let’s get down to strabusiness ... let’s get down to strabusiness •get your...

Let’s Get Down to STRABusiness

Wisconsin 2018 Nancy G. Torgerson, OD, FCOVD

Michelle Mott, COVT

Alderwood Vision Therapy Center, Lynnwood & Redmond, WA

Alderwood Vision Therapy Center drt@alderwoodvisiontherapy.com info@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 LEARNED VISION CAN BE RE-LEARNED VISION 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 align Called 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 Therapy Patient 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

Central/Peripheral Integration

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 therapy Linda Sanet , COVT, VT 101

Patient Questionnaire Alderwoodvisiontherapy.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 ca