Riquelme I, Henne C, Flament B, Legrain V, Bleyenhauft Y, Hatem SM.
Research in Developmental Disabilities 2015;43-44:61-71.
doi: 10.1016/j.ridd.2015.06.009
 
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.

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. 

Congratulations are in order as this year's wiring competition have been selected!

Student Winner
Early Detection of Visual Dysfunction in 5th and 6th Grade Readers Based on Head Movements and Head Position During Reading Activities
Nikita Katoozi 
Pacific University College of Optometry 
Class of 2018

Resident Winner
Infantile Nystagmus: Classification, Assessment and Management, A Review
Nathalia Broderick, OD
Pediatric and Infant Vision Optometry Resident at SUNY College of Optometry

​We’re pleased to introduce you to the OEPF iBook edition of a classic textbook in our field, Applied Concepts in Vision Therapy (ACiVT).  The popularity of the book resulted in OEPF periodically running out of the print edition, necessitating back orders.  Obviously the new iBook version obviates the need for print runs, and was anticipated in the preface to the Preface to the OEP Edition in 2008 which notes:  “The material in the text will be updated through Internet-based communications rather than new print editions.”
 
International enthusiasts can also buy the iBook and receive it instantaneously, obviating  shipping delays.
 
The iBook OEPF edition of ACiVT is a joint venture of OEPF and Ridgevue Publishing.  Ridgevue specializes in iBook productions with over a dozen optometry-related titles, and is managed by Mark Bullimore, MCOptom, PhD, FAAO.  Dr Bullimore is former editor of Optometry and Vision Science, the journal of the American Academy of Optometry.  

The price point of ACiVT in the iTunes store will be $39.99, but the introductory price is $29.99.  https://itunes.apple.com/us/book/id1123475850
ACiVT in iBook format can be viewed on any of the following devices:

1. iPad with iBooks 2 or later and iOS 5 or later
2. iPhone with iOS 8.4 or later
3. Mac with OS X 10.9 or later

​The iBook’s editor, Leonard J. Press, O.D., FAAO, FCOVD, has updated this version through hyperlinks in the original chapters, as well as blogs written specifically to supplement each chapter with added commentary and insights.

Purchasers of the ACiVT iBook can access new versions (currently in version 1.6) as updates are made.  There is no additional fee to download new versions. We expect to add instructional videos of diagnostic and training procedures in the coming months.​

Dr. Press is the Residency Site Supervisor for Vision Therapy & Rehabilitation in private practice in Fair Lawn, NJ, administered by the Southern College of Optometry, and Editor of Vision Development & Rehabilitation, the journal of the College of Optometrists in Vision Development. 

Doble JE, Feinberg DL, Rosner MS, Rosner AJ.  PM R. 2010 Apr;2(4):244-53. doi: 10.1016/j.pmrj.2010.01.011.  PMID: 20430325
 
By: Jessica Ruxton (Class of 2019)
Midwestern University, Arizona College of Optometry
 
Vertical heterophoria (VH) is a binocular vision dysfunction in which the eyes have different lines of sight. VH and traumatic brain injury (TBI) give rise to the similar symptoms including eye pain, dizziness, difficulty with reading, and psychological disturbances. The authors discovered that patients with both syndromes had a decrease in their symptoms after being treated with prism correction, and consequently conducted a retrospective analysis investigating the relationship between VH and TBI, as well as the effectiveness of the treatment. 

A database search from January 2005 to April 2008 revealed eighty-three TBI patients that had continued symptoms despite standard TBI treatment. Only forty-three had complete data sets and were included in the study. Baseline information indicated the majority of the TBI’s were caused by car accidents, the mean duration of symptoms was 3.6 years, and the mean duration of treatment was 3.6 months. Before and after prism was added to the spectacle correction, the patients completed the Vertical Heterophoria Symptom Questionnaire (VHS-Q) and subjectively ranked their symptom level with a percentage. The VHS-Q, developed by the authors, consists of twenty-five questions assessing VH symptoms on a scale of zero to seventy-five. 

The mean baseline score from the VHS-Q was 34.8 points; after treatment, the mean difference was 16.7 points. The mean subjective improvement was 71.8%. Based on the patient’s head tilt, the magnitude and direction of prism was determined. The higher eye required base up and small amounts were added until the symptoms were maximally reduced. Within twenty to thirty minutes, the patients noticed improvement which appeared to stay stable over time. On average, two to three months and three sets of lenses were needed to optimize the prescription, making this treatment cost and time efficient.  

Limitations to the study included the number of excluded patients, lack of placebo, and only one optometrist and one physiatrist treating the patients. The prevalence of VH in the TBI population could not be determined because of the sample size. However, from the authors’ experience, VH was very common in this group. Also, it was unlikely that a placebo would have affected the results as vertical prism has a noticeable effect. Those with VH noted a relief of symptoms, whereas those without VH developed symptoms when vertical prism was added to their prescription. 

The authors hypothesized that a TBI leads to a VH. When the cause of VH was a TBI, the higher eye had a lower line of sight and saw a higher image. The elevator and depressor muscles compensated to avoid diplopia and became strained.  The transient diplopia and blur seen clinically was a result of this extraocular muscle fatigue.  Since the patient was stationary and the visual input was changing, this was perceived as dizziness. Diagnosing and treating VH has been very difficult in the past, but adding the appropriate amount of prism eliminated the strain on the extraocular muscles which in turn eliminated the other symptoms. 

by Toni Bristol
 
It is hard to fathom that one word has the power to move people into action or stop them dead in their tracks, but words can do that; especially when your patients have to pay anything out of their own pockets for your services.
 
Just think about it for a moment, if a doctor told you that he or she thought that you might have XYZ, whatever that is, are you motivated to take action?  What if the doctor said you “have XYZ and need….,” does that make a difference?
 
If you are like most people, when the doctor is definitive, you are inspired to take action. Now, if you are truly uncertain about the diagnosis, I am not recommending that you state your conclusion decisively.  This only applies when you are certain.
 
If you think of yourself as a coach, and your goal is to educate your patients so they are inspired to take the necessary action(s) to help themselves or their child, your word choices become clearer. When you finish explaining your treatment plan to patients can you see that they are inspired? Or are they just being polite?
 
An athletic coach trains people with one thing in mind – improved performance. When you think of yourself as a coach when you are talking with patients, the words you use on a daily basis take on new meaning. 
 
Here’s some food for thought.  If I told you I thought you were an inefficient manager, you could easily interpret that to mean that I think you work too slowly. You may also feel that while it may not be the most efficient or effective management method, you still get the job done. 
 
Now let’s transition over to your exam room for a moment. You are explaining to a patient that their visual system is inefficient and that they need a program of vision therapy. The patient’s thought process is, “What’s so bad about that? It may take me longer, but I am still seeing well enough.” Something that is inefficient doesn’t warrant aggressive treatment. Yet a program which requires multiple visits to the doctor’s office and 10-20 minutes of work to be done at home 5 times per week is definitely aggressive.
 
So what’s the solution?  Try using the word inadequate in place of inefficient. If you told me that my visual system was inadequate, that instantly tells me something is wrong. This could easily warrant aggressive treatment, because it is not adequate to get the job done.
 
Please take a moment and review what you are saying to your patients to be sure you aren’t using any words that they won’t understand. 
 
If you aren’t sure what to say, need help figuring out how to coach your patients to take action, or have a topic you would like me to blog about, please feel free to email me.
 

Toni Bristol began consulting health care practices in 1984 and started specializing in vision therapy practice management and marketing in 1988.  She developed the powerful and most effective case presentation method for vision therapy, the BRISTOL CASE PRESENTATION METHOD™.  For almost 30 years, she has helped thousands of optometrists in the U.S., Canada, Australia and Malaysia. Toni has shared the wealth of her expertise internationally through her articles that have been published in Optometry & Vision Development journal, VISIONS, eVisions and VP Today.  www.expansionconsultants.com.

Interview by Nicholai Perez, OD

Every year, one student is elected to represent all the colleges of optometry in the US, Puerto Rico and Canada as the AOSA’s OEPF National Student Liaison. More than that, they were selected because they have shown a passion and commitment to the organization and it’s mission. Kristin Adams is a 4th year student from the Inter American University of Puerto Rico, School of Optometry that serves as the liaison. Kristin has proven to be an up-and-coming leader and OD in her own right. I recently had the pleasure of speaking with Kristin about her life, accomplishments and her mission with the organization. We are excited to have her on board as the start of a new generation of Optometrists Changing Lives.
 
Please tell us a little bit about yourself, Kristin!
I was born and raised in Northeastern Minnesota. I graduated from the College of Saint Scholastica in Duluth, Minnesota with a Bachelor’s of Arts degree in Languages and International Studies and minor in Political Science while pursuing my optometry school pre-requisites.  

I am a 4th year student at Inter American University of Puerto Rico School of Optometry. I chose Puerto Rico for the integration of the Spanish language and the amount of vision screenings on the island.

Currently, I am honored to serve OEP and the American Optometric Student Association as the National Student Liaison. My role consists of being the communicator between the organizations and the local liaisons. I also have the opportunity to write biannual contributions for the AOSA Publication, Foresight. In the last issue, my article explains and highlights all the benefits of OEP for student members.

On a more personal note, helping others and volunteering are important to me whether it’s in my local community or abroad.  For over the last 10 years, I have volunteered with high school foreign exchange students. As I grew and made many friends from my yearlong exchange in Switzerland, I want to promote cross-cultural learning through helping host families and students. Last year, my husband and I opened our home in Puerto Rico to my younger Swiss host sister for her to attend high school, learn a new language, and experience a new culture. If anyone has questions about hosting a high school exchange student or being one, feel free to ask me!

I absolutely love animals whether it’s going for a ride on my horse, working with organic dairy cows, or taking my 2 dogs to the park. I also enjoy volunteering with my church’s youth group, baking, quilting, traveling, playing board games, and spending time with my husband, Tim.
 
You definitely have a passion for behavioral optometry. What sparked the interest?
When growing up, I never cared for school. My older brother and sister were straight-A students, so I was motivated to do well academically. Yet, it was difficult for me to work on my homework or read assignments. Starting in sixth grade, my mother made a deal with me in order to complete novels – if I read one chapter out loud, she would read the next chapter out loud.  We did this for years. I never understood why my friends read books for fun. I met all the requirements to graduate high school with honors except completing ten classic literature novels. I still regret not graduating with that distinction, but at that time, it seemed so impossible.  

Starting in junior high, I had frequent headaches. My parents took me to the medical doctor, the dentist, and the optometrist. They prescribed medications, performed surgery, and told me I could see 20/20; however, the headaches continued. No one had taken the time to address the true cause of my problems growing up. All of their methods were Band-Aids. No one saw that I had trouble converging my eyes.
By the time I began college, my academic workload tripled; I was studying large amounts. The headaches increased. I started to realize that I was unconsciously covering my left eye while reading textbooks. I then knew something wasn’t right with my vision. I soon had reading glasses with prism that alleviated my symptoms for a while. When I arrived at optometry school, I learned about convergence insufficiency, the world of vision therapy, and ultimately behavioral optometry.  

I soon realized that my symptoms were not unique, and it made me realize that others were also out there undiagnosed with a range of visual conditions. It made me question what was happening with the children who were struggling with reading novels but didn’t have the same support or role models like my siblings? What about the children who had symptoms worse than mine? That’s when I read Dr. Paul Harris’s article from OEP, The Prevalence of Visual Conditions in a Population of Juvenile Delinquents. I was strongly moved and knew as an optometrist I could make an impact that could change the course of a child’s life; that was my future.  

Another spark that lit the fire of my passion is the testimony of Robin and Jillian Benoit.  I am thankful for their promotion of behavioral optometry as OEP speakers.  Jillian’s Story: How Vision Therapy Changed My Daughter’s Life as well as the numerous testimonies in Dear Jillian: Vision Therapy Changed My Life Too cemented to me that vision is more than 20/20.  

As I continue to learn more and dive into behavioral books, there is no doubt in my mind that behavioral optometry is my calling. There is an integrated and holistic approach, and I need to learn as much as possible about it to help my patients.
 
What got you involved with the OEP and how has your experience been with the foundation?
Actually, the reason I became involved with OEP is because of you, Nicholai!  So, thank you very much!  The first week of optometry school, you made a presentation as the OEP local liaison.  It caught my attention, and I knew immediately that I wanted to help you arrange OEP events at school. That opened the door into meeting wonderful guest speakers, impacting fellow students, serving two years as local liaison at IAUPR, and now serving as National Student Liaison for OEP. It has also lead to my growing library of amazing OEP books; books that I have read, and more books that I cannot wait to read!  This is something that I thought I would never say growing up!

My goal as National Student Liaison is to increase the presence of OEP to all schools of optometry in the U.S. and Canada. I want every student to take advantage of the great education OEP has to offer including the OEP curriculum courses, seminars, books, the Optometry & Visual Performance journal, its blog, and the Optometrists Change Lives program which makes speakers accessible to each school with the help of sponsors like HOYA.  Currently, I am working with local liaisons and OEP to arrange events across the country. My goal is for students to continue using OEP resources after they receive their diploma.   
My experience with the foundation has been nothing but fabulous. Everyone involved with OEP has been so welcoming and encouraging. It’s a relationship I plan to continue my entire life.
 
As part of the new generations of behavioral optometrists, how do you see yourself contributing to OEP after you cross that graduation stage?
One of my first steps after graduation is to obtain a yearlong residency.  My immediate goal is to learn as much as I possibly can from OEP members and resources. There is such a fountain of knowledge available, and I want to soak up as much information as possible to continue OEP.
Throughout my lifetime, I see myself making a positive contribution to and with OEP.  The foundation is doing great things in this world, and I want to continue being a part of it.  My ultimate goal is to serve on the OEP Board of Directors. Education is very important, and I can see myself as an OEP lecturer across the country and world.  
I also plan to perform research and write case reports to help progress the profession. As I learn from reading Optometry & Visual Performance, I would love to see my articles helping other practitioners through this outlet.  Currently, I am very thankful to be a part of this OVP blog and hope to continue to contribute to it for years to come.

Being affiliated with OEP also means being part of other networks such as BABO and ACBO. You recently spent time in Australia during your externship rotations and had an opportunity to spend time at the ACBO conference! Can you tell us a little bit about your experience?
Yes!  I spent time rotating through the clinics at the University of Melbourne and the Australian College of Optometry.  It was a great experience seeing optometry in a different country as well as meeting wonderful people and of course seeing some beautiful landscapes and amazing wildlife!
As soon as I knew I was going to Australia, I brought up the Australasian College of Behavioural Optometry’s website to find information on their meetings.  It was perfect timing because their annual conference featuring Dr. David Cook was during my time down under.

Everyone was very welcoming at the conference!  Dr. Cook engaged the audience as he shared on strabismus and amblyopia in his lecture titled, Seeing Beyond Illusion.  The new ICBO One app (which I recommend that you install on your phone) had an NACBO section which helped me integrate into the group.  By the way, the ICBO One app is free and provides a way for behavioral optometrists across the world to connect.  

One evening, there was a black tie affair with a “Phantom of the Ocular” themed dinner.  Everyone was dressed to the nines.  There was fascinating entertainment from an illusionist, honors and awards to outstanding optometrists and therapists, a fun photo-booth, and of course dancing!  Never have I seen a dance floor fill so quickly.  Australians know how to have a good time!  OEP executive director, Kelin Kushin was even burning up the dance floor.

I can’t wait for the 8th ICBO conference April 26-29, 2018 in Sydney!  Return to Oz!  I look forward to seeing you there!

Reviewed By:
Benoit Lamberts Brussels - Belgium - Europe www.visionandlearning.be


Chung K, Mohidin N, O’Leary DJ. Vision Research 2002;42:2555-9.
http://www.sciencedirect.com/science/article/pii/S0042698902002584

Myopia is not just a refractive condition that you can just compensate for with glasses, contact lenses, or even refractive surgery. I emphasize the semantic ”compensate” because, even with surgery where all the data should ideally show a situation close to plano, even if you no longer refract myopically, you ARE still a myope. In treatment for myopia, Sherwin J. Isenberg used the term management because the myopia is not cured. He stated that the use of the word cure indicates that the patient is being restored to his or her former state of health.
 
The prevalence of myopia in the adult population in most Eastern countries is upwards of 80%. The impact of myopia on the economic, social, and well being of the population may have irreversible impacts such as a higher risk for glaucoma and retinal detachment. Liang et al. confirmed high myopia is potentially associated with complications that may lead to blindness. The prevention of myopia is very important, especially among young children.
 
There are many studies addressing the why and how to cure myopia, or in a more realistic approach, how to slow down myopia. Investigations include acupuncture, the effect of ambient light, ortho-K, atropine, near add, dual or progressive addition lenses (PAL), and vision therapy (VT). The article presented is on the topic of under correction.
 
Ninety-four subjects (myopes aged 9-14 years) participated in the study for a period of 2 years. Half were given the full correction for full time wear and the other half was the under-corrected for a maximum visual acuity of 6/12 as part of a full examination. The exclusion criteria included more than 2 diopters of astigmatism in each eye, significant binocular problems, and abnormal ocular health.
 
The results of the 2 year study demonstrates a mean progression in the under-corrected group of -1.00D while in the fully corrected group, there was an increase of -0.77 D.  The study shows no significant differences in other ocular parameters nor in the reading hours.  
 
Some considerations about the methodology should be brought to the forefront.

1. The authors speak about a full optometric routine examination, but what is included in this examination?
2. How was “no binocular vision problems” determined ? What testing was completed ?
3. Follow up was performed every 6 months. Why was it not appropriate to get an appointment as soon as the subject noticed a decrease in his acuity ?
4. The study used a coin-toss method for randomization which was well explained
5. The initial refraction was on average -2.68 D but one could question if this was already too late or too high an amount to start off patients. What if they started with children with less myopia or myopia that had just started ?

 
Are there any other alternatives/recommendations to the criteria ?
 
The criteria of a VA of 6/12 seems to be inappropriate because crisper vision in school is needed for distance activities. No binocular vision testing appears to have been completed!
Interestingly, the research seems to demonstrate that during the first six months that the axial length did not change in either group, but there was already a change in the level of myopia! We could conclude there is a lag between the functional change and the organic change. Could we conclude that function leads the organ? In my opinion, a six month period for check ups is too long. I would recommend a 3 month period or sooner if a change in vision was reported.
 
Conclusion

Was the purpose of this research to demolish ideas, or perhaps create some awareness on how to lead visual care? As readers and eye care specialists, it is our role and responsibility to look closely. Reading just the title and the abstract is not enough and may mislead our judgment, and worse, mislead our patients. When reading new information we need to fully understand and have a positive but critical attitude to get and to share the right information for the benefit of our patients.

By: Jessica Ruxton (Class of 2019)
Midwestern University, Arizona College of Optometry

Doble JE, Feinberg DL, Rosner MS, Rosner AJ.  PM R. 2010 Apr;2(4):244-53. doi: 10.1016/j.pmrj.2010.01.011.  PMID: 20430325

Vertical heterophoria (VH) is a binocular vision dysfunction in which the eyes have different lines of sight. VH and traumatic brain injury (TBI) give rise to the same following symptoms: eye pain, dizziness, difficulty with reading, and psychological symptoms. When patients with both syndromes had a decrease in their symptoms after being treated with prism correction, the authors conducted a retrospective analysis investigating the relationship between VH and TBI as well as the effectiveness of the treatment. 

A database search from January 2005 to April 2008 revealed eighty-three TBI patients that had continued symptoms despite standard TBI treatment. Only forty-three had complete data sets and were included in the study. Baseline information indicated the majority of the TBI’s were caused by car accidents. The mean duration of symptoms was 3.6 years, and the mean duration of treatment was 3.6 months. Before and after prism was added to the spectacle correction, the patients completed the Vertical Heterophoria Symptom Questionnaire (VHS-Q) and subjectively ranked their symptom level with a percentage. The VHS-Q, developed by the authors, consisted of twenty-five questions assessing VH symptoms on a scale of zero to seventy-five. 

The mean baseline score from the VHS-Q was 34.8 points; after treatment, the mean difference was 16.7 points. The mean subjective improvement was 71.8%. Based on the patient’s head tilt, the magnitude and direction of prism was determined. The higher eye required base up and small amounts were added until the symptoms were maximally reduced. Within twenty to thirty minutes, the patients noticed improvement; this appeared to stay stable over time. On average, two to three months and three sets of lenses were needed to optimize the prescription, making this treatment cost and time efficient.  
Limitations to the study included the number of excluded patients, no placebo, and only one optometrist and one physiatrist treating the patients. The prevalence of VH in the TBI population could not be determined because of the sample size. However, from the authors’ experience, VH was very common in this group. Also, it was unlikely that a placebo would have affected the results as vertical prism has a noticeable effect. Those with VH noted a relief of symptoms, whereas those without VH developed symptoms when vertical prism was added to their prescription. 

The authors hypothesized that a traumatic brain injury leads to vertical heterophoria.  When the cause of VH was a TBI, the higher eye had a lower line of sight and saw a higher image. The elevator and depressor muscles compensated to avoid diplopia and became strained.  The transient diplopia and blur seen clinically was a result of this extraocular muscle fatigue.  Since the patient was stationary and the visual input was changing, this was perceived as dizziness. Diagnosing and treating VH has been very difficult in the past, but adding the appropriate amount of prism eliminated the strain on the extraocular muscles which in turn eliminated the other symptoms.