Download - Let’s Get Down to STRABusiness...Let’s Get Down to STRABusiness •Get your growth mindset in gear as we start with the fundamentals of ABC (learning a safe approach when working

Let’s Get Down to STRABusiness

Wisconsin 2018Nancy G. Torgerson, OD, FCOVD

Michelle Mott, COVT

Alderwood Vision Therapy Center, Lynnwood & Redmond, WA

Alderwood Vision Therapy [email protected]@alderwoodvisiontherapy.com

Nancy Torgerson, O.D., FCOVD Michelle Mott, COVT

• Lynnwood

• 16006 Ash Way, #101

• Lynnwood, WA 98087

• 425-787-5200

• Redmond

• Vision therapy services only

• Bear Creek Professional Center

• 17130 Avondale Way, #114

• Redmond, WA 98052

• 425-787-5200

Disclosure:Goffe Torgerson, my husband, had a vision therapy supply company, GTVT and he sold the rights to reproduce some of the products to Bernell. 1/23/18 Nancy Torgerson, OD, FCOVD

Michelle Mott has nothing to disclose.

Let’s Get Down to STRABusiness

• Get your growth mindset in gear as we start with the fundamentals of ABC (learning a safe approach when working with patients with anomalous binocular correspondence), learn the ups and downs of treating with patients with vertical challenges and the ins and outs of patients with exotropia and esotropia. A fun and dynamic workshop geared toward active vision therapist/doctor/patient care TEAM members learning through patient stories, hands-on discovery and interaction. The goal is to help end the senseless struggle and misinformation about the joys and challenges of people with strabismus.

Learn:• The historical shift of care from anomalous retinal correspondence, to

anomalous correspondence to anomalous binocular correspondence, (ABC)

• A safe vision therapy approach for strabismus and ABC, to avoid diplopia

• The value and art of emphasis on peripheral fusion lock before central fusion to gain stereovision

• What difference stereovision can make in daily life

• What opportunities may be blocked without vision therapy

• Core vision therapy procedures to use gain peripheral fusion and stereovision

• To collaborate regarding ABC with your colleagues , OMD and other professionals

• About resources available regarding ABC

Introduction

Start With Why!

DISCLAIMER – VISION ISN’T EVERYTHING…

VISION IS A PIECE OF THE PUZZLE

VISION GUIDES US• Seeing

• Processing

• Directing action in response to visual information, other senses and past experience

• Eyes, brain and body working together

• Directing movement

• A learned process

• Rehabilitation - neuroplasticity

VISION IS LEARNEDVISION CAN BE RE-LEARNEDVISION CAN BE ENHANCED

VISUALLY READY TO LEARN?VISUALLY READY TO WORK?VISUALLY READY TO PLAY?VISUAL SKILLS CAN BE DEVELOPED

Perception and Sensory Match

Aim, Focus, Track, Team

Central/Peripheral Integration

Eye Health Eyesight

Nerves Muscles Metabolism

HEALTH

VISION ACQUISITION

VISUAL ATTENTION

VISION PROCESSING

PERFORMANCESchool,Sports, Life,

Relationships

•How is vision impacting what you NEED to do?

•How is vision impacting what you WANT to do?

•How is vision impacting HOW WELL you want to do it?

WHAT IS STRABISMUS?

Two eyes don’t alignCalled strabismus or tropia

Test: unilateral cover test

Eso, exo, vertical, hyper, hypo, com, non-comitant,

Cover Test

•Direction of misalignment:• Inward: convergent strabismus or esotropia

• accommodative esotropia

• Outward: divergent strabismus or exotropia• Vertical: vertical strabismus, hyper or hypotropia

•Which eye turns:• Right eye (OD)• Left eye (OS)• If goes back and forth between eyes: alternating• One eye more than another OD >OS, OS > OD

•At what distance is the misalignment:•Distance•Near

•Is the angle the same in all 9 areas of gaze•Yes: comitant•No: non-comitant

• III Nerve, • IV Nerve• VI Nerve• Brown’s Syndrome

•Amount of time:•Constant•Once in a while: intermittent

Alternating Cover Test

•Amount of deviation

•Measured in prism diopters

Language is important:

I am a person with strabismus vs.I am a strabismic

Patient has strabismus vs.Patient is strabismic

Patient is a person vs.Patient is a diagnosis

Goals in Vision TherapyPatient vs. Doctor Goals

• Being less clumsy

• More comfortable with night driving

• Eyes more cosmetically aligned

• Not just about stereopsis

• Stereopsis may be a bonus

Versus:

• Better optometric findings and stereopsis

Start With Why

Patients with Vertical Strabismus Challenges

•What problems can a vertical imbalance create or compound for a person’s body?

•What impact can vertical imbalance have on being anxious, fearful or fearless?

• That problems can a vertical imbalance create or compound for a child under 5 years old?

Visually:

•What problems can a vertical imbalance create or compound for a person in kindergartener to 2nd

grade?

•What problems can a vertical imbalance create or compound for a person reading chapter books?

•What problems can a vertical imbalance create or compound for a person learning to read music and/or play an instrument?

Visually:

•What problems can a vertical imbalance create or compound for a person involved in sports?

•What problems can a vertical imbalance create or compound for a person that is a gamer?

•What problems can a vertical imbalance create or compound for an adult?

Visually:

• Look directly your hand and feel corner of wall. Is it straight? Put ambient lenses on.•What does the corner of the wall look like?• Look at your hand and feel the corner of the wall.

What does it look like? What does it feel like?• Intellectually one knows that it is straight but their

eyes now tell them and their touch agrees that the wall is curved. • The visual input overrides the tactile information at

hand. •Vision guides motor.

Vision Leads Motor

Perception and Sensory Match

Aim, Focus, Track, Team


Eye Health Eyesight

Nerves Muscles Metabolism

HEALTH

VISION ACQUISITION

VISUAL ATTENTION

VISION PROCESSING

PERFORMANCESchool,Sports, Life,

Relationships

Evaluation

• Investigates the relationship between vision and•Balance Posture Movement•Coordination Orientation Identification•Localization Awareness•Central/peripheral organization

• Prescribes lenses and prisms• Clarity and comfort Relieve visual stress• Enhance performance Guide visual potential

•Vision therapyLinda Sanet , COVT, VT 101

Patient QuestionnaireAlderwoodvisiontherapy.com/patientforms/

What tests and/or findings are helpful to gain information regarding a vertical imbalance?

• Cover Test: distance and near

• EOM: range

• Vertical and horizontal deviation distance and near

• Vertical and horizontal range distance and near

• Accommodation

• Stereopsis

• Suppression

• Sensory Motor Evaluation

•Hand Held Maddox

•Worth 4 Dot

•CS tracings

•Preschool Testing• Dinosaur Stereopsis

Hand Held Maddox

• C/P – PHOROPTER: PERIPHERAL BLOCKED OUT SO FINDINGS MAY BE DIFFERENT THAN IN FREE SPACE

Worth 4 Dot

Preschool Tests

Dinosaur Stereopsis Test for Preschoolers

How can a sensory motor evaluation (SME) be helpful to you in planning vision therapy?

SENSORY MOTOR EVALUATION/BROCK STRING

Nerve palsies and their impact on vision therapy

Exam Forms

Prism Adaptation Test• If no area of fusion, compensatory prism may aid

fusion so that visual ranges, flexibility and sustaining skill can be developed through vision therapy•Trial minimal power of prism in trial frame for 30

minutes in the reception area and then retest. Can you reduce the amount of prism power and maintain fusion?

• If prism helps gain fusion, prescribe minimal prism to gain fusion to use in conjunction with vision therapy.• CAUTION!!! If more prism power is needed at the end

of 30 minutes, avoid prism. Using compensatory prism may be problematic and patient may continually adapt need more power.

Compensatory Prism 4/2017

65 year old female. Brain tumor at 51, stroke at 62. Constant double vision that dances when she looks around and goes away when covers an eye. Since 2002. Prism glasses don’t do much. Had cataracts removed OU, 4-5 years ago. Tried prism glasses, didn’t help. Dizzy. Skips lines when reading. Closes right eye.

Evaluation: Diplopia with VA OU at distance, not at near. No double down game. Double straight forward: distance and near. Cover test: OD hypertropia, esop, alternates, greater in left gaze and up gaze.

Maddox rod: D: 3 BD OD, 3-4 BO N: 3.5- 4 BD, 3-4 BI

Down gaze: 1 BD

Single: D: 4 BD OD, 3BO OS N: 4 BDOD and 5 BI OS

Trialed with Fresnel for distance – loved it. RX made. Started VT.

LOW LEVEL THINKING

Appropriate use of schemes

TASKNeeds to be the right task at the

right time.

TOO LOW LEVEL

THINKINGInappropriate use of exiting schemes

HIGH LEVEL THINKING

New schemes are developed

A-ha!

A-ha!No more:

business as usual

Habitual Can be an old or new

habit

Business as usual

With practice becomes low level

Melt downAvoidanceI don’t know

HIGH LEVEL THINKING

Visual Skills

Vision Therapy Is…

• The art and science of arranging conditions so that the patient becomes aware of new relationships in his visual world, and through these new relationships learns to utilize processes that allow him to extract a greater amount of information in a more efficient manner.

Vision Therapy Is…

•Retraining the brain

Vision Therapy

•Goals: patient, parent, doctor, vision therapist

•The why of the activity

• Introduction to activity incorporating patients why

•Procedure

•Visualize/imagine activity

Vision Therapy

•Are you ready?

•Socratic dialogue

•Level of thinking: high, low…

•Reflection

•Celebration

•Record

Keys to being a great vision therapist…

“Start where they are, go where they ain’t,” WC Maples, OD, FCOVD

Example: Worth 4 dot with red/green glasses in 9 positions of gaze at distance and near

Start where they are binocular and “work the edges” to expand area of binocularity

Start where they are, go gently to where they need to go.

Watch for ABC – work from peripheral fusion to central. If ABC, avoid detail.

“Start where they are….

go where they ain’t.” WC Maples

Vertical Imbalance Precautions

•Do NOT break down binocularity that is already present•What exam findings should you be aware of?

•Do NOT create more double vision•What can you watch for?

•Start with large targets without accommodative demands and reduce to smaller targets with accommodative demands with time.

•Start with typical head tilt and with time move toward straight

•With a standing activity, patient can stand on 2 scales to give feedback if weight is equally balanced. If not, how can they change it?

Vision Therapy Oculomotor Activities

•Calisthenics•Goal equal range and fluidity of movement in

different areas of gaze, distance and near: OD, OS and OU

•Belgau Bean Bag Toss•With eyes only• Follow with nose

• Start with large targets without accommodative demands and reduce to smaller targets with accommodative demands with time.

• Start with typical head tilt and with time move toward straight

• With a standing activity, patient can stand on 2 scales to give feedback if weight is equally balanced. If not, how can they change it?

• Work not only on getting balance on scales, but use that info to potentially help in other activities. If tends to lean more right…put weight on left shoulder during quoits, luster, fusional activities, etc.

Working the edge

Vertical Imbalance Precautions

•Do NOT break down binocularity that is already present• What exam findings should you be aware of?

•Do NOT create more double vision• What can you watch for?

• If a person has binocularity, be aware of • COVER TEST• POSITION OF GAZE• VERTICAL PHORIA• STEREO• HEAD TILT, COVER AN EYE,…• CHECK IN WITH PATIENT…• BUILD AWARENESS

Peripheral Activity: Sanet Vision Integrator

Peripheral Activity: Space Fixator

Peripheral Activity: Coin Pinch

Brock String

• Large or small paper plate with red/green glasses in 9 positions of gaze• Where can they fuse?• Where is luster?• Where is double?• Where is suppression?• “Work the edges.” How can you increase the range of

luster?• Can you reduce the size of the target?• Can you increase the accommodative aspect of the

target?

•Use a weight on one shoulder when sitting or standing•When sitting, use a weight on right or left leg

Brock String With Beads/Letters

•Brock string in 9 positions of gaze• At what distance and gaze is the bead single with

physiological diplopia as your guide that both eyes are working together?

• Move to edge of where it is hard and see if they can increase range

• If there is a head tilt trial adding:• balance board

• bean bag on head

• weight on one shoulder

• or stand on two scales.

• Use smaller targets as able

WHEATSTONE

Wheatstone

• Place cards at different levels to aide fusion

• Gain range of convergence and divergence

• Goal to get the two targets level

Horizontal Chalkboard Windshield Wipers

Binocular Space Fixator

•Space fixator:

•Look, ready, touch

•What feedback tells you and the patients that there is a problem in alignment?

Turn the Vecto!

Vertical Challenges Vision Therapy Activities

• Vectograms: distance and near

CS Tracings

PRISMS• Do you know if patient has prism ground

in their glasses?• Do prism orientation in opposite direction

of the prism in their Rx to increase range, flexibility and endurance work to try to decrease their need/reliance of prism in their Rx.

• Prism rotation: right eye, left eye at near/far, with suppression awareness controls, with stereo targets, localization incorporating different gazes, activity and movement.

• Vertical prism flips: base up, base down, right eye, left eye, with near/distant targets, with suppression awareness controls, with stereo targets, localization incorporating different gazes, activity and movement.

Vertical Prism Twirl

Vectogram: Quoits

Eccentric Circles

Vertical Prism Jumps

•Position where it is easiest to gain single•Take prism away and keep single and clear

•Repeat with prism in front of the other eye

•In time: base up to base down, flip

Vertical Prisms

Brock stringVectogramsRed/green window anaglyphs

VTS 4: Vertical

Vertical Mini Vecto

Worth 4 dot

•Distance

•Near

COVER – UNCOVER - RECOVERY

•Cover an eye

•Even as one eye is covered try to look at a target with both eyes aiming together

•Uncover eye with goal that eye make little movement as they are already aimed together

Optometric Photo Therapy (pi-omega goggle, penlight Bagolini Lenses) with Brock String

Case Studies of Patients with Vertical Challenges

Case 1 – Patient with Vertical Challenge

• 50 yo – hx of patching as a child, never surgery, monovision

• Referred by PT for significant difficulties with dizziness and headaches that have not improved enough with vestibular therapy

• No double vision, but has never seen 3D – knows she uses only one eye at a time


• VA cc: 20/20 each eye

• CT: CAXT, ~ 15 R hyper

• 0 stereo, alt suppression W4D

• Initiated optometric phototherapy (syntonics) first for 3 months.

• 6 months VT• Dizzy symptoms have resolved; no balance issues, seeing considerable float

on vectos and 3D movies, can get luster

• Stereo: 100 sec of arc, Fusion W4D near, supp dist


• 12 months VT• R hyper has gone from 12 PD to 1-2 PD

• Getting more depth on smaller targets, Can keep “luster” at near and fusing eccentric circles in free space

• By 14 months, R hyper is to 0 in all gazes – stereo still measuring about 100 sec of arc.

Case 2 - Patient with Vertical Challenge

• 63yo M – longstanding constant alt ET, surgery then post – VT• 55 PD alt ET with small vertical component• VA cc : 20/20 each eye, stereo: 0, W4D alt suppression

• 1-week post-surgical• Reports no double, slight discomfort• W4D: double, stereo 3/10 (140 sec of arc)• Maddox Rod Testing near: 5-20 EP depending on gaze, ~20 PD L hyper right gaze,

lower right worse

• 3 months VT• “Amazing” – seeing 3D for first time, no double, eyes are straight• W4D fused, stereo 8/10 (30 sec of arc)• CT: EP, L hyper• Maddox Rod testing: 8 Eso, 4 L hyper


• 42yo F – longstanding vertical – double vision which is currently somewhat alleviated with prism in glasses

• VA cc 20/20 each eye, CT/Maddox Rod testing primary gaze: 18 L hyper – needs 18 BD OS to fuse in phoropter

• New Rx: 6 PD vertical, 1 PD BO to get fusion• Began VT


• 9 months VT• Vertical phoria 18 BD OS, but reduced to 3 PD vertical in glasses with fusion,

no BO needed

• Stereo: 25 sec of arc

• 18 months VT• Dizzy spells gone, int dbl in certain gazes

• Stereo: 25 sec of arc, Vertical phoria 9 BD OS

• 24 months VT• Stereo: 20 sec of arc, Vertical phoria 5 BD OS

• Rx changed to 1 PD vertical in glasses

Exotropia: Panoramic Viewing

Visual Thinking Approach for Patients With Exotropia

Bilateral MovementsVisual Motor Foundation

Mental Map of Body

Body Lifts Dots on Back

Swimming in Place Hop Patterns

Angels in the SnowFlashlight Walk

Randolph Shuffle Ball Dribble

Chalkboard Circles Randolph Shuffle/rhythm

SVI Circles Flashlight Walk

Marsden Ball Tap/Stomp Ball Dribble

Bilateral Movement

❖Snow Angels/Body Lifts

❖Marsden Ball Tap (Stomp/Spin)

❖Hand/Finger Dance

❖Cross Body Walk/Randolph Shuffle

❖Duck Pigeon

❖Vestibular/Visual Activities

Rocking and Swinging!


❖Peripheral Bean Bag Swat❖Marsden Ball Orbit with Hart Chart❖Chalkboard O’s with Small Central Chart❖Space Fixator with Chart❖Space Fixator with Eccentric Circles❖Infinity Walk with Chart❖Marsden Ball Tap/Stomp with Chart

Accommodation

Binocular

• When working on binocular tasks, typically simultaneous perception is the hardest, so start with 3rd degree targets and work backwards.

• Cross Eyes at Will: Brock String

• Voluntary Vergence with Physiological Diplopia• Letter on Window

• Vectograms

• VTS4

• Eccentric O’s

• Brock String

Sanet Vision Integrator - SVI

•Eye/Hand Saccades: with center active (MFBF, red/blue)

•Rotator : with center active (MFBF, red/blue)

•MacDonald Chart (MFBF, red/blue)

Case Studies of Patients with Exotropia Panoramic Viewing

Case 1 – Patient with Exotropia, Panoramic Viewing Challenges• 51yo F - Congenital large-angle

alternating XT and R hyper

• Had amblyopia as a child and patched. Constant eye turn but can switch what she uses, eyes get tired, loses place with reading and computer.

• Generally fixates with OS

• Never has done VT

• Stereo: 0, W4D: alt suppression

3 months of VT

• Much less fatigued, can read at night, less bothered by lights.

• Getting moments of depth, can do brock string but tiring.

• IAXT (can align when asked to “focus hard”) – small R hyper at near.

• Stereo: 400 seconds of arc, W4D intermittent suppression dist/near

6 months of VT

• Stereovision and depth in real life coming in and out. Eyes much less tired. Seeing depth on quoits.

• Eye is not turning out as often.

• IAXT (easily aligns or alternates when asked)

• Stereo: 400 seconds of arc, W4D intermittent suppression/fusion dist/near

• NPC: 6/9

Case 2 – Patient with Exotropia, Panoramic Viewing Challenges• 71yo M – CLXT s/p stroke

• Presented 13 months post stroke with constant diplopia. Patched OS full time.

• Finished with PT and OT but having difficulty with balance and mobility.

• Not reading anymore.

Case 2 – Patient with Exotropia, Panoramic Viewing Challenges

• Exam Findings:• VA cc 20/30 OD, 20/25 OS• 50 PD CLXT, 10 PD L hyper• Could intermittently fuse target with 45-50PD BI

at distance and 50-60 BI at near


• 8 weeks VT:• 20PD BI split was ground into intermediate distance

glasses for use in therapy (Fresnel was first)• Consistently fusing, stereopsis, improving vergence

ranges

• 22 weeks VT:• Temporal occlusion alone and can maintain

alignment • 25 PD ILXT, 200 seconds of arc stereo


•34 weeks VT • using temporal occlusion in VT and at home, but tape

patch when tired

• ~10 PD ILXT that he re-fuses immediately

• 30 seconds of arc stereo

• NPC: 5/7 (first time able to perform)

Case 3 – Patient with Exotropia, Panoramic Viewing Challenges• 2.5yo F - Intermittent XT

• Since 10 months old, intermittent eye turn out. More noticeable as began watching TV and usually sits with head turned far right (left gaze viewing).

• Referred by pediatric ophthalmology to see if VT would be helpful

• Dist VA sc OD: 20/25, OS: 20/32

• 25 PD IAXT, 80% fixating OS

• NPC: 4/6 inches

• Stereo: 400 seconds of arc

Case 3 – Patient with Exotropia, Panoramic Viewing Challenges• Began with glasses and vision therapy

• 3 months of VT• Parents not noticing eye wandering anymore. Still turning head to right when

viewing distance at times but less. Both eye turn and head turn rare with glasses on.

• Dist CT: int 15 RXT, more without glasses

• Near CT: int 10 RXT, rare (1 time)

• NPC break: 2 inches

• Stereo: 140 seconds of arc (wirt circles)

• Currently in her 2nd 3-month unit of VT

A Road Less Traveled Anomalous Binocular Correspondence (ABC)

Vision Therapy Approach

Anomalous Retinal CorrespondenceAnomalous CorrespondenceAnomalous Binocular CorrespondenceAnomalous Cortical Correspondence

Anomalous Correspondence

Anomalous Correspondence Anomalous Binocularity• Anomalous: inconsistent with or deviating from what is usual,

normal, or expected : irregular, unusual

• Correspondence: the agreement of things with one another

• Binocularity: the ability to focus upon an object with both eyes and create a single stereoscopic image. Eye teaming.

UNUSUAL EYE TEAMING

Historically Vision Therapy For ARC

•Add prism to disrupt ARC

•Create double vision

•Work to achieve fovea to fovea connection

HISTORICALLY:Synotophores

• Eyes remained misaligned but gain of sensory matching

• Motoric mismatch with binocular illusion

• In instrument lack of periphery and eye/hand integration

Fusion: unification from corresponding retinal points into a single visual percept.

Sensory Fusion: to appreciate two similar images, one from each eye and see them as one.

Motor fusion: to align the eyes in such a manner that sensory fusion can be maintained.

Fredrick Brock, OD Stereomotivator

•Projected anaglyphs •Use of free-space•Movement and touch

Dr. Brock had intermittent divergent strabismus andexperimentedwith alignment of his eyes.

“A simple matter to fuse the two images, but this results in appreciable difference in the general appearance of the landscape.”

“When I first was able to position my eyes for fusion, the resulting percept, a sense of palpable pockets of space between objects, was entirely novel.”

Sue Barry, PhD

Brock’s Warning“Elimination of the visual periphery with the use of stereoscopes presents a viewing situation that is removed from reality and one that may be hard for a patient, new to stereoscopy, to interpret.”

Dr. Brock tried to get behind his patients’ eyes and think as they did.

DEPTH

PERCEPTION

STEREOVISION

STEREOPSIS

DEPTH PERCEPTION CAN RELY ON MONOCULAR CUES:

Convergence of lines to vanishing point


Customary size of objects


Object overlap

Depth Perception Stereovision Stereopsis

•Stereovision: qualitative stereopsis• Spatial sense•Binocular localization of either natural or dichoptic

images• Emphasizing what Sue Barry has called “a palpable

volume of empty space”

STEREOVISION

• Binocular stereovision

• Qualitative stereopsis

• Having a stereoscopic sense even though may not develop global stereopsis

• Important and many times overlooked, benefit of binocular vision

• “Patients, especially with infantile esotropia, may not develop precise foveal-to-foveal fixation and fusion, but the change with gaining stereovision can be unmistakable”

“I am so much better!”

“You can’t be better. You don’t have RanDot

Stereopsis yet!”

Listen to Your Patient Goals I want to be or have…

• My eyes to look straighter• More comfortable with night

driving• Less nervous with heights• Eyes straighter in photos • Able to hike more easily• Able to look someone in the

eye

• Not just about stereopsis, stereopsis may be a bonus

•Stereopsis: quantitative stereopsis, global

•Pointing the two foveas in the same place at the same time so that sensory and motor information will coincide

Depth Perception Stereovision Stereopsis

Global StereopsisMy

understandingas best I see it

Without the polaroid glasses it

is impossible to complete the test

when it is truly global stereopsis

STEREOVISION VS. STEREOPSIS

DEPTH

PERCEPTION

STEREOVISION

STEREOPSIS

Two Key Visual Brain Pathways

#1: “WHAT IS IT?” #2: “WHERE IS IT AND HOW SHOULD I RESPOND?”

• What? – ventral stream• Static object, shape and color

• Where and how? – dorsal stream• Spatial relationships• Movement

WHAT?

DORSAL STREAM

VENTRALSTREAM

WHERE & HOW?

VISION THERAPYArranging conditions that are

Giving an opportunity to learn in a new way

VISION THERAPY

Spatial localization!

Where and how before the what.

•Achieve patient’s goal while avoiding long term double vision

• Improve cosmetic appearance• Binasal or medial occlusion

• Improve stereovision

• Improve performance in life

• Improve stereopsis

Shaping The Path For Success Treatment Goals With Patients With ABC

What will vision therapy help create?

BINASAL OCCLUSIONUNILATERAL MEDIAL OCCLUSION

AC: NO MONOCULAR WORKExcept: calisthenics, eye position awareness, OKNAvoid all other monocular Avoid central tasks

Developing Stereovision: peripheral to central –stay away from small details, monocular viewing, patching and AVOID CENTRAL TASKS

•Best way to get double is to do central, accommodative tasks!

•So, don’t do central tasks!

•Do NOT attempt to improve central visual acuity•Do not work on

the amblyopia or attempt to improve visual acuity until peripheral lock is established unless your doctor tells you otherwise

Eye Movement with Proprioception

•Proprioception of Eyes and Body

•Calisthenics

•Open Eye Rotations

•Margolis Eye Throw

•Closed Eye Rotations

• Thumb Pursuits

Grounding

• Where am I?• Where is my head on my body?• Where are my eyes in my head?

What are the common foundational building blocks for people with strabismus?

Foundation for Visual Thinking Through:Vision AttentionPeripheral AwarenessSpatial AwarenessC/P IntegrationMovement and IntegrationVestibular Integration

CENTRAL/PERIPHERAL PARVO/MAGNOFOCAL/AMBIENT VENTRAL/DORSAL STREAMS

Esotropia/Anomalous Correspondence

Peripheral awareness

Not all or nothing, subtle changes

Exotropia

Central peripheral integration

VESTIBULAR

VISUAL ATTENTION

PERIPHERAL AWARENESS

C/P INTEGRATION SPATIAL AWARENESS

FOUNDATION FOR VISUAL THINKING

VISUAL MOTOR LATERALITY

Visual Thinking Through Movement & IntegrationReflexesID/Establish Your Dominant SideBilateral Integration & ThinkingBalance-Coordination of Body Axes/Action & Anti Gravity Thinking Handwriting/Finger Thinking/Fine Motor Eye/Hand Coordination Eye/Hand Coordination for Sport Readiness & Skill Building

•

Bilateral MovementsVisual Motor Foundation

Visual Thinking Through Movement & Integration

Jumping JacksCross Body WalkRandolph ShuffleWalking

Visual-Vestibular Integration

Vestibular and Balance

• Spinning/rocking

• Angels in the Snow: standing

• Hopping patters

• Balance Beam – pick up bean bags

• Balance board: stack bean bags on head and hands

• Standing on one foot• One foot in front of the other

• Zapping Robots

• Catch A Falling Star: toe touches

CREATING PERIPHERAL AWARENESS“NINJA VISION”

Increase Peripheral Awareness – “Ninja Vision”

Space fixatorPeripheral bubble popPeripheral bean bag dropHand/finger danceCoin pinchPost-itsWalking Awareness


• Marsden Ball Tap/Cross Body Taps

• Marsden Ball Half Body turn

• Marsden Ball Orbit

• Catch/Throw

• Peripheral Balloon Catch/Toss/Bat

• Block Sort (on table/rotator)

• Vecto Quoits with Obstacle Course

• Vecto Quoits: localize with circle, touch objects with float

CREATING PERIPHERAL FUSION LOCK AND PERIPHERAL STEREOPSIS

Peripheral Fusion Lock/Peripheral Stereopsis

• Luster

•Vecto Massage Quoits

•Quoits localization

•Quoits projected

•Above using balance, weights, movement, and high plus

AC: NO LUSTER – SPLIT FIELD

Luster

• With high plus lenses

• With red/green or red/blue glasses

• Projected light

• White Wall

DEVELOPING PERIPHERAL STEREOPSIS

LANGUAGE CAN MAKE A BIG DIFFERENCE

•Saying it differently….•Where does the Quoit looks like it is floating?•…seem to be floating?•How does it seem to be?• It is an illusion and is tricky so… tell me where you

think it looks like it is?•My experience: polarization much better results

than anaglyphic targets

VECTO Massage: Goal: awareness and localization of space, appreciation of SILO

• Have a space with a neutral wall, w/o visual clutter .

• Assess if patient understands concepts of: behind/in front, closer/ further.

• Patient wears polaroid glasses.

• Place Quoits in holder with a dot on acetate in the middle of the rings

• Hold 3-5 inches away from nose

• Coach patient to look through the vectos as in looking across a lake.

• Massage the rings slowly from 3 base out to 3 base in, VERY SLOW.

• “What are you aware of as I change the rings?”

Vecto massage cont.• Shake the Quoits. “Look at the dot and be aware of the rings.”

• “Can you look at the dot and be aware of the left side of the room? • Right side? Both sides? What changes do you see or seem to see?• Left/right side and the ceiling? And the floor at the same time? • What changes do you seem to see?• Can you imagine green fog filling in the space between your nose and the dot

and the left/right/ceiling and the floor? What changes do you see?

• Circle the Quoit’s size and position with a finger or pointer• Ferris wheel/merry-go-round or carousel

• If they can achieve SILO (base out: smaller/in, base in: larger/out), then slowly move the Quoits out further from the patient as they work on maintain SILO awareness

• With movement of finger or pointer does the position change or stay stable?

Vecto Massage cont.• With increase in Quoits distance from patient, float should

appear greater.

• Stop when the distance from the float does not change with the increased distance or it decreases.

• Initially discuss the change in size of the Quoits.

• Next the distance change, “let me know if the rings are getting closer or further from the dot. This is fantasy-like. You know it isn’t really floating towards and away, but it looks like it does.”

• Goal in time to be able to appreciate both size and distance.

• Truth detector: switch the polaroid lenses. Is float is opposite in direction?

PERIPHERAL to CENTRALLOOKING IN A NEW WAY – “AIR BETWEEN”

X

Y

Z

Peripheral Fusion Lock/Peripheral Stereopsis

• Luster

•Vecto Massage Quoits

•Quoits localization

•Quoits projected

•Above using balance, weights, movement, and high plus

Spatial Awareness

• Step Estimation

• Fixation – peripheral localization: items on the table

Spatial Awareness High Level

• Sort one inch blocks – groups of color

• Rings over bowling pins

• Fixation – peripheral Localization (items on the table)

• Large Attribute Blocks sort

Case Studies of Patients with AC

Case 1 –AC Road

• 4yo F - Strabismic Amblyopia – infantile XT, post-surgical XT/hyper (at 6 months), related nystagmus and midbrain lesion

• Surgeon discontinued care and referred to us due to low cooperation and high anxiety at exams. (Unable to get any findings after 3 attempts).

• Turns head to right when looking distance, eyes drift and “dance” often. Per patient, has a good eye and a “blobby eye”.

• Cardiff cards: 20/64 OD and OS grossly, 20/32 OU

• Int 15-20 LXT, variable fixation

• ? Luster

• Cyclo: +2.50 OU

Began vision therapy – AC Road

1 month into VT

• Great changes in eye alignment. She can now be prompted "to focus" and keep her eyes straight. She can now even cross her eyes (this is new over the last couple weeks). Eyes "dance" a lot less, especially right eye. Left eye still dances. Reports vision is "still squishy" but less than before. Sometimes more "squishy" than other times. Eye still turning often. No double noticed

• Improved fixation: ILXT and ILHT– 40% of time aligned distance, 65% of time aligned near

3 months into VT

• Usually fixates with right eye at distance; left eye usually out/up, but when prompted can align

• Much more talkative than last exam, minimal anxiety,

• Very good visual awareness today and good verbal descriptions of what she is noticing

• Nystagmus much improved – latent OS only seen today when OD covered, noncom. Full range

• B on Stereopsis 200 sec of arc at 16”

MODIFIED AC Road – still minimal patching, but going to smaller targets

6 months into VT

• Now flying on new scooter and riding bike. Eye teaming better and better each week. Mom is so happy awareness is there. Can use her eyes together on command. Eye still turns and XXX says it's because she forgets. But can keep alignment if prompted. Doing lots of 3D at home and getting huge awareness of depth perception. Says left eye vision is still squishy. Hasn't been wearing glasses a ton.

• Ortho and int. 20 LXT throughout exam but never on CT (distance and near)

• Rocks back and forth in chair beginning of exam, just came from VT

• Stereo 6/10 (50 seconds of arc)

• SL: 20/40 OD, 20/40 OS

• Prism bar near: BO 34/>40/X BI X/25/20

Case 2 – AC Road

• 35yo F – small angle ET with hx of strabismus surgery as an infant

• Reports has used right eye her whole life, and maybe at times left eye at near in certain gazes (cross fixation)

• Dist VA sc OD: 20/25, OS: 20/25-2• CT: 20PD alt ET distance and near• Stereo: 0• W4D: OS suppression distance , if works hard, int double at near• ? Luster – mostly OS suppression• +AC with afterimage• Central unsteady fixation left eye

Case 2 – AC Road

• 3 months of VT• Aware of periphery now – can tell when tunnels down. Still very OD

dominant.• 15 PD AET distance and near• Subjective phorias: 15-18 eso distance, 3-9 eso near• Stereo: 0

• 6 months of VT• Knows she is binocular a lot of the time, sometimes suppression

• Noticing depth a lot at near (instilling drops, looking at cat close up, ripples in pillow sheets).

• 100 seconds of arc stereo – local animals, 400 sec of arc local wirt circles• Subjective phorias: 6 eso distance and near

Case 2 – AC Road

• 12 months of VT• Noticing some double at distance and very close to lined up, can suppress whenever

needed• Her optometrist commented that she looks so straight now, even in upgaze• CT: flick of ET to 10PD ET distance, 20 CAET near• Stereo 140 seconds of arc• Subjective phorias: 2 exo distance, 4 eso near• Has substantial vergence ranges at this point• *at this point still +AC with after image testing

• 15 months of VT• Vision is BETTER when using two eyes versus one, and it’s easier to do so• CT: 10 CAET distance and near• Stereo: 100 seconds of arc with wirt circles

“… if we all take some responsibility to start with WHY and inspire others to do the same, then, together, we can change the world.”

ENDING SENSELESS VISUAL STRUGGLES

THANK YOU!

Think over the day.

What are a couple things that you have gained through this

time together?

Resources

• Barry, SR. Work & wisdom of Dr. Fredrick W. Brock. Journal of Behavioral Optometry 2011: 22 (3): 59-63.

• Barry SR. Fixing My Gaze: A Scientist’s Journey into Seeing in Three Dimensions. New York: Basic Books, 2009:94.

• Cook, David L. The Shape of the Sky: The Art of Using Egocentric Stereopsis in the Treatment of Strabismus. J. Vision and Reh. 2(4): 211-237, 2016.

• Cook DL. Considering the ocular motor system in the treatment of anomalous retinal correspondence. J Am

• Optom Assoc 1984: 55 (2): 109-117.

• Levi DM, Knill DC, Bavelier D. Stereopsis and amblyopia: A mini-review. Vision Res 2015: 114 (9) 17-30.

• Schor C. Perceptual-Motor Computational Model of Anomalous Binocular Correspondence. Optometry and

• Visual Science 2015: 92(5): 544-550.

• Vishwanath D. Toward a new theory of stereopsis. Psychological Review 2014: 121 (2) 153.

• M.H. Birnbaum (August 1981). "Perspectives on the contributions of Frederick Brock". Am J Optom Physiol Opt. 58 (8). pp. 667–670. PMID 7025647.

• Frederick W. Brock; Isadore Givner (June 1952). "Fixation anomalies in amblyopia". AMA Arch Ophthalmol. 47 (6): 775–786. doi:10.1001/archopht.1952.01700030794008.

• Frederick W. Brock. "Fusion disturbances in binocular vision". doi:10.1111/j.1444-0938.1944.tb03185.x. Article first published online: 24 March 2009

• Suter P and Harvey L. Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury. Taylor & Francis: 2011

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