Kristin Adams, OD
Chicago College of Optometry-Midwestern University
Optometrists, vision therapists, and exhibitors from across the country gathered in Pittsburgh, Pennsylvania November 4th and 5th, 2017 for the Middle Atlantic Congress of Optometry. The theme was “The Role of the Visual Process in Athletic Performance.”
Vision has been defined as the deriving of meaning and the directing of action as a product of the processing of information triggered by light. Without a doubt, athletes need to act quickly. They can improve in their sport when their visual performance is enhanced; optometry can play an integral role in the success of youth, amateur, and professional athletes. The importance of the visual process, proper evaluations, and oriented therapies carried through the meeting.
Dr. Mark Gordon started the weekend and discussed attributes and visual skills that make an athlete. Dr. Geoffrey Heddle gave insight in how to evaluate an entire sports team at their athletic facilities during a session titled, Sports Vision Testing Without Home Field Advantage. With audience participation, Drs. Gordon and Heddle demonstrated numerous evaluation methods and therapy activities. Dr. Greg Kitchener provoked thoughts as he presented on the Visual Process. Vision Therapy: What Is It Good For? was the topic of Dr. Steven Gallop’s talk. Dr. Paul Harris shared sports vision testing and treatments that occurred at the University of Memphis as well as several cases from football players to equestrians to biathletes.
The tone of the meeting was relaxed and friendly. All speakers welcomed questions and encouraged discussion. The conference also allowed time to peruse the exhibit hall and get to know fellow attendees.
Overall, the Middle Atlantic Congress of Optometry hosted hours of great education and socializing. I look forward to this year’s program and to meet both regular and new attendees! Will I see you there? This year's meeting is October 20-21, 2018 in Pittsburgh, Pennsylvania. Drs. Heidi Wise, Greg Kitchener, and Paul Harris will be speaking on topics related to "Finding Balance in Visually Asymmetric Demands: Neurological and Optical Constraints." Here is the link for more information: http://www.oepf.org/sites/default/files/OEP_MAOC_2018.pdf
I also highly suggest you watch the calendar on the Optometric Extension Program Foundation’s website (http://oepf.org/oepf_calendar) or events section on their Facebook page (https://www.facebook.com/OEPFoundation/) for dates and details of the many other Congresses of Optometry!
Congratulations are in order for the winners of the writing competition for students and residents!
Supan Parikh, HBSc, OD
University of Waterloo
The Interrelation between ADHD and Vision
Nguyen Tran, OD
Center for Vision Development Optometry
Management of Recent Onset Diplopia Secondary to 4th and 6th Cranial Nerve Palsy: A Case Report
ARTICLE REVIEW: Efficacy of vision therapy in children with learning disability and associated binocular vision anomalies
Jameel Rizwana Hussaindeen, Prerana Shaha, Krishn Kumar Ramani, Lalitha Ramanujan, Journal of Optometry 2018;11(1):40-8.
Reviewed by Desiree Vanderstar, OD Resident, Southern College of Optometry
In India, the prevalence of learning disabilities is approximately 15% in 8-11 year olds, with reading as the primary area of concern. It is logical that this should raise concerns about the efficacy of the visual system in this group of children. Literature supports that about 80% of the children who have been identified to have a learning disability have also been shown to have accommodative and vergence difficulties. This includes convergence insufficiency (CI), poor accommodative and vergence facility, reduced fusional ranges, and reduced amplitudes of accommodation. These difficulties can lead to reduced reading speed, poor accuracy and overall lower reading efficiency.
The authors propose that it is essential to assess the binocular system in children with learning disabilities but that there is a lack of randomized controlled trials testing the efficacy of vision therapy in this subset of the population. This article defines a learning disability as “a generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, resonating or mathematical skills”.
Their aim was to establish the frequency of binocular vision (BV) issues in children diagnosed with specific learning disabilities (SLD), such as poor reading or writing and to assess efficacy of vision therapy (VT) in improving their oculomotor, accommodative and vergence parameters. They also compared visual efficiency parameters between children with normal binocular vision and non-strabismic binocular vision anomalies (NSBVA’s).
The study was carried out at a school for children with learning disabilities. All 96 children, aged 10-21, underwent a comprehensive eye exam and binocular vision testing. A single student with Down’s syndrome and a single student with a pervasive disorder were excluded. The remaining 94 students had been previously diagnosed with a specific learning disability and all had documented problems with reading, writing and spelling. All children had normal IQ levels for their age and had no reported neurological issues. Eleven had a comorbid diagnosis of attention deficient disorder.
Of those 94 students, 46 were diagnosed with a NSBVA and were enrolled in a pre and post-experimental study design. This included 22 patients who received no intervention and 24 patients who were enrolled in 10 session of vision therapy.
Binocular vision testing included: Randot stereo plates, extraocular motility testing, cover test at distance and near, push up amplitudes, monocular and binocular accommodative facility, monocular estimate method of retinoscopy, near point of convergence (NPC), step vergences at distance and near with negative fusional ranges tested prior positive fusional vergence (PFV) ranges and the developmental eye movements (DEM) test. Vision related quality of life assessment (VR-QOL) was assessed using the modified COVD VR QOL questionnaire and symptomology was assessed verbally by asking about eyestrain, headaches, eye pain, or other visual discomfort associated with near work. Reading rate was assessed by asking each child to read a given paragraph for 3 minutes. Errors were subtracted and the reading rate was calculated for 1 minute of time.
Vision therapy was completed on the school premises for 45 min during regular class hours. The procedures used were adopted from Scheiman and Wick protocol for NSBVA and were carried out by an optometrist who would modify the technique whenever necessary according to the child’s responses. The activities focused on training vergence and accommodation through utilization of computer based therapies, tranaglyphs and vectograms. Teachers were blinded to which students received treatment and for ethical reasons, the control group was also administered vision therapy after the study brought to completion.
Of the 46 patients diagnosed with a NSBVA, 31 had accommodative infacility, 11 had convergence insufficiency, 1 had divergence excess, 1 had fusional vergence dysfunction and 2 had convergence insufficiency comorbid with accommodative infacilty. Mann – Whitney U statistical testing a revealed significant difference between NPC break and recovery, near PFV break and recovery, monocular and binocular accommodative facility in children with normal BV compared to the NSBVA group.
After 10 sessions, BV parameters and reading rate were reassessed in all test subjects. This helped examiners evaluate the true effect of vision therapy, negating placebo, learning and test retest effects. All parameters, except negative fusional vergence showed statistically and clinically significant difference post VT, when compared to baseline. In contrast, none of the control/non-intervention group showed statistically significant changes. The largest effects were seen on accommodative facility and PFV, followed by accommodative facility and NPC.
The average VR QOL score prior to therapy was 8 in the NSBVA and 3 in the normal BV group, with a higher number indicating a reduced quality of life. These scores did not show statistically significant improvements. However, the administration is often limited by bias on the part of the teacher or caregiver. This is an area that will require more study and exploration
The DEM results showed that all children diagnosed with a learning disability had a longer than expected horizontal time, whether they were diagnosed with a NSBVA or not. This supports that patients with specific reading related learning disabilities have poor saccadic eye movements. The median reading rate was also slower in the NSBVA group and faster in patients who had a faster time on the horizontal component of the DEM. As is logically expected from these results, the DEM results were negatively correlated with reading rate. This is in agreement with other literature. DEM horizontal and vertical times did not differ post VT. This result was expected, as the bulk of the therapy worked on accommodative and vergence activities. A regime dedicated to improving oculomotor skills would likely yield similar statistically significant improvement, as were seen in vergence and accommodative abilities.
Overall, the study confirms that children with specific learning disabilities have higher frequency of NSBVA when compared to age matched controls. These anomalies are an added hindrance to their pre existing reading difficulties.
The majority of the studies’ patients were identified as having convergence insufficiency or accommodative infacilty, and thus, the results are especially applicable to these two diagnoses. Since the differences in BV parameters were not present in the control group, the effects can be attributed to VT alone, without placebo, test re-test or learning effects factored in.
Also, because 5 of the 9 criteria for ADHD in DSM IV overlap with symptoms of CI (loss of concentration when reading, reading slowly, failure to complete assignments and trouble concentrating in class), it is extremely important to screen all of these patients for BV anomalies. In order to provide the best care, a comprehensive binocular vision assessment should be a part of the treatment plan for all children with LD’s and vision therapy should subsequently be recommended, especially to those with NSBVA’s.
From the OEP Archives!-GN Getman, OD lecture: PAC MAN: The Latest Threat to Visual Welfare. Presented at the San Jose Optometric Vision Therapy Conference
Welcome to the latest installment in this amazing series helping to keep some of the most influential behavioral optometrists from our past alive and at your fingertips! If you like this, please keep an eye out for the final issue of Optometry & Visual Performance for 2018 where we will feature amazing articles from OEP's 90 years!
The highly anticipated part 2 of AM Skeffington's lecture "The Basis for Dynamic Refraction" has been posted, now with a special introduction from OEP Secretary Treasurer Dr. John Abbondanza, You can listen below.
Welcome to the first in a new series! OEP will be celebrating 90 years young so we wanted to use the opportunity to bring back some of the nuggets of gold that are hiding in the vaults. Brought to you with the technological help of Dr. Nate Bonilla-Warford, this series is a blast from the past but the topics are still relevant and crucial to the practice of optometry.
Article Review: Colored Glasses to Mitigate Photophobia Symptoms Posttraumatic Brain Injury. J Athl Train Clark J, Hasselfeld K, Bigsby K, Divine J. 2017 Aug;52(8):725-729.
O.D. Candidate 2018
Southern College of Optometry
Concussions, or mild traumatic brain injury (mTBI) affect millions of Americans every year. While post-concussion symptoms tend to vary greatly among those affected, those commonly reported include headache, confusion, visual disturbances such as blur, and often a sensitivity to light. In fact, photophobia is so common that those exam rooms designated for post-concussion evaluations are by rule kept dim. Often, this sensitivity to light causes a significant decrease in the activities of daily living (ADLs) because of the high illumination demands of many workplaces and background illumination of computer screens. While traditional sunglasses can provide some relief in outdoor settings, indoor and computer demands render their use impractical. In investigating the potential of colored lenses to mitigate photophobia, the authors discovered no research on such lens use, nor did they find specific protocols for athletic trainers using colored lenses with post-concussion patients. Seeing the need for research in this area, the authors sought to first, discover how many post-concussion patients suffered from photophobia; second, determine to which frequencies of light patients were most photophobic and which provided the most relief; and third, create a paradigm to aid in choosing the appropriate colored lens for each patient.
To help meet their three goals, the authors conducted a retrospective chart analysis of consecutive concussion patients. These patients presented to a university-based concussion clinic with post-concussion visual symptoms. When deciding which patients to include in the analysis, the authors elected to focus on concussion patients with visual disturbances, including photophobia, which lasted more than 3 weeks post-concussion. Many were excluded from the study due to an unwillingness to have light shined in their eyes when investigating relief with tinted lenses.
Once selected, patients were exposed to a penlight without glasses in normal, indoor lighting to establish a baseline measure of photophobia. Each patient was then given tinted lenses in red, green, blue, violet, rose, indigo, orange, yellow, aqua, turquoise, pink, plum, and magenta. Each patient was exposed to the penlight with these lenses and sorted the lenses into 1 of 3 groups; glasses that helped with symptoms, glasses that had no effect, and glasses that made symptoms worse. Once complete, each participant was asked to perform several ADL tasks, such as walking or reading, using the lenses that helped. Patients who participate in athletics were instructed to wear dark glasses outside and the recommended colored lenses when doing inside or computer tasks. They were also instructed to wear wide-brimmed hats outside, dim the light intensity on screens, and avoid wearing dark sunglasses inside.
There were 51 post-concussion patients examined in this study, but 12 were excluded from the analysis because they did not have visual symptoms. Of the 39 patients examined, none showed color blindness when tested with Ishihara plates. In testing the patients, 85% (33) experienced a decrease in symptoms, per the subjective responses of the patients, with 1 or more colors of glasses. Blue provided relief in 15 of 33 patients, with green, red, and purple also providing relief in several patients. No adverse effects were reported, and only yellow never provided relief. There were three patients who experienced no relief with any lenses.
While this assessment clearly demonstrates the benefits of colored lenses in reducing photophobia in post-concussion patients, the authors acknowledge the limitations of their analysis. They are quick to point out the subjective nature of the study, indicating that any reduction in symptoms depends solely on each patient’s experience with the lenses and penlight. The authors also acknowledged the small sample size, limiting the ability to provide widespread application to a larger population. Also, because the subjects in this study represented a very narrow group of photophobic patients, it is difficult to suggest that colored lenses could mitigate symptoms in others with photophobia.
The authors were successful in meeting their three goals; they discovered that roughly 76% of post-concussion patients have photophobia, a decrease in symptoms can occur with colored lenses, and certain lenses, especially blue, green, red, and purple, seem to decrease photophobia in most people.
Riquelme I, Henne C, Flament B, Legrain V, Bleyenhauft Y, Hatem SM.
Research in Developmental Disabilities 2015;43-44:61-71.
By: Kristen Vincent (Class of 2017)
Pennsylvania College of Optometry, Salus University
Prism adaptation (PA) is an efficient therapeutic mediation to shift the visual field horizontally. The horizontal movement of the visual field reveals a clear directional influence on visuo-motor and sensory-motor communications. To offset the visual field deviation, the individual has to reestablish his mobility, leading to a modification of sensorimotor coordinates. Removal of the prism glasses creates the egocentric coordinates of the sensory-motor reference frame to be altered, thus generating immediate visual and proprioceptive adjustments in the direction of pointing and reaching, named after-effects. After-effects are the critical component in determining the value of PA.
PA has been a successful intervention for performance adaptation in a variety of spatial task in adults: both in healthy individuals and in patients with unilateral neglect following stroke. Due to its abiding influence, PA is considered an efficient method for rehabilitating unilateral spatial neglect by shifting the neglected hemisphere into the “seeing” field.
PA is also utilized for correcting strabismus in children, and research shows that even infants at 6-9 months of age exhibit adaptive responses to PA. The visuo-motor relationship is an attractive focus for therapeutic mediation in children since perceptuo-motor procedural learning fundamentally occurs at school age. While unilateral neglect, described as a deficit in attention and appreciation of stimuli on the paretic side of the body, has been characterized in children with cerebral damage, the achievability of PA in these children had not been explored prior to this study.
While wearing prismatic glasses, PA involves the simultaneous performance of a sensorimotor task within the visual space. Repetition of pointing movements toward visual targets is regarded as the standard procedure, both in healthy individuals and in unilateral neglect patients. As an alternative procedure to the repetitive and tedious pointing tasks, a series of visuomotor activities performed with daily life objects i.e. ecological tasks, has been recommended as more varied and appealing for long-term management. Therefore, the present study investigated the beneficial effects of PA supplemented with selected game tasks as a feasible, child-friendly alternative to the aforementioned ecological task procedures proposed for adults. It also aimed at determining whether one session of prism adaptation could generate substantial visuomotor after-effects in children with unilateral brain lesion compared with neutral glasses.
The participants of the study included 21 children with unilateral brain lesion resulting in hemiparesis. The children were divided into two study arms: one group was randomized to prism treatment, the other to neutral glasses. The intervention for all participants involved one daily task session on two consecutive days, one day consisting of ecological tasks and the other of game tasks. Children were encouraged by verbal instruction to perform all tasks bimanually for a duration of 20 minutes. All procedures were conducted while children wore glasses: prismatic glasses in the prism group and neutral glasses in the control group. Prismatic glasses deviated the visual field 20 prism diopters (approximately 11 degrees) towards the non-paretic side.
During the ecological task session, children completed an assortment of 10 visuomotor activities based on the handling of common daily life objects. During the game task session, participants completed an assortment of 10 common children games selected for promoting lateral investigation of space. To measure visuomotor adaptations provoked by the intervention, children executed two open-loop pointing tests just before and immediately after each intervention: (1) the visual open-loop pointing test, i.e. a visuoproprioceptive test with opened eyes, and (2) the subjective straight ahead pointing test, i.e. a proprioceptive test with closed eyes. Instantaneous effects of PA have been correlated with changes of these pointing assessments.
After intervention with ecological tasks in the prism group, visuoproprioceptive pointing errors of 9 (out of 11) children had drifted towards the hemiparetic side. In this same group, after intervention with game tasks, visuoproprioceptive pointing errors of 9 (out of 11) children had drifted towards the hemiparetic side. In contrast, the control group presented these findings: visuoproprioceptive pointing errors of only 1 (out of 10) child displayed a shift toward the hemiparetic side after intervention with ecological tasks, and visuoproprioceptive pointing errors of 4 (out of 10) children displayed a shift towards the hemiparetic side after intervention with game tasks.
Results were similar for the proprioceptive test. After intervention with ecological tasks for the prism group, proprioceptive pointing errors of 10 (out of 11) children had drifted towards the hemiparetic side and after intervention with game tasks, proprioceptive pointing errors of 9 (out of 11) children had drifted towards the hemiparetic side. In contrast, in the control group, proprioceptive pointing errors of 7 (out of 10) children displayed a shift towards the hemiparetic side after intervention with ecological tasks, and proprioceptive pointing errors of 4 (out of 10) children displayed a shift towards the hemiparetic side after intervention with game tasks.
This was the first study to justify the feasibility and effectiveness of prism adaptation in a pediatric population with unilateral brain lesion. It was proven that one single session of PA therapy was successful in stimulating after-effects, measured by subjective straight ahead pointing and visual open-loop pointing. As anticipated, PA in hemiparetic children provoked visuoproprioceptive after-effects towards the paretic hemispace, i.e. in a direction contralateral to the optical shift created by PA. On an interesting note, these after-effects were more distinct in children with right hemispheric lesion. A greater proprioceptive pointing error towards the paretic hemispace in the prism group compared to the control group was also observed. Moreover, game tasks presented to be as effective as ecological tasks at provoking prism adaptation-related after-effects. The children were more engaged and interested while playing common games than while conducting ecological tasks, and therefore games may promise longer interventions in children with visuospatial impairments.
After-effects are the clinical correlate of modified cortical networks involved in spatial attention and awareness while performing neglect recovery. Consequently, the manifestation of after-effects in children with unilateral brain lesion proposes the presence of short-term plasticity of cortical areas within the visual reference frame.
The prismatic glasses (20 prism diopters) utilized in this study induced a shift of the visual field by about 11 degrees during the performance of tasks and resulted in after-effects of 4 degrees on average. A larger magnitude of prisms would have afforded a larger after-effect, but this could have produced other disadvantages including distortion and unmeasurable displacement while pointing.
Limitations of the study included small sample size and it comprised primarily of children with right hemiparesis (i.e. left hemispheric lesion). The results proposed that PA effects could be larger in children with left hemiparesis (i.e. right hemispheric lesion), yet a larger and more homogenous sample is indicated to corroborate the reliability of this finding.
Since PA therapy requires repetitive intervention to produce long-lasting effects, further research is necessary to establish the efficiency of a long-term intervention in the rehabilitation of brain-damaged children with visuospatial deficits and/or neglect. Future studies should also assess different intervention durations to authenticate the most effective therapeutic dosage scheme in children. Lastly, exploration of acquiring differential improvement of extensive cognitive, motor, and sensory effects in children, as has been presented in adults, is needed. This study lays the groundwork for future research on the subject and unravels new possibilities for the rehabilitation of children with neurological dysfunctions.
Article Review: Effect of chromatic filters on visual performance in individuals with mild traumatic brain injury (mTBI): A pilot study
Fimreite V, Willeford KT, Ciuffreda KJ. Journal of Optometry 2016;9(4):231-239.
By Sato Mananian
AZCOPT OD 2019 Candidate
The purpose of this pilot study was to investigate how spectral filters influence reading performance in patients with mild traumatic brain injury (mTBI). Patients who have suffered an mTBI often suffer a deficit in reading skills such as pursuits, saccades and fixations. These deficits are primarily due to an oculomotor dysfunction. Accommodative dysfunction and light sensitivity may also contribute to a patient’s decreased reading ability. Light sensitivity is a common sequela of mTBI and can often be treated with band pass spectral lenses to reduce the intensity of light patients see. It has also been found that filters that particularly transmit blue light decrease accommodative demand, providing additional relief to these patients. This study sought to determine the optimal tint for improved reading ability in mTBI patients with the above-mentioned symptoms.
The study examined 12 individuals recruited from SUNY State College of Optometry who had suffered concussions from either a sport related accident, a car accident or another traumatic event. These participants were past the natural recovery phase of 6-9 months. The subjects had a BCVA of 20/20 at distance and near, OD, OS and OU. Eligibility criteria for the study included a diagnosis of mTBI based off a loss of consciousness for less than 30 minutes, post traumatic amnesia lasting less than 24 hours, and a Glasgow Coma Scale score of 13-5. The average age of subjects in the study was 35 years old, with a range of 21-60 years of age. The study used a control group made up of 12 visually normal individuals with an average age of 23.3 years of age and a mean spherical refractive error of -2.75D, ranging from +1.25D to -6.25D. The control group excluded individuals with a history of seizures, strabismus, amblyopia or ocular systemic disease.
Data was gathered using the Visual Evoked Potential (VEP) and the Visagraph II. On the VEP, subjects viewed a visual stimulus of an alternating black and white checkerboard pattern. The visual stimuli were viewed binocularly through one of the following three spectral filters: (a) gray/neutral, (b) blue (425 nm) and (c) red (650 nm). The gray/neutral density filter was used as the control. Studies done using the Visagraph employed the same three band-pass chromatic filters as the VEP as well as viewing glasses. These filters are commonly used in this patient population to reduce symptoms of photophobia.
The results of the study showed that filter type did not alter the number of fixations, regressions, fixation duration, or VEP amplitude and latency. Patients with mTBI made more fixations and regressions than controls during testing. When comparing findings, no effects were seen in five of the six test parameters due to filter type used. There were notable differences in reading rate for these two groups with the different filters. However, although there was no statistically significant correlation with filter and performance on reading rate tests or VEP amplitude, it was noted that 6 subjects in the control group were shown to read best with the blue filter. Similarly, in subjects who suffered an mTBI preferred the precision tint filters when reading.
The study concluded that reduction in overall luminance due to the use of filters may have been the primary cause of increased visual comfort because of the predisposition to photophobia in this population regardless of the color or type of filter used. Furthermore, the preferences for certain filters in each group may indicate an increase in visual comfort for these patients, which regardless of its statistical significance, is valuable information that can be used to help this unique patient base.
The researchers hope to repeat the study with a larger sample size, longer test period, and reassessment of patient skills in real life settings. The future study will further observe the use of tinted filters with the hopes of discovering additional benefits for mTBI patients. Ideally, the study would like to set the standard for future doctors to use spectral lenses in early treatment for symptomatic relief in this patient base before long term therapy is able to offer relief.