—Amanda Zeller Manley, OD, FCOVD
R.M., a 28-year-old man, was getting headaches more and more frequently when using a screen. As someone who spent most of his workday on the computer, this was a problem. A previous eye doctor told him he was out of luck, too old to fix his problem. R.M. had amblyopia, and his new eye doctor had referred him to me.
Last weekend was the 61st Annual Kraskin Invitational Skeffington Symposium (KISS), held in Bethesda, MD. One of the most exciting presentations was given by Dr. Paul Harris, a prolific author, developmental optometrist and professor at Southern College of Optometry. He reported that a group of scientists and clinicians are preparing a publication with new clinical guidelines on the treatment of amblyopia.
The old paradigm for amblyopia treatment is something most people are familiar with to some degree– patching. I think most adults can think back and remember a child at school wearing a stick-on eye patch, and probably getting teased about it. While patching can temporarily improve visual acuity (how many letters you can read off the eye chart), it does nothing to improve the other visual problems present in amblyopia, such as difficulties with eye strain, visual crowding, contrast sensitivity, and using the eyes as a team (among others).
Newer research has shown that not only is patching not the best method of treating amblyopia, it’s not even necessary except during active therapeutic activities. Instead, treating the entire visual system –as a system— produces superior results that last. The key is that amblyopia is not a “lazy eye”, but rather a problem in how the brain uses the two eyes.
It’s interesting that using whole system, or binocular vision, techniques is described as “NEW“, when Developmental Optometry has been doing this clinically for a hundred years.
Developmental optometrists had been using binocular vision perceptual learning techniques for decades before the concept hit the mainstream in research. In the last 25 years, perceptual learning as it relates to vision therapy has been discussed more and more in the fields of psychology and vision science. Many computer games have been developed that capitalize on perceptual learning to develop true and lasting visual skills. However, I and my developmental optometry colleagues have found that working in 3D space (rather than a flat 2D screen) generates a knowledge of “Where am I?” and “Where is it?” that more easily translates into real-world visual scenarios.
Another important acknowledgement in the current scientific literature is that there is no cutoff age for improvement of visual skills and development of binocular 3D vision. Instead, using a binocular vision approach to therapy in conjunction with appropriate compensation of refractive error (glasses or contact lenses), yields excellent results. This mirrors what we have seen clinically. Adult patients frequently reach normal or near-normal levels of visual performance, and in nearly all cases see significant improvements in quality of life.
Publishing new treatment guidelines, taking into account all of the data supporting established developmental optometry clinical therapies, will bring amblyopia remediation out of the dark ages and provide hope to so many patients who have been told, “It’s too late for you.”
As for R.M., as he completed vision therapy, he no longer experienced headaches and eye strain. He was more productive at work, and very happy that his efforts had paid off. He wasn’t too old, after all!
For the nerds, some additional papers on perceptual learning, adult amblyopia, and vision:
It is important to understand that while our eyes take in visual information, that information is sent to the brain where it is processed. If the information that is sent to the brain is faulty, it can make learning very difficult.
While learning disability websites list a variety of accommodations that can help children with Visual Information Processing Disorders, it is important for parents and educators to understand that these are signs that a correctable vision problem is playing a role in a child’s learning challenges.
Many individuals with learning disabilities also have ADHD (Attention Deficit Hyperactivity Disorder). One of the signs that a vision problem may be contributing to one’s learning challenges is a short attention span when it comes to reading and near work. This behavior could easily be mistaken for ADHD.
A study published in the November 2013 issue of the Journal of Attention Disorders states that “attention and internalizing problems improved significantly following treatment for Convergence Insufficiency.” Convergence insufficiency is an eye coordination disorder which can make reading difficult and cause symptoms such as eye strain, double vision, loss of concentration, and frequent loss of place when reading and working up close, all which play a negative role in learning.
The National Eye Institute of the National Institutes of Health recently funded a 5-year, 8 million dollar study called the Convergence Insufficiency Treatment Trial – Attention and Reading Study (CITT-ART). This will be a national multi-center clinical trial that involves optometry, ophthalmology, psychiatry, and education in evaluating how this eye-teaming problem impacts a child’s attention and reading performance.
These studies are very exciting because we are sure they will prove what we have seen in our patients over the years: Vision problems, including eye coordination and eye movement disorders, can and do impact the ability to read and pay attention. We are able to help children and adults.
For more information visit our website: http://www.VisionTherapyDC.com
April is National Autism Awareness Month, and there has been a lot of information in the news about the rising rates of autism spectrum disorders. The CDC now estimates that as many as 1 in 68 children are now being diagnosed with ASD. This is particularly frightening as it’s not well understood what is behind this abrupt rise.
While such research is ongoing, it’s important to consider what we as parents and providers can do right now to improve the quality of life of those with ASD. The College of Optometrists in Vision Development (COVD) has issued a press release discussing the impact of vision in ASD:
“While the search to find the exact cause for ASD is ongoing, the visual link to autistic behaviors provides some answers and help to improve quality of life,” states COVD President, Dr. Ida Chung, O.D., FCOVD.
The most recent Review of Optometry has three news items emphasizing the importance of infant and child eye and vision evaluation– not just a screening done by the pediatrician or school nurse.
The first describes how retinoblastoma, a rare but potentially fatal eye cancer found in children, can be detected by the appearance of a white pupil in baby photos. It used to be thought that early stage eye cancer couldn’t be detected this way, but a recent study found that early disease in a child as young as 12 days can be visible as a white pupil.
When treated early, retinoblastoma is often curable.
Next, a new study shows that in children with autism, changes in visual behavior can be
detected in the first few months of life. The children that were later diagnosed with autism started out showing normal eye contact with caregivers, but over the next several months their eye contact decreased. Decrease in eye contact began somewhere between two and six months of age. Since the social interaction (eye contact) started out intact, it suggests that there may be another opportunity for early intervention in autism.
Finally, researchers in Sweden discovered that children born before 32 weeks gestational age had a much higher– up to 19 times– risk for retinal detachment by adolescence or young adulthood. The risk for retinal detachment increased with age. So for children born prematurely, it’s very important to have annual dilated eye examinations. It’s also critical to know the signs and symptoms of a retinal detachment: sudden onset or sudden increase of floating spots in the vision, which may look like hairs, cobwebs, or debris in the visual field; flashes of light in the affected eye; and what may look like a curtain or shadow over part of the visual field. If a person notices any of these symptoms, it’s critical to contact an eye care provider immediately. A retinal detachment is an emergency, and the sooner it can be repaired, the more likely the person’s sight can be saved.
If you have any concerns about your child’s developing vision, the first step is a comprehensive eye and vision evaluation. The American Optometric Association sponsors a public health initiative called InfantSEE, which provides no-cost examinations to children between 6 and 12 months of age. Infantsee.org can help you find a participating provider in your area. Yearly eye examinations are also now covered by all insurances as an essential benefit for children under 19 as a part of the Affordable Care Act.
At the Vision & Conceptual Development Center, we provide evaluation and non-invasive, non-surgical treatment for a variety of vision disorders, including Convergence Insufficiency, Strabismus (eye turn), Amblyopia (lazy eye), problems with tracking, Visual Perceptual disorders, and visual anomalies secondary to developmental delay, autism, concussion, stroke, or brain injury. We are also InfantSEE providers.
I recently had a discussion with a parent about behavior and vision problems. A mom of
one of our patients told me that the biggest change she has noticed is that,
“It’s not nuclear war anymore,”
when she tells her daughter it’s homework time. This makes perfect sense to me, and we hear similar stories all the time. If you, as an adult, were asked to do something frustrating,
arduous and painful, on a daily basis, you would eventually refuse. You might even throw a temper tantrum.
Maud at AwfullyChipper wrote to me that
“I really want to make others aware of vision therapy because I know there must be many children out there who’ve just been labelled slow readers (or disruptive, ADD, etc.) when in fact they have vision difficulties. I hope I can help spread the word.”
In fact, studies have been published showing that, indeed, “adverse academic behaviors” decrease following successful treatment for Convergence Insufficiency, one of the more common binocular vision problems we see. The behavior questions used in the study were:
It’s important to note that there are other symptoms that may point you to a vision problem. For a more comprehensive list, see our Weighted symptom checklist.
—Amanda Zeller Manley, O.D., F.C.O.V.D.
It’s always nice when research proves the benefit of what we’ve already been doing in clinic.
For the last several years, as e-readers have become more prevalent, I have been recommending them to many of my patients. In our clinic, we have found that by increasing the font size (which also increases letter/word spacing and decreases the number of words per line), many of our vision therapy patients report that they can read more quickly, with better comprehension and less fatigue.
So I was quite pleased to hear an NPR story a few days ago about a study described in the journal PLOS ONE. Researchers had dyslexic students read on specially formatted iPods or printed text. For many of the students, reading on the iPods (limited to about 3 words per line) greatly improved their reading speed and fluency.
The lead researcher, Matthew Schneps, director of the Laboratory for Visual Learning at the Harvard-Smithsonian Center for Astrophysics, postulates that the mechanisms involved include visual attention span; saccades (the small word-to-word eye movements we make when reading); and visual crowding. By limiting the amount of text per line, deficiencies in those areas don’t have the same effect as when a person reads a normally printed page.
What I find interesting is that in the article, there was no mention of whether these students had had a comprehensive vision examination to look for oculomotor dysfunction, convergence problems (excess or insufficiency), or other binocular vision disorders. In numerous other publications, there have been links between dyslexia and eye movement disorders and binocular vision problems. In many studies of learning disabilities and vision disorders, it has been found that up to 70% of students who have been diagnosed with a learning disability have a vision problem that may be causing or exacerbating that learning difficulty. It would be interesting to see whether the population described in Dr. Schneps’s study has a similar incidence of vision problems.
Fortunately, vision therapy has shown to be a very effective tool in eliminating the underlying visual problems that interfere with reading and learning. And in the meantime, an iPod fits neatly in your pocket.
The September issue of Vision & Learning News has news you can use, just in time for back to school. Are your kids having vision issues that keep them from learning as well as they should? Are they working too hard to get their homework done?
The 5 most common signs that a vision problem may be interfering with your student’s ability to read and learn are:
Just one of these symptoms could mean that your child is struggling with a vision problem.Call today to schedule a developmental vision evaluation: (301) 951-0320
Visit our website for a complete symptom checklist.
Find our previous newsletters on our website.
Please join us for a very special evening. Dr. Harry Wachs and Dr. Serena Wieder will discuss their new book, Visual/Spatial Portals to Thinking, Feeling and Movement: Advancing Competencies and Emotional Development in Children with Learning and Autism Spectrum Disorders
This long-awaited text provides therapists and parents interventions for use at home, school, and therapy offices. Involving affect-based Floortime approaches and other problem-solving experiences, these strategies address unrecognized challenges that often derail life competencies, learning, and development. More about the book and authors here.
Thursday, February 28, 2013, 7pm
The event will be held at our office:
The Vision & Conceptual
6900 Wisconsin Avenue, Ste 600
Chevy Chase, MD 20815
We will be serving wine and cheese, so please RSVP to help us plan.
R.S.V.P. to Canden Webb, Patient Care Coordinator Canden@VisionTherapyDC.com or 301-951-0320 to receive entry instructions.