Exciting New Research on Amblyopia (Lazy Eye) Treatment

—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.

skeffington symposium

Dr. Jeffrey Kraskin

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:

Improving vision in adult amblyopia by perceptual learning

Perceptual Learning Improves Stereoacuity in Amblyopia

Binocular visual training to promote recovery from monocular deprivation

Amblyopia and Binocular Vision

Perceptual learning, aging, and improved visual performance in early stages of visual processing

Applying perceptual learning to achieve practical changes in vision

Does your child play soccer or football?

kid soccer headerWhen your daughter is on the soccer field heading a ball, she may help win the game, but she may actually be hurting her brain. While most parents know that their child is at risk of a head injury when playing football, a lot of people don’t know that head injuries can occur even with a helmet from the impact. Also, soccer is also one of the top sports that can also result in head injuries.

A recent study found that 85% of concussions go undiagnosed. Another study found that nearly 63 percent of varsity soccer players had symptoms of a concussion at some point, but only about 19 percent actually knew it. The reason this can happen is because you do not have to lose consciousness to have a concussion, so most players will experience a blow to the head and get right back into the game. However, repeated blows to the head can accumulate and cause just as much damage as a concussion.

When someone has a head injury they typically have vision problems that can be small boy footballtemporary or permanent. When a vision problem is causing or contributing to a problem with reading, balance or movement, the recovery process will move very slowly until the visual component is treated.

Visual rehabilitation is vital, as soon as possible. There are a variety of symptoms which are involved in Post Trauma Vision Syndrome, including:

  • Blurred vision, especially when reading
  • Headaches
  • Double vision
  • Pain in the eye or eyes
  • Poor reading comprehension
  • Sensitivity to light
  • Loses place when reading
  • See a complete checklist of symptoms

boy footballIt should also be noted that sometimes symptoms of a concussion might not even appear for days, even weeks after the accident. Some symptoms may last only seconds, while others linger much longer, months and even years. Additionally, some symptoms might disappear after time, such as eye pain or headaches, and yet other symptoms remain, i.e., blurred or doubled vision. Keep in mind, that when someone is experiencing any of the above symptoms they could also have difficulty with reading and learning, as well as physical activities.

Head injury patients with resulting vision problems are very similar to patients we see at our office who have vision problems that interfere with reading and learning. Vision therapy is very effective at eliminating blurry and/or double vision, focusing problems, poor concentration, and reduced comprehension, to name a few, when they are due to a vision problem.

If you or your child have had a blow to the head, or suspect Post Trauma Vision Syndrome, call us today at 301-951-0320 to schedule a vision evaluation and get on the road to recovery.

April is National Autism Awareness Month

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.

 

There has recently been a lot of research involving the role of vision in autism spectrum and other disorders, which you can read about here and here. There’s also a piece about eye movements in ASD in the Huffington Post.
autism
In our practice, every day we see children with ASD who exhibit visual processing deficits that interfere with school, play, and social interactions. Fortunately, most of these visual anomalies can be improved through vision therapy.
“Visual processing problems are common in individuals with autism spectrum disorders. They can result in lack of eye contact, staring at objects, or using side vision… Suspect a visual processing problem if you see an autistic child tilt his head and look out of the corner of his eye… a child with poor vision processing may fear the escalator.”– Temple Grandin in The Way I See it: A Personal Look at Autism & Asperger’s
One of the most promising autism therapies available is DIR/Floortime, an approach which influences the style of the vision therapy we offer at the Vision & Conceptual Development Center. In fact, my colleague Dr. Mehrnaz Azimi Green holds an Intermediate Certificate as a DIR/Floortime provider. We first engage the child based on his individual interests, and adapt our therapy techniques based on those interests. We find this tailored approach to be successful with both neurotypical children and those with ASD or other special needs.
We also provide education to other professionals regarding the role of vision in autism spectrum disorders. To keep up-to-date with our speaking schedule, please join our mailing list (we send an e-newsletter about once a month), or visit our Facebook page.
The slides from our most recent lecture, prepared for Parent University, can be accessed here.

Is it a Behavior Problem? Or a Vision Problem?

I recently had a discussion with a parent about behavior and vision problems. A mom of

photo from Newsbusters.org

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:

  • How often does your child have difficulty completing assignments at school?
  • How often does your child have difficulty completing homework?
  • How often does your child avoid or say he/she does not want to do tasks that require reading or close work?
  • How often does your child fail to give attention to details or make careless mistakes in schoolwork or homework?
  • How often does your child appear inattentive or easily distracted during reading or close work?
  • How often do you worry about your child’s school performance?
weighted symptom checklist

weighted symptom checklist

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.

April is National Autism Awareness Month

Many of the patients we see for Vision Therapy have Autism Spectrum Disorders (ASD). Vision Therapy is a very effective treatment for many of the vision problems associated with ASD, such as poor eye contact, side viewing, visual stimming (such as staring at lights or spinning objects). VT is also effective for strabismus and amblyopia, which are more common in people with ASD. However, it is usually only after parents have exhausted all other forms of therapy that they address their child’s visual issues. This is understandable, yet frustrating.

It is understandable that a parent can’t often tell that the child is experiencing a vision problem, since we can’t see through another person’s eyes. And when a child isn’t able to clearly articulate what they’re experiencing visually, and assumes that what he sees is the same as what everybody else sees, how can he ask for help?

At the same time, it’s frustrating when a child struggles for years with difficulties with tracking, saccades (quick eye movements that are essential for reading), convergence (pointing the two eyes together at near), or visual integration, when these problems can be easily remedied. COVD.org and VisionTherapyDC.com have more information about vision and autism, including symptoms checklists for vision problems.

April should be not just Autism Awareness Month, but Autism and Vision Awareness Month.

Our Winter Mini-Symposium was a Success!

Last night, February 24, 2011, we hosted a mini-symposium at the new and improved Vision & Conceptual Development Center. We had fifteen people in attendance representing a variety of professional backgrounds.
Our first speaker was Joseph Manley, MD, discussing the American Academy of Pediatrics position statement on Learning Disabilities, Dyslexia and Vision. Dr. Manley’s premise is that the AAP is ignoring peer-reviewed research and evidence-based medicine in their assertion that vision therapy is not an appropriate treatment for children with learning disabilities and dyslexia. Dr. Manley presented numerous sources who found a higher incidence of vision problems in children with dyslexia and learning disabilities.

I was the second speaker, with a talk titled Vision, Behavior, and Academics, in which I explored the documented binocular vision problems in students with inappropriate classroom behavior, and how that impacts the learning of all students.

Finally, our keynote speaker was Jean Thomas, MD. Dr. Thomas is the President of Child & Family Integrated Therapies, LLC, which is a part of Integrated Therapeutic Services for Families and Children, Inc, in Kensington, MD. Formerly on staff at Children’s National Medical Center in Washington, DC, Dr. Thomas is recognized nationally and internationally for her contributions to an interdisciplinary effort to develop age-specific mental health diagnostic criteria for children aged birth through three years old. In her talk last night on Early Disruptive Disorders, Dr. Thomas emphasized the importance of the family interactions and dynamics to develop the best outcome for the troubled child.

All in all, the evening was a success, and we look forward to many future educational events for professionals, parents, and patients. To sign up for our mailing list, please click here.

Are you mad as hell?

There is a lot of opinion on the internet, some good, some bad, and a lot that is completely confounding. I recently came across a post on mothering.com in which the original poster describes her daughter’s success in vision therapy and the significant positive changes that have occurred in her life as a result. Great! We have patients in our office every day who tell of the improvements they see in school, work, hobbies, and many other areas of daily life. I always love hearing more.

But in this case, another mom replied that VT has only been proven effective for strabismus and convergence insufficiency.

Where does this idea come from? There is an abundance of data showing otherwise, that in fact vision therapy is an effective treatment modality for numerous other visual dysfunctions. For an incomplete yet impressive listing, see the COVD website. It is frustrating to me and the rest of the community of developmental optometrists, educators, and others who care for children that the science gets swept aside and replaced with opinion. The opinions are repeated again and again until they seem to be true.

Just last week a mother brought her son in to see me. He had numerous symptoms consistent with a binocular vision problem. Sure enough, testing showed he had convergence insufficiency. The mother was relieved to find out the reason for her son’s symptoms, but worried that her mother and others in the family would ridicule her for seeking treatment in the form of vision therapy. So opinion not based in fact may stand in the way of this boy’s academic, sports, and life success.

Dr. Len Press posted this morning about a patient with double vision from convergence insufficiency whose ophthalmologist told her that vision therapy was bogus. Yet the Convergence Insufficiency Treatment Trial was published in the Archives of Ophthalmology. Not the archives of Optometry. Biases (opinions) get in the way, even when it’s published in ophthalmology’s own literature. And these biases prevent children from getting the care they need, and result in children suffering needlessly. Which is something that should make us all mad as hell.