Post on 30-Jun-2018
transcript
5/13/15
1
Vision Therapy Services in a
Primary Care Practice Graham Erickson, OD, FAAO, FCOVD
Pacific University College of Optometry
Incorporation of Vision Therapy into Daily Practice
• 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
5/13/15
2
Copyright restrictions may apply."
Scheiman, M. et al. Arch Ophthalmol 2005;123:14-24.
Convergence Insufficiency Symptom Survey
• Review of key data: – Phorias: Normal at far, abnormally high exo at near – Low AC/A – Decreased Positive Relative Vergence (BO)at near
• Not uncommon to find reduced BI at near also • Poor Vergence Facility (more difficulty with BO)
– Decreased (receded) NPC or Capobianco method • Worsens with repetition
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
CONVERGENCE INSUFFICIENCY
Role of the AC/A
Blur “Neuro-optical”
Phasic Accommodation
AccommodativeAdaptation
Tonic Accommodation
Accommodative Response
Fixation Disparity
Phasic Vergence
Vergence Adaptation
Tonic Vergence
Vergence Response
AC/A
CA/C
• If target is at 40cm and PD = 60mm, convergence demand is 15Δ
• If Normal AC/A ~4/1 and accommodative response = 2.5D, the patient must exert slightly more than 5Δ of fusional and/or proximal vergence to achieve target fusion
• If AC/A ~2/1, the patient must now exert almost 10Δ of fusional/proximal vergence to achieve fusion
Role of the AC/A
• Vision Therapy (ETT:8-15 visits) – Home-Based Pencil Pushups? – Home-Based Computerized Therapy? – Office-Based Therapy?
• Base-In prism at near • Lenses (???)
Review of Treatment Prioritization
5/13/15
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
Phase 1 • 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
Phase 1
• 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
Phase 1
• 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?
Phase 1
5/13/15
4
• 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 1 Phase 1 & 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
PHASE II: Relative Vergence • Computer-Based Vergence Training
– Step vergence demands – Works in break/recovery zone – Random dot and multiple choice formats – Jump vergence format
Phase 2 VT Procedures for CI
• PHASE III: Open Space Vergence – Eccentric Circles/"Lifesaver" Cards – BIM/BOP Activities
• 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 3 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 +1.00
• Opposite for Divergence Activities
5/13/15
5
Issues for Office-Based Therapy
• Follow-up and Maintenance Therapy – 3 mo/6 mo
• Equipment needs/cost: – Barrel Cards $ – Brock Strings $ – Lifesaver Cards $ – Flippers $$ – Computer Vergence Program $$$
MANAGEMENT OF AMBLYOPIA
OCCLUSION THERAPY FOR AMBLYOPIA
• Occlusion methods – Total occlusion – Partial occlusion
TOTAL OCCLUSION
• Adhesive bandage (Opticlude, Coverlet) • Light Perception occlusion foil
(Bangerter) or clear contact paper • Patch (Pirate-style or patchworks) • Opaque contact lens
PARTIAL OCCLUSION • Bangerter occlusion foils (graded) • Over-plussed optical lens
– spectacle or contact lens • Atropine penalization
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
5/13/15
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.
5/13/15
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 $$$