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

Vision Problems Masquerade as Learning Disabilities

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

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.

You’ll shoot your eye out!

Blue laser toys have burned holes in the retinas of 30 boys, recently reported Saudi Arabia’s King Khaled Eye Specialist Hospital and Johns Hopkins Medicine. These toys, available on the internet, may seem harmless but in fact can cause serious eye damage. So if your child received such a toy over the holidays, you may want it to become “lost”. Just tell Uncle Bob that UPS never delivered.

You'll shoot your eye out!

Lasers? No way!

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.

Scientific Basis for an Accommodation Already in Use in VT Practices

books

Image courtesy of adamr/ FreeDigitalPhotos.net.

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.