Resident Award Winner

Alicia X. Wong, OD
Clinical Findings and Management of an Abducens Nerve Paresis secondary to Guillain–Barré Syndrome

Student Award Winners

       Katilyn Broberg (OD 22)                                                   Tamara Latinovic (OD 22)
Midwestern University Chicago College of Optometry​ 

Gerardo After a Brain Injury is Still Gerardo

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!
​
Student Winner
Supan Parikh, HBSc, OD
University of Waterloo
The Interrelation between ADHD and Vision

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. 

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. 

AJ McCleary
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. 
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