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Advanced Amblyopia Treatment Learning Objectives 9/22/2015 Advanced Learning Objectives: Amblyopia Learn about vision training for amblyopia to: Treatment 1. Decrease suppression 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) 1 9/22/2015 The prevalence Common of amblyopia is Causes of approximately Amblyopia: 3.5% of the 1. Misalignment population. of the eyes (strabismus) 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.” 2 9/22/2015 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 — Binocular vision 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. 3 9/22/2015 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 4 9/22/2015 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. 5 9/22/2015 (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 6 9/22/2015 (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 7 9/22/2015 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) 8 9/22/2015 (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 9 9/22/2015 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 10 9/22/2015 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 11 9/22/2015 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 12 9/22/2015 (MFBF) Activities (MFBF) Activities — Colored overlays BIOCULAR (BIOC) BIOCULAR 13 9/22/2015 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 14 9/22/2015 (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 15 9/22/2015 (Bioc) Activities Split Vectograms 5. Spilt Vectograms vPolaroid- Mirror Activity ANTI-SUPPRESSION ACTIVITIES ANTI-SUPPRESSION 16 9/22/2015 ANTI-Suppression ANTI-Suppression Activities Activities — Sherman Cards- entire deck ANTI-Suppression ANTI-Suppression Activities Activities 17 9/22/2015 ANTI-Suppression ANTI-Suppression Activities Activities ANTI-Suppression Activities BINOCULAR 18 9/22/2015 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. 19 9/22/2015 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 20 9/22/2015 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. 21 9/22/2015 First Degree Activities First Degree Activities — Bird in Cage — Mirror Superimposition: Bird in Cage 22 9/22/2015 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 23 9/22/2015 2. Stereoscope cards 4. Computer activities: VTS3/4 3. Fusion Cards Flat fusion 1 & 2 Morganstern’s Visicare cards- Pre-fusion through Basic fusion 24 9/22/2015 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 25 9/22/2015 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-Cheiroscope In-instrument
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