9/22/2015

Advanced Learning Objectives: Learn about vision training for amblyopia to: Treatment 1. Decrease 2. Improve fixation 3. Improve accuracy of accommodation 4. Develop depth perception 5. Improve acuity

Jen Simonson, OD, September 2015 FCOVD All lecture slides and Boulder, Colorado links are available on USA www.bouldervt.com

Potential Benefits of a Amblyopia Binocular New research is Approach: validating that a 1. Improved treatment binocular model compliance of treatment is 2. More functional superior to improvement than patching – especially in occlusion the development of Is our best treatment therapy. Is our best treatment patching stereopsis patching an eye? an eye? 3. Less regression 4. No harm to better seeing eye (reverse amblyopia)

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The prevalence Common of amblyopia is Causes of approximately Amblyopia: 3.5% of the 1. Misalignment population. of the eyes () Mild 20/40 2. A refractive (6/12) or better error Moderate (anisometropia) 20/40-20/80 Is our best treatment Is our best treatment patching an eye? (6/12-6/24) 3. Form Severe patching an eye? deprivation 20/80-20/200 (6/24 – 6/60) (ptosis/cataract)

Strabismus 13:93, 2005 S.E. Loudon, H.J. Simons, SUPPRESSION: THE CAUSE OF The History of the Treatment of Amblyopia AMBLYOPIA Robert F. Hess, PhD Director of Vision Research, Department of Ophthalmology ◦ Assumed these conditions McGill University, Canada interfered with the architecture of — “Recent findings have provided strong evidence the developing brain. that amblyopes actually have an intact binocular infrastructure including binocular processes, even in the adult amblyope. However, what appears to ◦ Patients with amblyopia were have been lost is only a sign of suppression assumed to be anatomically under binocular viewing conditions. Current monocular and lacked the evidence indicates that suppression plays a capacity for functional primary role in both the binocular and binocularity monocular deficits.”

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AMBLYOPIA TREATMENT STUDY -18 BACKGROUND WHY is suppression Developed?? HTTP://PEDIG.JAEB.ORG/STUDIES.ASPX?RECID=235 Amblyopia affects more than acuity! Double Blurry Visual — Contrast sensitivity — dysfunction Vision Vision Confusion — Poor stereopsis — Accommodation dysfunction Confusión — Fixation dysfunction DobleDoble — Vergence dysfunction Visual — Poor visual information processing La visión doble es muy dificil Supresión hace que sea más Confusión visual es cuando — Poor reading fluency La visión doble es muy dificil cuando la impresión es fácil de procesar la imagen dos cosas diferentes cuando la impresión es — Reduced visual-motor integration pequeña y poco espaciados. más clara. aparencen en el mismo pequeña y poco espaciados. Supresión arregla. lugar. Supresión arregla.

AMBLYOPIA TREATMENT STUDY (ATS-18) — Binocular iPod treatment for amblyopia MONOCULAR

— DICHOPTIC treatment http://mvr.mcgill.ca/Ro — Compare binocular game bert/clinicaltrial/clinical play for 1 hour/day to trial.html Occlusion for 2 hours/day. — Ages 5-13 and 13-17.

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Monocular Occlusion Types v Traditional treatment vComplete: “pirate” v Use one eye at a time patch, “Band-Aid” patch, cover, hand v Goal: Equalize ocular skills

Ø Fixation Ø Pursuit Ø Saccades Ø Focusing Abilities

Occlusion Types Occlusion Types

vTranslucent: light, but no detail vBlur: Bangerter foils, tape, contact lens, nail polish and atropine

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Occlusion Types Occlusion Types

vPartial: bi-nasal or vLiquid Crystal bi-temporal Glasses: Amblyz, Eyetronix

(M) Activities (M) Activities

— Fixation- — Saccades- the ability to swiftly and ability of smoothly jump accurately from one point the eye to to the next. accurately aim to one point in space.

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(M) Activities (M) Activities

— Pursuits: the ability to smoothly and — Accommodation - ability to focus clearly accurately follow a moving object. and accurately.

(M) Activities (M) Activities

— Anti-suppression — Detail recognition: Resolution ◦ After-image ◦ Line scrubbing ◦ Macula Integrity Tester

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(M) Activities (M) Activities

— Detail recognition: Recognition — Detail recognition: Vernier Acuity

http://www.nature.com/pr/journal/v60/n4/fig_tab/pr2006267f1.html

(M) Activities (M) Activities

— Detail recognition: Crowding — Prism Training

Monocular Prism Jumps – • Awareness of eye movements

• Localize direction and amount of movement

• Smaller amounts of prism are more difficult

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MONOCULAR FIXATION IN A BINOCULAR FIELD

Monocular Fixation in a Binocular MONOCULAR FIXATION IN A Field (MFBF) BINOCULAR FIELD — Anti-suppression v One eye sees detail and the other eye — Detail recognition sees the background in the same space. 1. Hide and Seek (pom poms on black felt)

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(MFBF) Activities

vHide and Seek

Monocular Fixation in a Binocular Field (MFBF)

Monocular Fixation in a Binocular Field (MFBF) 2. iPad Activities: v Goal: accurate 1. Background – set to Black perception of details with one eye and the perception of the background with the other 2. Image – set to Red eye. 3. Can change SIZE and SPEED

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Both eyes see the iPad, but only the left eye can follow the red bear: (MFBF) Activities

3. Button Boards: Sanet Vision Integrator (SVI)- Eye Hand, Rotations, Saccades with Red patch or Red/Blue Glasses

With a white background, the eye covered Use the blue lens on the amblyopic by the blue lens sees the target. eye

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Saccadic Fixator with red/green (MFBF) Activities glasses: — The red light is vSaccadic Fixator blocked by the with R/G glasses green filter. — Use the red lens on the amblyopic eye.

(MFBF) Activities (MFBF) Activities

v Acuvision with Red and Green Glasses 4. Red- Ink Coloring books/letter tracking

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Red letter charts Red letter charts

(MFBF) Activities (MFBF) Activities 5. Red/White/Black Cards: Sherman Cards- separated to use one color only

v Carl’s Cards- separated to use one vRotating Pegboard color only with red numbers

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(MFBF) Activities (MFBF) Activities

— Colored overlays

BIOCULAR (BIOC)

BIOCULAR

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Biocular (Bioc) Biocular (Bioc) vThe ability to see information from both eyes, although the images are in different vGoal: to improve the ability of both eyes spaces. to alternately shift focus in an un-fused situation, which will facilitate anti- suppression and prepare the patients for simultaneous perception.

(Bioc) Activities (Bioc) Activities 1. Vertical Prism dissociation with ball on 2. Squinchel string

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(Bioc) Activities (Bioc) Activities

3. Red/Red Rock 4. Red/Green filters placed side-by-side

(Bioc) Activities (Bioc) Activities

vRed Green filters placed vAnaglyphic projection side-by-side on reading material, crossword puzzle, hidden pictures etc.

vPolarized or Red/Green bar readers with the appropriate glasses

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(Bioc) Activities Split Vectograms

5. Spilt Vectograms

vPolaroid- Mirror Activity

ANTI-SUPPRESSION ACTIVITIES

ANTI-SUPPRESSION

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ANTI-Suppression ANTI-Suppression Activities Activities

— Sherman Cards- entire deck

ANTI-Suppression ANTI-Suppression Activities Activities

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ANTI-Suppression ANTI-Suppression Activities Activities

ANTI-Suppression Activities

BINOCULAR

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Binocular (B)

v The ability of the brain to fuse information from both eyes into one image. v Degrees of Binocular: Binocular • First Degree Fusion/ Simultaneous perception • Second Degree/ Flat Fusion • Third Degree/ Stereopsis

Single, Clear Binocular Vision

First Degree Activities First Degree: — Simultaneous awareness of dissimilar targets Simultaneous — In the SAME place (vs. biocular, which is NOT Perception fused into the same space)

vGoal: To see images from each eye in the same space.

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First Degree Activities First Degree Activities

— Luster-The perception of information from both eyes simultaneously; with Red/Green 1. Flashlight Activities: Press Lites glasses this is a shimmery color. — Activities: White toys, Flashlight activities

Press Lites First Degree Activities

2. Cheiroscopic tracing

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Cheiroscopic tracing - OPTO First Degree Activities

3. Hole in Hand

First Degree Activities First Degree Activities 4. Red Light/Red Ring: — Cook’s Rings Red print circle on a paper placed over a red filter with a penlight behind both. Patient wears Red/Green glasses.

Can also use a red laser pointer and a red circle drawn on a white board.

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First Degree Activities First Degree Activities — Bird in Cage — Mirror Superimposition: Bird in Cage

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First Degree Activities Second Degree/ Flat Fusion — Mixed Vectograms vGoal: Use both the eyes to combine common borders and to align two images received from each eye into a single perception.

1. Mirror superimposition Second Degree Activities

— Mirror Superimposition

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2. Stereoscope cards

4. Computer activities: VTS3/4 3. Fusion Cards Flat fusion 1 & 2 Morganstern’s Visicare cards- Pre-fusion through Basic fusion

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Third Degree Fusion/ Stereopsis THIRD DEGREE FUSION/

— The ability to perceive float and localize a STEREOPSIS target using binocular depth perception

Stereopsis Stereopsis

— Integration of similar objects with some disparity that causes stereopsis

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SILO= small-in and large-out Third Degree Activities — Accurate perception is of closer targets becoming smaller and further targets v In-instrument Techniques: becoming larger § Stereoscope with Convergence/ Divergence Cards § Aperture Rule § Amblyoscope, Synoptophore § W-

In-instrument Third Degree

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Stereoscope for iPad Third Degree Activities

vAnaglyphic or Polarized Lens Techniques § Alphabet fusion book § Keystone Cards § Vectograms § Tranaglyphs

Vectograms Projected vectograms

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Fixed Anaglyphs Variable Anaglyphs

Third Degree Activities- Free Space Fusion Techniques Brock String — 3-Dot/Barrel card — Prism flippers — Thumbs BI/BO — Prism Bar — Lifesaver card — Magic Eye books — Mountain card — Star cards — Eccentric circles — String and Dowel — Yardstick and Pins — Brock String

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Modified Brock String: Convergence & Divergence

Third Degree Activities- Third Degree Activities- Computer Fusion Techniques Computer Fusion Techniques — VTS3/4- Near and projected stereopsis — Vision Tap — Vision Builder- Random Dot Stereopsis, — OPTO Vergence, Jump Vergence — HTS- Random Dot Stereopsis

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Improving Patient Compliance Improving 1. Provide a written patient prescription compliance 2. Present reading material on the diagnoses 3. Provide an office policy sheet Treatment Calendar regarding vision training

Improving Patient Compliance Graph the patient’s 4. Give written progress in instructions and developing normal: goals • Acuity 5. Be available for • Focusing skills questions • Tracking skills 6. Track progress with • Depth Perception logs and reports • Vergence skills 7. Schedule follow-up evaluations

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Sample Patching Prescription Lazy Eye Tetris Your doctor has prescribed patching for the treatment of amblyopia. Please follow these instructions as directed. Remember to wear glasses or contact lenses when patching, so a clear image is on your amblyopic eye. — https://www.youtube.com/watch?t=36&v=

Type(s) of Patch recommended: Vp7hfacpBp0 □Adhesive bandage (Opticlude, Coverlet) □Blur foil (Bangerter), clear contact paper or transparent “magic” tape □Patch (Pirate-style or patchworks) □Spectacle clip □Frosted lens □Opaque contact lens □Over-plus optical lens (spectacle or contact lens) □Atropine penalization Your amblyopic eye is Patch this eye: Hours per day: Days per week: the:

Examples of activities to complete while patched:

References — Fortenbacker, OD, FCOVD “Advanced Amblyopia Treatment for Better Results” – 2015 COVD Annual Meeting. — S.E. Loudon, H.J. Simonsz , “The History of the Treatment of Amblyopia.” Strabismus, 13:93, 2005. — Amblyopia Treatment Study (ATS18) Study of Binocular Computer Activities for Treatment of Amblyopia – http://pedig.jaeb.org/Studies.aspx?RecID=235 — Bateman, R., Danner, R., Dowis, R., et al. (1985). Manual of Esotropia Therapy. Colorado Vision Consultants: Colorado. — Press, L. Press lites – procedures for visual field awareness. Optom Vis Perf 2013;1(2):62-7. http://www.oepf.org/sites/default/files/OVP1-2_article_Press_web.pdf — COVD. (2009, July). COVD fact sheets. Retrieved from www.covd.org — Headline, T. C., Wahlmeler, I., & Bedes, V. (2005). The Vision Therapist's Toolkit. San Jose: California. — Press, L. J. (1997). Applied Concepts in Vision Therapy. Mosby: 978-0815167297. — Birch, Eileen E. “Amblyopia and Binocular Vision”. Prog Retin Eye Res. 2013 March; 33: 67-84. Doi:10.1016/j.preteyeres.2012.11.001 — Simonson, J. Optometric Management, Volume: 48, Issue: December 2013, page(s): 26 – 33.

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