Incorporation of Vision Therapy into Daily Practice. Vision Therapy Services in a Primary Care Practice. Considerations. Management Considerations

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1 Incorporation of Vision Therapy into Daily Practice Vision Therapy Services in a Primary Care Practice Graham Erickson, OD, FAAO, FCOVD Pacific University College of Optometry Adequate data Consultation Explanation of problems Presenting treatment options Estimation of vision therapy duration and prognosis for success Establishing goals Establishing goals for the patient Determining realistic endpoints for therapy Considerations Patients may prefer home-based VT due to: Cost Time Distance OD may prefer home-based VT due to: Space Staffing Patient base Equipment needs Management Considerations Patient motivation Frequency of office visits Length of office visits Office visit records Maximizing home-based activities and establishing short-term goals Monitoring patient progress Finishing a vision therapy program Home-Based VT Management Rent or Sell VT equipment set Factor in staff time for equipment acquisition and kit creation If renting, factor in replacement costs Prepare written instructions for each of the procedures prescribed Follow-up and Maintenance Therapy Monthly Progress Evaluations Post - VT Progress Eval s at 3 mo. and 6 mo. CONVERGENCE INSUFFICIENCY Review of key problems: Symptoms on Case History Give the patient a C.I.S.S. Convergence Insufficiency Symptom Survey Validated for 9-18 y.o. s Score >16 suggests abnormal symptoms Beware of overlap w/accommodative symptoms 1

2 Convergence Insufficiency Symptom Survey CONVERGENCE INSUFFICIENCY Review of key data: Phorias: Normal at far, abnormally high exo at near Low AC/A Decreased Positive Relative (BO)at near Not uncommon to find reduced BI at near also Poor Facility (more difficulty with BO) Decreased (receded) NPC or Capobianco method Worsens with repetition Scheiman, M. et al. Arch Ophthalmol 2005;123: Copyright restrictions may apply." CONVERGENCE INSUFFICIENCY Review of key data: Effects on Accommodative Testing Decreased plus acceptance on FCC MEM? Decreased NRA Reduced Binocular Accommodative Facility More difficulty with plus Normal monocular facility results Blur Neuro-optical Fixation Disparity Role of the AC/A Accommodative Adaptation Phasic Accommodation Phasic Adaptation Tonic Accommodation AC/A CA/C Tonic Accommodative Response Response Role of the AC/A If target is at 40cm and PD = 60mm, convergence demand is 15 Δ If Normal AC/A ~4/1 and accommodative response = 2.5D, the patient must exert slightly more than 5 Δ of fusional and/or proximal vergence to achieve target fusion If AC/A ~2/1, the patient must now exert almost 10 Δ of fusional/proximal vergence to achieve fusion Review of Treatment Prioritization Vision Therapy (ETT:8-15 visits) Home-Based Pencil Pushups? Home-Based Computerized Therapy? Office-Based Therapy? Base-In prism at near Lenses (???) 2

3 General VT Considerations for CI Relative ease or difficulty: Primary objectives and goals: Normalize gross convergence Develop voluntary convergence Normalize positive fusional vergence amplitudes Normalize binoc. accom. amplitude and facility Normalize negative fusional vergence amplitudes Normalize positive & neg fusional vergence facility Typical length of therapy: 8-12 weeks Home-Based = 4-5 sessions VT Procedures for CI PHASE I: Gross Convergence NPC Procedures Brock String 3-Dot/Barrel Card Brock String Monitors suppression Monitors vergence posture Modifiable Distances Ramp vs Step/Jump Lenses Prisms Voluntary Brock String: Step 1 NPC (bead pushup) Work in the break/recovery zone Emphasize clarity and fusion Can add plus lenses Can add look-aways at recovery point Brock String: Step 2 Bead Jumps Set near bead at NPC recovery point Other 2 beads spaced at intermediate distances Emphasize clarity and fusion Can add Plus lenses Can add BO prisms Can add look-aways Can add target movement and non-primary gazes Brock String: Step 3 Bug-on-a-String Set near bead at ~40 cm Imaginary bug walking up the string Emphasize slow movement of X Can add look-aways Why is this step important? 3

4 5/13/15 Allbee 3-Dot (Barrel) Card Extreme NPC procedure Assist with cut card and pushup Assist with minus lenses Add look-aways Challenge with plus lenses Phase 2 PHASE II: Relative Computer-Based Training Step vergence demands Works in break/recovery zone Random dot and multiple choice formats Jump vergence format Phase 3 Eccentric Circles/"Lifesaver" Cards 1. Smooth/Step vergence Use pointer to help achieve fusion Monitor suppression/fusion Pushups 2. Jump vergence Look-aways Pursuits 3. BIM/BOP therapy & Phase 2 Accommodative Activities (Binocular) Start with monocular therapy as needed Move to binocular distance rock and flippers when ready Near-Far vs Flippers Emphasize clarity Emphasize speed VT Procedures for CI PHASE III: Open Space Eccentric Circles/"Lifesaver" Cards BIM/BOP Activities BIM / BOP BIM: Base-In prism and Minus lenses BOP: Base-Out prism and Plus lenses For Convergence Activities (and Exo s): BIM assists fusion BOP challenges fusion Example: Opaque Lifesaver Card thru Opposite for Divergence Activities 4

5 5/13/15 Issues for Office-Based Therapy MANAGEMENT OF AMBLYOPIA Follow-up and Maintenance Therapy 3 mo/6 mo Equipment needs/cost: Barrel Cards $ Brock Strings $ Lifesaver Cards $ Flippers $$ Computer Program $$$ OCCLUSION THERAPY FOR AMBLYOPIA Occlusion methods Total occlusion Partial occlusion PARTIAL OCCLUSION Bangerter occlusion foils (graded) Over-plussed optical lens spectacle or contact lens Atropine penalization TOTAL OCCLUSION Adhesive bandage (Opticlude, Coverlet) Light Perception occlusion foil (Bangerter) or clear contact paper Patch (Pirate-style or patchworks) Opaque contact lens Atropine Protocols Sound eye gets 1% atropine Daily vs weekend ung vs. gtts Amblyopic eye optically corrected Sound eye +/- Rx Duration of cycloplegia may not be as long as we think 5

6 Atropine Protocols Give handout regarding dilated pupil (sun effects, ER, etc.) Best for moderate-high hyperopia with shallow-moderate amblyopia Issues of binocularity ATS1 & ATS4 Considerations for occlusion method Cosmesis Compliance Age VA and performance needs Binocularity issues Amount: 2 hours/day Increase up to 6 h/day as needed ACTIVE VISION THERAPY Rationale Increase efficacy of occlusion therapy Reduce treatment time Improve visual deficits Better results with older amblyopes ACTIVE VISION THERAPY Common Visual Deficits Poor form discrimination Deficient accommodative skills (amplitude, accuracy & facility) Deficient eye movement skills Central suppression Deficient vergence skills ACTIVE VISION THERAPY P1: Monocular Activities P2: Monocular in Binocular Field Activities P3: Binocular Activities Caveats: Fast-Pointing Activities Resolution vs. Spatial localization activities Computer therapy options Experimental Game May Benefit Kids With Amblyopia 1/23/15 JAMA Ophthalmology: research suggests that youngsters with amblyopia who underwent treatment with an experimental video game on an ipad not only had improved vision similar to using a patch, but also retained their vision improvements for a whole year. 6

7 Monocular Therapy Activities Eye-hand coordination (throwing, hitting, tracing, picking up, etc.) Resolution activities (hidden pictures, letter searches, card games, etc.) Accommodative amplitude and facility (monocular) Near-Far vs Flippers Monocular in Binocular Field Activities Anaglyphic or Polarized TV Trainer and Bar Reader Anaglyphic tracing books, playing cards, workbooks Anaglyphic computer therapy programs Binocular Therapy Accommodative amplitude and facility (binocular) Computer programs for vergence amplitude and facility COMPLIANCE ISSUES Education of parents, patient, teacher, etc. Parents need to champion this cause Decorate patches & Eye Patch Club Home activity kits with instructions Track and demonstrate improvements in-office Issues for Office-Based Therapy Follow-up and Maintenance Therapy 3 mo/6 mo Equipment needs/cost: Monocular activities $ Anaglyphic materials $$ Flippers $$ Computer Program $$$ 7