To BV or Not to BV:VT in the Primary Care Office

To BV or Not to BV:
VT in the Primary Care Office
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor
Illinois Eye Institute
Illinois College of Optometry

Private Practice
Harwood Heights, Il.

Non-strabismic BV disorders

Prevalence
• Convergence Insufficiency: 1.3% to 37% of
the population; most report 3-5%
• Convergence Excess: ~6%
• Accommodative disorders: 3-5%

Subjective Complaints of
Patients with BV Disorders

• Blur
• Headache
• Aesthenopia
• Diplopia
• These complaints are usually
associated with near work

Visual Efficiency Examination:
Basic Tests
• Visual acuity
– May find reduced acuity at
near or complaints of
blur at near (intermittent problems)
• Cover test
– Distance and near
– Repeat during the exam to see if
fatigue changes your result
• Nearpoint of convergence
– Repeat several times

Basic Tests
• Visual acuity
– near or complaints of
– blur at near
• Cover test
fatigue changes your result

Basic Tests
• Visual acuity
– near or complaints of
– blur at near
• Cover test
– fatigue changes your result

Basic tests

• Stereopsis
– Look for reduced steropsis
• Less than 70 seconds of arc
• Accommodative amplitude
– Either push-up method or minus lens method
– Minimum amplitude = 15 - (0.25) age
– So a 20 year old should have at least 10
diopters of accommodation

Basic tests
• Accommodative facility
– Perform monocularly and binocularly
with suppression control (+/-2.00)
• ~10 cycles per minute is diagnostic
• Vergences
– Use either prism bars or Risley prisms
– Sheard’s criteria
• Need twice your phoria in reserve
• Example: a 10 pd exophore at near needs 20 pd BO
reserves

Basic tests
• Accommodative facility
– Perform monocularly and binocularly
– with suppression control (+/-2.00)
• ~10 cycles per minute is diagnostic
• Vergences
– Use either prism bars or Risley prisms
– Sheard’s criteria
• Need twice your phoria in reserve
• Example: a 10 pd exophore at near needs 20 pd BO
reserves

Other tests

• Phorias
– Von Graefe phorias
– Maddox Rod techniques
• Suppression
– Worth 4 Dot

Other Tests

• Dynamic Retinoscopy
– Monocular Estimation Method
– Expected Values: +0.50 to +0.75 D
• Fixation Disparity Testing
– Wesson Card
– Bernell Fixation Disparity (Associated Phoria)
– Disparometer

Other Tests

• Fixation Disparity
Testing
– Wesson Card
– Bernell Fixation
Disparity (Associated
Phoria)
– Disparometer

Common BV Syndromes

• Convergence Insufficiency
– Most common syndrome
– Symptoms: aesthenopia, headaches,
blur, diplopia, loss of concentration
• associated with near work
• often occur near the end of the day

Convergence Insufficiency

• Signs:
– An exodeviation at near
• Can even be an intermittent exotropia at near
– Receded NPC value
• NPC larger than 10 cm
– Reduced BO vergences at near
• Often fail to meet Sheard’s criterion

Convergence Excess

• Symptoms: Diplopia, headaches,
aesthenopia
– almost always near related
• Signs:
– Esophoria at near
• Use detailed accommodative target or you may miss
the esophoria
– Vergences
• BI vergences at near may not compensate

Convergence Excess

• Signs
– Dynamic Retinoscopy
• May be the most significant test
• Typically a high lag of accommodation
• Lag may be +1.00 to +2.00 DS at 40 cm
• Lags greater than +2.50 D at 40 cm should suggest
uncorrected hyperopia

Fusional Vergence Dysfunction

• Symptoms: aesthenopia, headaches, blurred
vision (Binocular Vision/Visual Discomfort Dx)
– Associated with reading or near work
• Signs:
– Phorias: Normal at distance and near
– Reduced BI and BO vergences at distance
and/or near

Accommodative Disorders

• Symptoms: blur,
headache,
aesthenopia, fatigue
when reading,
difficulty changing
focus from one
distance to another

Accommodative Disorders

• Signs
– Accommodative Insufficiency:
• Reduced amplitude of accommodation
• Minimum Accommodation: 15 - (0.25) (age)
– Accommodative Infacility
• Failure of monocular facility testing
• Expected value: 11 cpm

Other BV Disorders

• Divergence Excess
– Prevalence of ~0.5 to 4%
– Exophoria greater at distance than near
– Frequently first discovered in grade school
• Divergence Insufficiency
– Very rare!
– Esophoria greater at distance than near
– Be careful to rule out lateral rectus palsy!

Strabismus & Amblyopia

3-5% of the population
Tx appropriate at all ages
May do out of office VT
and achieve success!

Exotropia

CI, Intermittent XT @ near

DE, Intermittent XT @ distance

Accommodative Esotropia

First seen in 2-4 year olds

Uncorrected hyperopia

High ACA

Diplopia & Head Turns/Tilts

Paresis or paralysis?

Duane’s Retraction
Syndrome

Amblyopia

Pathological until proven otherwise

Infants/Toddlers

Young Children

Busy Adults

Amblyopia

Pathological until
proven otherwise Anisometropia
Infants/Toddlers Bilateral Refractive Error

Young Children Strabismus (Constant)

Busy Adults

Treatment for BV Disorders
Evidence Based Medicine
Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in non-
strabismic accommodative and vergence disorders. Optometry. 2002;73(12):735-62

Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus pencil
pushups for the treatment of convergence insufficiency in young adults. Optom Vis Sci.
2005 Jul;82(7):583-95.
…vision therapy/orthoptics was the only treatment that produced clinically significant
improvements in the near point of convergence and positive fusional vergence.

Scheimann M et al. Randomised clinical trial of the effectiveness of base-in prism
reading glasses versus placebo reading glasses for symptomatic convergence
insufficiency in children. Br J Ophthal 2005;89(10):1318-23.
Base-in prism reading glasses were found to be no more effective in alleviating
symptoms, improving the near point of convergence, or improving positive
fusional vergence at near than placebo reading glasses for the treatment of
children aged 9 to <18 years with symptomatic CI.

Solan H et al. M-cell deficit and reading disability: a preliminary study of the
effects of temporal vision-processing therapy. Optometry. 2004 Oct;75(10):640-
50.

This research supports the value of rendering temporal vision therapy to children
identified as moderately reading disabled (RD). The diagnostic procedures and
the dynamic therapeutic techniques discussed in this article have not been
previously used for the specific purpose of ameliorating an M-cell deficit.
Improved temporal visual-processing skills and enhanced visual motion
discrimination appear to have a salutary effect on magnocellular processing and
reading comprehension in RD children with M-cell deficits.


Solan H et al. Is there a common linkage among reading comprehension, visual
attention, and magnocellular processing? J Learn Disabil. 2007 May-
Jun;40(3):270-8.

Solan H et al. Role of visual attention in cognitive control of oculomotor readiness in
students with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18.
Eye movement therapy improved eye movements and also resulted in significant gains in
reading comprehension.


Cotter S et al. Treatment of strabismic amblyopia with
refractive correction. Am J Ophthalmol. 2007
Jun;143(6):1060-3.

These results support the suggestion from a prior study that
strabismic amblyopia can improve and even resolve with
spectacle correction alone.

Scheimann M et al. Randomized trial of treatment of amblyopia in children
aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47.

Amblyopia improves with optical correction alone in about one fourth of
patients aged 7 to 17 years, although most patients who are initially treated
with optical correction alone will require additional treatment for amblyopia.
For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching
with near visual activities and atropine can improve visual acuity even if the
amblyopia has been previously treated. For patients 13 to 17 years,
prescribing patching 2 to 6 hours per day with near visual activities may
improve visual acuity when amblyopia has not been previously treated

• Treatment modalities
– Lenses
– Prisms
– Vision therapy
• Traditional therapy
• Computer therapy

Lenses as Treatment
Best Rx (clarity, comfort, function)
Refractive Error Amblyopia Binocularity Interference Rx if….
Concern Concerns with
Learning

Myopia >5.00D Under correct Depends >5.00D (any age)
eso/Fully on child’s >3.00D @>1yr
correct exo
age
Hyperopia >2.00D Under correct >2.50D >2.00D
exo/Fully
correct eso
Astigmatism >1.25D Depends >1.25D
on VA
Anisometropia >1.00D Monitor >1.00D >1.00D
BV/Stereo

Lenses as Treatment

• Best Rx (clarity, comfort, function)
• Accommodative disorders
– Can prescribe reading only Rx or an add
• Exodeviations
– Overminusing (DE)
– Not usually a first choice! Give add

Bifocals for Kids

Bifocal Seg Height

Infants/Toddlers
Pre-schoolers
Bi-sect pupil

Bifocals for Kids

Bifocal Seg Height

3-5 Years
Bottom 1/3 of Pupil

Bifocals for Kids

Bifocal Seg Height

> 5yrs
Bottom of Pupil

Bifocals for Myopia Progression
Gwiazda JE, Hyman L, Norton TT, Hussein ME,
Marsh-Tootle W, Manny R, Wang Y, Everett D;
COMET Grouup.
Accommodation and related risk factors associated
with myopia progression and their interaction with
treatment in COMET children.
Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143-
51.

Bifocals for Myopia Progression
. PALs were effective in slowing progression in these children, with
statistically significant 3-year treatment effects (mean +/- SE) for
those with larger lags in combination with near esophoria (PAL -
SVL progression = -1.08 D - [-1.72 D] = 0.64 +/- 0.21 D), shorter
reading distances (0.44 +/- 0.20 D), or lower baseline myopia (0.48
+/- 0.15 D). The 3-year treatment effect for larger lags in
combination with more hours of near work was 0.42 +/- 0.26 D,
which did not reach statistical significance. Statistically significant
treatment effects were observed in these four groups at 1 year and
became larger from 1 to 3 years. CONCLUSIONS: The results
support the COMET rationale (i.e., a role for retinal defocus in myopia
progression). In clinical practice in the United States children with
large lags of accommodation and near esophoria often are prescribed
PALs or bifocals to improve visual performance. Results of this study
suggest that such children, if myopic, may have an additional benefit
of slowed progression of myopia.

Prism as Treatment

• Can be used with CI, CE, DI, DE, Vertical
Deviations
• Prescribe the least amount of prism needed
– Determine the associated phoria with a Wesson
Card or Bernell Box
• Fresnel Prism trial, then Rx

Vision Therapy as Treatment

• The approach of choice for CI, Fusional
Vergence Dysfunctions, accommodative
disorders, and Amblyopia
– High chance of success with these disorders
– Results are typically long lasting
– Often can treat these disorders using primarily
home VT with in-office check-ups


• Traditional therapy
– Hand-eye, Vergence and Accommodative
procedures
• Computer Therapy
– Can attack hand-eye, vergence, accommodative
and oculomotor problems (Vision information
processing anomalies?)

Vision Therapy for Amblyopia

• Prescribe Rx
• Implement occlusion therapy
• Active vision therapy
• Monitor
• Change Rx/Tx as needed

Period of Sensitivity
vs
Period of Plasticity

Atropine
Repka MX, Cotter SA, Beck RW, Kraker RT,
Birch EE, Everett DF, Hertle RW, Holmes
JM, Quinn GE, Sala NA, Scheiman MM,
Stager DR Sr, Wallace DK; A randomized
trial of atropine regimens for treatment of
moderate amblyopia in children.
Ophthalmology. 2004 Nov;111(11):2076-
85.

Atropine
OBJECTIVE: To compare daily atropine to weekend atropine as prescribed
treatments for moderate amblyopia in children younger than 7 years.
PARTICIPANTS: One hundred sixty-eight children younger than 7 years with
amblyopia in the range of 20/40 to 20/80 associated with strabismus,
anisometropia, or both. INTERVENTION: Randomization either to daily
atropine or to weekend atropine for 4 months. Partial responders were
continued on the randomized treatment until no further improvement was
noted.
MAIN OUTCOME MEASURE: Visual acuity (VA) in the amblyopic eye after 4
months.
RESULTS: The improvement in VA of the amblyopic eye from baseline to 4
months averaged 2.3 lines in each group. The VA of the amblyopic eye at study
completion was either (1) at least 20/25 or (2) better than or equal to that of the
sound eye in 39 children (47%) in the daily group and 45 children (53%) in the
weekend group. The VA of the sound eye at the end of follow-up was reduced
by 2 lines in one patient in each group. Stereoacuity outcomes were similar in
the 2 groups.
CONCLUSIONS: Weekend atropine provides an improvement in VA of a
magnitude similar to that of the improvement provided by daily atropine in
treating moderate amblyopia in children 3 to 7 years old.

Atropine

Pediatric Eye Disease Investigator Group. The
course of moderate amblyopia treated with
atropine in children: experience of the
amblyopia treatment study.
Am J Ophthalmol. 2003 Oct;136(4):630-9.

Atropine
PURPOSE: To assess the course of the response to atropine treatment of
moderate amblyopia and to assess factors predictive of the treatment
response in children 3 years old to younger than 7 years old.
METHODS: A total of 195 children 3 years old to younger than 7 years
of age with amblyopia in the range of 20/40 to 20/100 from the atropine
treatment arm of this trial were enrolled and included in this analysis.
At baseline, daily topical atropine was prescribed for the sound eye.
During follow-up, a plano spectacle lens was prescribed for the sound
eye for patients whose amblyopia had not been successfully treated
with atropine alone. Follow-up examinations were performed at 5
weeks, 16 weeks, and 6 months. The primary outcome measure was
visual acuity in the amblyopic eye at 6 months.
CONCLUSIONS: A beneficial effect of atropine is present throughout the
age range of 3 years old to younger than 7 years old, and with an
acuity range of 20/40 to 20/100. A shift in near fixation to the
amblyopic eye is not essential for atropine to be effective in all cases.
Sound eye acuity should be monitored when a plano spectacle lens is
prescribed for the sound eye to augment the treatment effect of
atropine.

Occlusion Therapy
Age (yrs) Per Day Schedule Minimum Exam
Frequency

1 4 60min periods 1 day on/1 day off Weekly
2 3 30min periods 2 day on/1 day off Every 2 wks

Amblyopia Therapy

What do we know about
amblyopia?
– More than decreased VA
– Visual-Spatial affects
– Accommodation
– Hand-eye
– Stereopsis

Active Vision Therapy

Hand-eye
Oculomotor
Accommodation

Have child “Do Stuff”
Interact with environment

Roberts CJ, Adams GG.
Contact lenses in the management of high anisometropic amblyopia. EYE.
2004;18(1):109-10

PURPOSE: Anisometropia of more than one dioptre during the sensitive visual period may
cause amblyopia. Its management requires refractive correction, and occlusion.
Compliance with treatment is critical if visual improvement is to obtained. High
anisometropia, poor initial acuity and mixed strabismic/anisometropia amblyopia are
predictive factors for a poor outcome. We evaluated contact lens use in the management
of high anisometropic amblyopia.
METHODS: Retrospective analysis of anisometropic amblyopia managed in a paediatric
contact lens clinic after standard amblyopia therapy of spectacles and occlusion therapy
had been tried.
RESULTS: Seven children (four male, three female) presented at age 3.5-6 years (mean 4.5).
Six had myopic anisometropia 6.0-18.4 dioptres (mean 10.4 dioptres) and one 6.75
dioptres hypermetropic anisometropia. The initial corrected acuities of the amblyopic
eyes were 6/18 to 1/60. Five patients used contact lenses with a range from 5 months to 4
years. Final acuities were 6/12-1/60. Two myopes with 6 dioptres anisometropia
improved three to four Snellen lines, one with 8.8 dioptres improved one line. Three with
>10 dioptres anisometropia did not improve. The hypermetropic patient improved part
of one Snellen line.
CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study
contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres.


Phases of Therapy
• Monocular (HE, OM, ACC)
• Biocular (HE, OM, ACC, Anti-suppression)
• Binocular (Vergence, Acc)
• Integration/Stabilization
Do it all at the same time!

Traditional Therapy Procedures

• Hand-Eye Procedures
– mazes
– dot to dot
– cutting
– coloring
– filling in O’s

Traditional Therapy Procedures

• Vergence procedures
– Brock String
– Lifesaver card
– Anaglyph Series (BC920, others)
• Accommodative Procedures
– Minus lens dips
– Flippers
– Hart Chart

Vergence Procedures

Brock String
Simple
Inexpensive
Easy
Effective

Vergence Procedures

Life Saver Cards

BO and BI
Good fusion
Anti-suppression
Inexpensive
Effective

Vergence Procedures

Fusion Cards
Random dot
targets
BC 920, BC 50
Anaglyph series

Vergence Procedures

Aperture Rule

“Flying W”

Stereoscopes

Accommodative Procedures

Rock Card

Flippers

Anti-suppression

Accommodative Procedures

Hart Chart
the old
standby

Computer Vision Therapy
• Can attack vergence, accommodative, and
oculomotor problems
• Most programs are set up to record patient’s
performance each session
– Removes the problem of compliance!
• Different products on the market
– Home Therapy System
– Computer Aided Vision Therapy
– Psychological Software Services

Computer Vision Therapy

• Computer based vision therapy program
• Patient can use at home, work, wherever
they have access to computer
• Trains eye movements, vergences,
accommodation, and perceptual skills

Why use Computer Aided VT?

• “I’d like to do VT in my practice, but...”
• Patients who cannot afford office VT
• Patients who cannot make a time
commitment for office VT
• Patient compliance problems
• Insurance or Third Party Problems

How do you incorporate
Computer Aided Vision
Therapy in your practice ?
• Diagnose the patient!!!
• Assign a therapy protocol
• Computer aided VT in the office
• Schedule follow-up appointments
• Evaluate the patient’s progress/Follow-up

Computer Aided VT Resources

Neuroscience Center of Indianapolis
http://www.neuroscience.cnter.com/


Computer Orthoptics
HTS (Home Therapy System)
http://www.homevisiontherapy.com/


Computerized Aided
Vision Therapy
Gary Vogel, OD, FAAO
Available from Bernell
800-348-2225
http://www.bernell.com/

Computerized Aided
Vision Therapy
Module 1 Track and Read
Visual attention/fixation test
Visual reaction time test
Short term visual memory test
Eye tracking test

Computerized Aided
Vision Therapy
Module 2: Visual Therapy
Visual information processing skills
Left-right warm-ups Directional reactions
Directional questions Random targets
Directional grids Tachistoscopic arrows
Satellite commando game

Computerized Aided
Vision Therapy
Visual Skills Therapy
Tic-Tac-Toe rotations Spatial Sequencing
Spatial Patters BPDQ Grids
Circles, Boxes, Triangles Geo Boards
Rotating patterns

Computerized Aided
Vision Therapy
Therapy Procedures
Visual attention/fixation Tracking with Numbers
Span of recognition Random eye movements
Short term visual memory
Large angle eye movements

Computerized Aided
Vision Therapy
Visual Figure Ground Skills
Target counting Character searching
Letter locator Dot to dot
Shapes Hidden patterns

Computerized Aided
Vision Therapy
Visual Closure Skills Therapy
Circles & boxes Lines & rectangles
Closing on center Closing patterns
Letters/numbers dot to dot
Closing words Tracking with sequences/words
Verbal saccades Tracking with stories

Computerized Aided
Vision Therapy
Module 3: Computer Vergences
Jump vergences (single/double targets)
Smooth vergences Pursuit vergences
Life saver drills
Anti-suppression games

Brainware Safari

http://www.brainwareforyou.com/

Brainware Safari
Helms D, Sawtelle SM. A study of the effectiveness of
cognitive therapy delivered in a video game format. Optom
Vis Dev 2007;38(1):19-26.

Students in the study group showed an average of 4 years and 3
months improvement on tests of cognitive skills, compared to
4 months improvement for the control group and showed an
average of 1 year and 11 months improvement on tests of
achievement compared to 1 month for the control group.

http://www.brainwareforyou.com/

Conclusions

• Easy way to incorporate VT for BV
disorders into your practice
• Monitor the output to check for compliance
and tricks!
• Remember that the key is in diagnosing
patients and follow-up

VT Equipment

Use the tools
discussed

You do not need a
whole room of
VT “stuff”

WWW Sites for BV/VT
NVC Adult Amblyopia Treatment
http://www.neuro-vision.com/

WWW Sites for BV/VT

NVC Adult Amblyopia Treatment
What is the treatment like? During the sessions, the patient
sits five feet from a specially designed computer screen in a
darkened room, wearing special glasses that occlude the
strong eye. The patient uses a mouse to respond to treatment
tasks and receive audio feedback through speakers
or headphones.

To begin the treatment process, a doctor performs an eye
examination in order to determine the exact type of lazy eye
that the patient has and the visual acuity of the patient. The
patient will then begin a series of sessions, generally twenty
to forty, depending on the initial visual acuity and the
patient's progress throughout the treatment.

WWW Sites for BV/VT

Gemstonevision.
Org

BV Organizations

COVD http://www.covd.org/
OEP http://www.oep.org/
949-250-8070

AAO BV Section
http://www.aaopt.org/secti
ons/bvppo/aaobvp.html 301-984-1441

BV Organizations

PAVE/Parents Active
for Vision Education
http://www.pave-eye.com/

Neuro-Optometric
Rehabilitation Association
http://www.noravc.com/

Patient WWW Sites

3 D Pictures
http://www.vision3d.com/optical/
index.shtml#stereogram

How Does Binocular Vision Work?
http://www.vision3d.com/stereo.html

Patient WWW Sites

• http://www.chil
dren-special-
needs.org/visio
n_therapy/what
_is_vision_ther
apy.html

Position Statement on VT
AOA, AAO, COVD many others:
Position Statement on
Optometric Vision Therapy

“The American Optometric Association
affirms its long standing position that
optometric vision therapy is effective in the
treatment of physiological, neuromuscular and
perceptual dysfunctions of the vision
system……..”

Practice Management

Myths

VT is Too Expensive!
You Can’t Make Money Doing VT!

Which is it? Can’t have it both ways!

Practice Management

First
Comprehensive Examination
Then
Visual Efficiency
Strab/Amblyopia
Follow-up

Practice Management

All BV Disorders are a
Medical Condition
CI, CE, DI, DE, Pursuit/Saccade Dysfunction

Practice Management

Accommodative disorders
tend to be refractive
Accommodative insufficiency, excess, infacility,
instability, etc

Practice Management

Visual Discomfort
is a medical diagnosis

Practice Management/Marketing

Use the Internet!
Private Office
Email Mailing Lists
Social/Business Connection Sites
Blogs

Social/
Professional
Connections

Email Mailing Lists

Optcom
BVPE
VTOD

Questions? Contact:
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor, Pediatric/Binocular Vision Service
Illinois Eye Institute/Illinois College of Optometry
3241 S. Michigan Ave. Chicago, Il. 60610
312-949-7280 voice 312-949-7668 fax
Private Practice 708-867-7838
dmaino@ico.edu MainosMemos.blogspot.com
www.nw.optometry.net www.ico.edu

To BV or Not to BV:VT in the Primary Care Office

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