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

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.

More Reasons Your Child Needs an Eye Exam, Not a Vision Screening

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

Using eye-tracking technology, researchers found that infants later diagnosed with autism showed a decline in attention to others’ eyes by two to six months of age.

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.DSC_0294

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.

Meet the Authors

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.

Please join us for this informal gathering where you can chat with the authors and have them autograph your copy of the book while you enjoy some wine and cheese. Limited quantities of Visual/Spatial Portals will be available for purchase.

Thursday, February 28, 2013, 7pm

The event will be held at our office:

The Vision & Conceptual

Development Center

6900 Wisconsin Avenue, Ste 600

Chevy Chase, MD 20815

(301) 951-0320

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.

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.