergarten through graduate school.  Think about the possibilities……. Geometry, architecture, anatomy, engineering, sculpture, biology, geology.  Pick one of these subjects and imagine what you might do if you could use 3-D images in your lesson plan.  The possibilities are limitless!  Now move beyond the classroom, because 3-D vision, or stereopsis, is becoming a requirement for many careers and vocations.  Teaching with 3-D technology will be a requirement in order to prepare students to practice with that technology.

And now, imagine a child who cannot perceive 3-D images because of a vision problem.  These children will be at a distinct disadvantage, not only in the classroom, but in life!

The good news is that help is available.  Dr. Dori Carlson, the president of the American Optometric Association, points out that “for the estimated 1 in 4 children that have underlying issues with overall vision, 3-D viewing can unmask previously undiagnosed deficiencies and help identify and even treat these problems….If deficiencies are identified the student can be directed to care consisting of a comprehensive eye exam and treatment with glasses and/or individualized rehabilitative vision therapy.  As an added benefit, this course of action may also assist the child in most all reading and learning tasks.  Overall these 3-D viewing potentials, tied to enhanced and protected vision, provide increased assurance that no child will be denied lifetime opportunities and an equal chance to succeed in school and later in life.”

The ability (or inability) to perceive 3-D images may provide a more sensitive assessment than a standard eye chart in the identification of children with vision disorders! What are some of these vision disorders that can reduce stereopsis and perception of 3-D images?

• Refractive problems, such as myopia (nearsightedness) and hyperopia (farsightedness).
• Strabismus, or an eye that turns in or out, all of the time or some of the time.
• Amblyopia, or lazy eye, when one eye does not see or perform visual tasks as well as the other.
• Binocular deficits, such as convergence insufficiency, can can cause significant discomfort and even double vision, in addition to poor 3-D viewing.
• Accommodative deficits, or poor focusing skills can cause blur and discomfort during 3-D viewing.

The time is now, make sure your children have the visual skills they need to perform both inside and outside the classroom.  Take your kids to see a 3-D movie! If your child doesn’t seem to appreciate the 3-D effects, consider this a blessing in disguise….next stop is a comprehensive eye examination.

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Sports Vision: An Interview with Dr. Arnold Sherman

Dr. Arnold Sherman is a Fellow of COVD and a Diplomate of the American Academy of Optometry. He has served as a consultant to the NY Jets, the NY Rangers, and the US Olympic Committee. He has worked with athletes of all ages, from little leaguers through the professionals. He maintains a private practice in Merrick NY and is a member of the clinical faculty at SUNY Optometry.

Part 1 — Baseball

Dr. M: Thanks for sitting down with me to answer my questions about vision and sports. Sitting here in Bryant Park, I can feel spring! That means baseball, lacrosse, and tennis! And of course your favorite, hockey playoffs are starting. Let’s talk about elite athletes first. How would you describe the visual requirements to succeed in these sports?

Dr. S: All these sports are different and they all require different visual skills. But let’s look at what they have in common first. Baseball, hockey, lacrosse, and tennis all require the athlete to respond to a moving target. Vision is the signal that directs the muscles of the body; the eyes LEAD the body. Vision utilizes the eyes for input, the brain for integrating information from the other senses, and the action system of the body for output.

Dr. M: Can we get specific? How does that apply to these sports?

Dr. S: Let’s start with baseball. Vision provides the batter with information as to “WHERE” and “WHEN.” Where is the ball going to be and when do I swing? A fastball traveling at 90 mph reaches the bat in 400 milliseconds—less than a half second! It takes 150 milliseconds to initiate the swing and make contact with the ball. Therefore, the hitter has at most 250 milliseconds to decide whether or not to swing. Vision has to be razor sharp. Superior size, strength bat speed and agility cannot make up for inefficient processing of “where” and “when” to respond.

Dr. M: Even the most successful major league hitters are only successful about 35% of the time. Can improvements in vision have big impact?

Dr. S: In baseball and other sports, most performances that fail are not due to the wrong physical movement but the movement being performed at the incorrect time or in the incorrect place. In baseball, fine tuning the visual time machine can result in raising a batting average to the next level. Joe Mauer (catcher for the Minnesota Twins) is a perfect example. He never swings at the first pitch. He’s not afraid to stand at the plate with 2 strikes because he has gathered visual information from seeing several pitches and that helps him get to the right place at the right time when the right pitch is delivered.

Dr. M: What is the most important visual skill for baseball players?

Dr. S: One of the most important skills is binocularity. You need both eyes following the ball in order to make accurate judgements about “when” and “where.” You need to turn your head toward the pitcher enough to get both eyes working together. Once you have your head posture figured out, you may need to make adjustments to the rest of your body, because, remember, the EYES LEAD THE BODY.

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Parachutes, Optometric Vision Therapy and Randomized, Clinical Trials

Martínez PC, Muñoz AG, Ruiz-Cantero MT.Treatment of accommodative and nonstrabismic binocular dysfunctions: A systematic review.Optometry. 2009 Dec;80(12):702-16.

CONCLUSION: Scientific evidence exists for the efficacy of vision therapy for convergence insufficiency. Insufficient scientific evidence exists on the best therapeutic options for treatment of the other nonstrabismic binocular anomalies and accommodative disorders.

Comments: Are these authors really this naive? Do they really think you cannot treat patients’ problems unless the treatment has had randomized, clinical trials conducted? Do they practice in an ivory-tower bubble? Medicine has NEVER waited for the clinical trials before treating. Should optometry be held to a different standard? There is enough research at various levels (Observational Studies, Case-control Study, Cross-sectional Studies, Integrative Studies and Case Series studies) to support optometric vision therapy as a viable treatment. If these authors bothered to look at this research they would have known better than to come up with this erroneous conclusion! Go to http://www.covd.org for a listing of these papers.

Please see the paper below. It illustrates just how “obsessed” some folks can become with “evidence based medicine”. We need good science to support clinical care. Good clinical care usually occurs while the science tries to catch up. DM

Smith GCS, Pell JP. (2003). Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ, 327(7429), 1459-1461. DOI: 10.1136/bmj.327.7429.1459

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

Gordon C S Smith, professor1, Jill P Pell, consultant2

Abstract

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.
Design Systematic review of randomised controlled trials.
Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.
Study selection: Studies showing the effects of using a parachute during free fall.
Main outcome measure Death or major trauma, defined as an injury severity score > 15.
Results We were unable to identify any randomised controlled trials of parachute intervention.
Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

From: http://www.MainosMemos.blogspot.com

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