Download Vision Therapy Basics for the Primary Care Optometrist

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
Tanya Polonenko, OD, FAAO
Residency Trained Optometrist in Vision Therapy and Rehabilitation

What is Vision Rehabilitation?
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Definition
Neuroplasticity
Optometry’s Role
Goals of Vision Therapy
Improvements to expect & Prognosis Factors
Guidelines for Vision Rehabilitation
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When working with TBI patients
Key Concepts
Vision Rehabilitation Sequence
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Vision Rehabilitation Procedures
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Does it work?
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Current research
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How to incorporate into your primary care practise
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Resources
70% of our brain as
Something to do with
VISION
Occipital Lobe (primary
visual cortex)
Parietal Lobe (spatial
inattention, perception)
Temporal Lobe (spatial
organization, object
recognition)
Frontal Lobe (initiates
voluntary saccades and
pursuits)
Midbrain and Pons (cranial
nerves)

An individualized treatment regimen prescribed to a patient in order
to:
o Provide medically necessary treatment to normalize diagnosed visual
dysfunctions
• Vergence
• Accommodation
• Oculomotor
o Improve visual comfort, ease and efficiency
o Enhance visual performance to meet defined needs of the patient
o Improve visual information processing
• Spatial organization
• Object perception
• Visual memory
• Visual attention
• Integration with other sensory modalities (motor, vestibular, auditory, etc)
1-4
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Brain (visual system) is able to create new connections and fortify
old ones by experience
Learning and plasticity can occur by myelination formation or remodeling white matter
Neurogenesis continues throughout lifetimes
Examples:
o rapid functional plasticity in primary somatomotor cortex and perceptual
changes after nerve block through MRI
o Visual development in adult amblyopes
5
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Optometrists can diagnose,
manage, and treat binocular
vision problems
Dysfunction of:
% of TBI
o Strabismic
Accommodation
41%
o Non-Strabismic
Vergence
56%
o Visual Perceptual
Oculomotor
51-57%
Strabismus
25-36%
Cranial Nerve Palsy
7-10%
Without appropriate
treatment, we are ignoring
25-57% of our TBI
population needs
5-26
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Alleviate signs and symptoms
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Achieve desired visual outcomes
o Clear, comfortable, single binocular vision
o Efficient coordination of visual functional skills
o Efficient visual information processing
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Meet the patient’s needs
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Improve the patient’s quality of life
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Return to daily activities
5-26
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Oculomotor Skills
o Improved accuracy and speed of pursuit and saccades
o Reduced number of re-fixations and regressions while reading
o Increased span of recognition
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Vergence
o Increased vergence ranges, speed, facility
o Reduced eyestrain, headache with near tasks
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Accommodation
o Increased amplitude, flexibility, facility
o Improved quality and stability of near vision
Comfort
Efficiency
Accuracy
Performance
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Most visual efficiency cases have a very good prognosis (7290% in CITT 2008)
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Important factors:
o Accurate diagnosis (rule out disease/trauma)
o Age/understanding of patient
o Treatment appropriate for diagnosis
o Patient compliance and motivation
o Stage in the grieving process
o Degree of brain injury
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Rehabilitation is a process that takes time
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Initially program can cause symptoms to be exacerbated
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Manage the increased symptoms while strength training
o Modify amount of time spent on exercises
o Slowly increase amount of exercises performed
o Monitor log for delayed symptoms
o Symptoms should not exceed 7 or 8/10
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Working with Patients with TBI
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Extent and severity of symptoms may not correlate directly
with degree of abnormality in clinical findings
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May have certain ability but at expense of excessive effort
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Visual hypersensitivity
o Real
o May not be over-reacting (most want to return to their normal life!)
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Mechanisms that normally help to function efficiently and
comfortably are compromised
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Quiet
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Avoid Fluorescent lighting
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Reduce clutter
 Speak
 Soft
voice
 Slow
 Ask
slowly
movements
for them to repeat
instructions
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Gain their attention
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Confirm they understand
the task
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Give instructions in small
steps
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Give breaks
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Increase demand in small
increments
o Amount of time
o Level of difficulty
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Key Concepts
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Determine a level at which the patient can perform easily
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Emphasize that changes must be made within their own
visual system (we can’t do the work for them!)
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Set goals (for both patient and doctor)
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Use techniques that provide them with feedback
(diplopia, blur, parallax, float….)
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Relate how exercises will impact daily living
Functional/Developmental/
Behavioural
Classical/Structural
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Visual processing as it relates
to anatomy, neurophysiology,
and sensorimotor substrates
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Emphasizes visual
development, function and
performance in the context of
their total behaviour

Treatment is based on
individual’s abilities, needs,
and goals
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A “visual stress test”
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Looks into fatigue, variability,
stamina
o Muscles and nerves
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Mechanics of vergence,
accommodative and
oculomotor systems
Bring measurements into the
“comfort zone” or “norms”
o Sheard, Percival, Morgan
Functional
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Develops visual
functional skills and
abilities
Behavioural
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o Oculomotor skills
o
o
o
o
o
o
o Accommodative rock
o Fusion range extension
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Looks how the visual
system develops and
integrates visual
information
Added holistic approach to
underlying organismic
processes to behaviour
Incorporates procedures
related to:

Movement
Awareness
Stress reduction
Visual information processing
Central-peripheral organization
Visuomotor function
Higher degree of holistic:
o Syntonics
o Bates (natural vision
improvement)
o Chinese Acupressure treatment
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Work on functional visual skills classically while addressing the developmental
and visual perceptual processing
• Antisuppression
• Awareness
Phase 1
Phase 2
• Bi-ocular
• Monocular
Phase 3
Phase 4
• Binocular
• Accomm
• Vergence
• Integration
• Flexibility
• Stamina
Phase 5
o Expand both but emphasize difficult area
o Build ability and stamina before flexibility
o Start with peripheral targets and work towards central targets
o Each eye has to learn how to work on its own before they are
expected to work equally to the partnership
o Can use lenses, prism
o Incorporate both free space and equipment
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Begin therapy by slowly stressing the direction of
difficulty:
o Exophoria with low base out – emphasize BO
o Esophoria with low base in – emphasize BI
o Accommodative Insufficiency – minus lenses
o Accommodative Excess – plus lenses
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To increase accommodative abilities:
o Begin by stressing direction of difficulty
o Later work on both relaxation and stimulation
o Emphasize the “feeling” of effort
o Equalize right and left eyes` skills
o Emphasize amplitude, then facility, fine control, and stamina
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To increase fusional vergence ranges:
o Maintain accommodation at the plane of regard and change the
stimulus to the vergence system
o Maintain vergence at the plane of regard and change the
stimulus to accommodation
o Emphasize amplitude, then facility, fine control, and stamina
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Your
Findings
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Chief Complaint: 33 year old male lawyer sustained concussion from MVC;
since has had headaches, double vision with reading, eye strain and
discomfort at near, words moving on the page, dizziness with movement.
Exam results
Interpretation
Phoria
Distance: 2 XP
Near: 14 XP
Higher exo at near
NPC
15/20, 18/25, 20/30
Low, Recedes with repetition
AC/A
2:1
Low
PFV/NFV
(40cm)
BO: 4/8/6 , BI: x/8/6
Low PFV
NRA/PRA
+1.00/-1.00
Low NRA and PRA
AA
OD 3D, OS 3.5D
Low
MEM
OD +1.25, OS +1.25
High accommodative lag
BAF
5 cpm (- longer)
Low
MAF
OD 7 cpm , OS 7.5 cpm
Low
Dx: Convergence Insufficiency and Accommodative Insufficiency
PHASE 1:
ANTI-SUPPRESSION
& AWARENESS
 Goal:
Anti-Suppression
and Awareness
o Discussion of Vision
o
o
o
o
o
Problem and Goals
Marsden Ball Tracking
Space Fixator
VO Star
Batwing
Cheiroscope
PHASE 2:
MONOCULAR
 Goal:
Equalize the skills
between both eyes
 Strategies: distances or lenses
o Monocular Accommodative Rocks
o
o
o
o
(+/-)
Hart Chart Saccades
Near-Far Hart Chart Saccades
Monocular Lens Sorting
Mental Minus (clear-blur-clear)
PHASE 3:
BI-OCULAR
 Goal:
Develop
monocular skills with
binocular awareness
o Monocular Fixation in a Bi-
o
o
o
o
o
Ocular Field (Red Acetate
with R/G glasses)
Split Prism Techniques
Split Vectograms
R/G tracking/workbooks
Red Rock
GTVT Chart
PHASE 4:
BINOCULAR
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Goal: Integrate both eye together and improve
Fusional Ranges and Accommodation
o Brock String
o Vectograms
o Tranaglyphs (Stationary and
Sliding)
o Bernellscope
o Batwing
o Computerized Vergence
Program
o Eccentric Circles
o Lifesaver Cards
o Aperture Rule
o Binocular Accommodative
Flippers
BROCK STRING
-
-
Correct
If you want to look at the
green bead, it is single
String “X” indicates you
are paying attention to
both eyes
Where the strings meet
is where you are looking
Bead is in the middle of
the “X”
-
Incorrect
You are looking farther
away than you want to
Must look closer
Look towards your nose
Move your eyes together
so they “touch”
-
Incorrect
You are looking closer
than you want to
Must look farther away
Look farther down the
string
Imagine looking down a
tunnel
-
-
Incorrect
Means you are suppressing or
ignoring information received by
one eye
You want to see 2 full strings
You need to make your brain
pay attention to both eyes again
Do either:
Blinking
Tapping the bead you
want to look at
Lightly tapping your
SLIDING TRANAGLYPH
Convergence:
Ensure that you see all the shapes:
For CONVERGENCE: Slowly move the slider
out from the thumb tag until you see double or
something disappears. Stop, and try to re-fuse
the images or make images appear. If you are
able to, continue to move the slider out until you
are unable to fuse the two images any longer.
Numbers to record
Note what the number is on the top (called the “break” –
when your binocular system breaks apart)
Nudge the slider in slightly and try again to refuse. If you are unable to do so for a few
seconds, continue to nudge the slider inward a
little bit and re-attempt
Once you are able to re-fuse the images, hold
the image single for 5-10 seconds, then rest.
Divergence:
Note what number is on the top (called the “recovery” –
when you are able to recover your binocular vision)
FOR DIVERGENCE: Repeat, but turn the
tranaglyph upside down so that the thumb tag is
now on the left side.
TIPS:
To help with re-fusing, use the red stick, by slowly moving
the stick towards you (for convergence) or behind the
tranaglyph (for divergence)
Remove the fogged sleeve to help with divergence (which
allows you to look past the tranaglyph to a distant target)
PHASE 4:
OCULOMOTOR
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Goal: Integrate both eye together and improve
Oculomotor skills
o Fixation Stability
o Computer Training
Techniques
o Mazes/Groffman Tracings
o Michigan Letter Tracking
o Marsden Ball
o Pegboard Rotator
o Kirschner Arrows
o Four-corner saccades
o PBQD slap tap
o Hart Chart saccades
o Saccadic Workbook
 There
are many areas
of brain needed for
tracking:
Cerebral
•Control of
saccades and
pursuits
o Pursuits/Saccades:
Brainstem (Pons,
Midbrain)
o Fixation: FEF, Parietal
lobe & \Prefrontal
cortex (for attention)
o Different pathways
o Both need to know
where objects are in
space
Brainstem
Cranial
Nuclei
Extra-ocular
Muscles
•Horizontal and
Vertical Gaze
Centers
•Control of eye
muscles
•Execute the eye
movements
MICHIGAN LETTER
TRACKING
GROFFMAN MAZES
PHONETIC FOCUS
HART CHART
SACCADIC WORKBOOK
PHASE 5:
INTEGRATION,
FLEXIBILITY, STAMINA

Goal: Improve stamina, enhance
skills, achieve accommodationconvergence flexibility
o Any Binocular Technique with +/- Lenses
o
o
o
o
o
(BIM/BOP)
Vectrograms/Tranaglyphs with Jumps
Binocular Prism Jumps with Saccades
Computerized Vergence Program with
Jumps
Eccentric Circles or Lifesaver with
Tromboning
Load activities, adding:
• Speed
• Metronome
• Balance board
PHASE 5:
VISUAL PERCEPTUAL
 Goal:
Improve processing
visual information
o Visual Memory
o Figure Ground
o Visualization
o Visual-Motor Integration
Final Results
Pre VT results
Post VT results
Interpretation
Norms
Phoria
Distance: 2 XP
Near: 10 XP
Distance: tr XP
Near: 8 XP
Higher exo at near
Well compensated
Ortho – 2XP
NPC
10/15, 13/15, 15/17
3/5, 3/5, 4/6
Normal, stable
At least 5/10
AC/A
2:1
2:1
Low
4:1
PFV/NFV
(40cm)
BO: 4/8/6 , BI: x/8/6
BO: 12/25/18
BI: 12/20/16
Normal
BO: 9/19/10
BI: x/7/4
NRA/PRA
+1.00/-1.00
+2.00/-3.00
Normal
+2.00/-2.25
AA
OD 3, OS 3.5
OD 10, OS 10
Normal
Min = 15 - (Age/4)
MEM
OD +1.25, OS
+1.25
OD +0.50, OS
+0.50
Normal lag
+0.50 to +0.75
BAF
5 cpm
9 cpm
Normal
8 cpm
MAF
OD 7 cpm
OS 7.5 cpm
OD 12 cpm
OS 12 cpm
Normal
12 cpm
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Improvement in Convergence Insufficiency Symptoms (double vision, eye
strain and discomfort at near, words moving on the page, etc.)
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3 month re-check, giving them homework 2-3 times a
week

Then, if needed, wean the procedures to once a week
(or biweekly) for another 3 months
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Yearly exams
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12 non-strabismic individuals with mTBI and diagnosed vergence and
accommodative disorders participated
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6 weeks (2 sessions/wk, 3 hours each); half did oculomotor training
(OMT) and half did placebo (P) training
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Results:
o
Improved amplitude and peak velocity of
• vergence (pfv and nvf)
• accommodation (monocular and binocular)
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o
o
o
Improved stereoacuity
Improved visual attention
Reduced near symptoms (CISS score)
o
No change in patients that did placebo VT
Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on vergence
responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2013: 50(9): 1223-40.
Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative
responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2014; 51(2): 175-92.
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12 subjects with mTBI participated in either oculomotor training
(OMT) or sham training (ST).
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6 weeks, 2 sessions a week. Trained vergence, accommodation,
version in randomized order across sessions.
Visual attention assessed by VSAT
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Results:
o
o
o
o
o
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Over 80% of abnormal parameters significantly improved
Reading rate improved
Amplitudes of vergence, accommodation improved
Saccadic eye movements improved in rhythmicity and accuracy
Improved visual attention and CISS score
Thiagarajan P, el al. Oculomotor neurorehabilitation for reading in
mild traumatic brain injury (TBI): An integrative approach.
NeuroRehabilitation. 2014. 34: 129-146.
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5 adults with stroke and 9 adults with TBI
8 weeks of training, 2 sessions/week

Training included single- and multiple-line simulated reading, as well
as basic versional tracking (fixation, saccade, and pursuit) using
infra-red eye movement recording technology
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Internal oculomotor visual feedback in isolation (4 weeks) or
concurrent with external oculomotor auditory feedback (4 weeks)
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Results:
o Improved objective accuracy with versional tracking
o Improved reading ability
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Ciuffreda KJ, et al. Oculomotor rehabilitation for reading in acquired
brain injury. NeuroRehabilitation. 2006. 21: 9-21.

13 control normal BV adults; 4 convergence insufficiency
adults
All participated in 18 hours of VT
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Results:
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o Reduction in NPC and NPC recovery point
o Reduction in Near Phoria
o Improved PFV, average peak velocity of convergence
o Significant increased functional activity within the frontal areas,
cerebellum, and brain stem significantly
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Alvarez TL, et al. Vision Therapy in Adults with Convergence Insufficiency:
Clinical and fMRI Measures. Optom Vis Sci. 2010; 87(12): E985–1002.

Functional activity and vergence eye movements were
quantified from 7 BV normal and 4 CI patients before and
after 18 h of vergence training.

Results: CI patient measurements after vergence training
were more similar to levels observed with BV normal
o Increased fMRI activity levels
o Increased speed in convergence response
o Improvement in CISS score

Alvarez TL et al. Functional activity within the frontal eye fields, posterior parietal
cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak
velocity: an ROI-based, fMRI study of vergence training. Front. Integr. Neurosci.,
2014; http://dx.doi.org/10.3389/fnint.2014.00050

12 BV normal patients and 4 CI patients. CI patients
underwent 18 hours of VT.

Results: After VT, peak velocity and exophoria
magnitude improved significantly in CI patients
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Alvarez TL. A pilot study of disparity vergence and near dissociated phoria in
convergence insufficiency patients before vs. after vergence therapy. Front. Hum.
Neurosci. 2015; http://dx.doi.org/10.3389/fnhum.2015.00419

The NIH funded a study to determine the best treatment
protocol for Convergence Insufficiency.

The results indicated that in-office VT is the treatment of
choice as it is the most effective treatment for
convergence insufficiency.
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

Randomized, multi-centered clinical trial
221 children ages 9-17 years with CI
Subjects subdivided into 4 groups and underwent 12 weeks of
either:
VT

Reduced symptoms by:
Office based VT
73%
Home-based pencil push-up (PPU) VT
43%
Home-based computerized VT + PPU
33%
Office-based placebo therapy
35%
Results:
o Remained symptom free 1 year later
o ~90% of those CI subjects who initially had reduced accommodative
amplitudes and facilities also developed normalized accommodative skills
with the VT program
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
Decide what conditions you are comfortable treating
and what tools you will need.

Compose written instructions to hand out.

Schedule an instructional session to review the
techniques together.

Sell or rent the required equipment to your patient.
Equipment
Cost
Instructions
Photocopy
Brock String
$2
Sliding Tranaglyph
$15
Red/Green Bar Reader
$10
Flippers (+/-2.00)
$19
Near and Far Hart Charts
Barrel Card
Total Cost
Photocopy
$3
$50
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

Your office registers for an institutional account (free)
Purchase DVD/codes for each patient, which will be
linked to your account
Software, Glasses, and Flipper Set: $110 USD (Your
cost)

What is “In-Office” VT:
o Usually weekly sessions of 45 minutes
o Homework to be completed at least 4 times between sessions
o Activities progress week by week
o The patient’s progression is monitored and the program can be
individualized for optimal results

Can get in touch with local clinics offering VT for specific
info:
o Do they have a referral form?
o What kind of patients do they treat?
o What is their background/training?
o What is their fee?



Canadian Optometrists in Vision Therapy and Rehabilitation
(COVT&R)
o Annual Meeting (August)

College of Optometrists in Vision Therapy and Rehabilitation (COVD)
o Tour d’Optometry for students
o Annual Meeting for students and optometrist (April)
o Can become a fellow (essays, clinical experience, exam, and interview)

Optometric Extension Program (OEP)
o Courses available

Vision Therapy Courses by Robert Sanet
o Courses available

Neuro-Optometric Rehabilitation Association
o Annual Meeting

Websites:
o Bernell - www.bernell.com
o Optego - www.optego.com
o McCray Optical - www.mccrayoptical.com
o Fresnel Prisms (prisms and bangerter foils) - www.fresnel-
prism.com
o GoodLite - www.good-lite.com
o HTS Inc - www.visiontherapysolutions.net

Can discover more at the annual meetings and exhibits
1. Weiss T, Miltner WHR, Liepert J, Meissner W, and Taub E. Rapid functional plasticity in the
primary somatomotor cortex and perceptual changes after nerve block. European Journal of
Neuroscience; 20: 3413–3423
2. Levi DM and Polat U. Neural plasticity in adults with amblyopia. Proc Natl Acad Sci U S A.
1996; 93(13): 6830–6834.
3. Levi DM. Perceptual learning in adults with amblyopia: a re-evaluation of critical periods in
human vision. Developmental Psychobiology. 2005; 46 (3): 222-232.
4. Zhou J, Reynaud A, and Hess RF. Real-time modulation of perceptual eye dominance in
humans. Proc Biol Sci. 2014 22;281(1795).
5. Ciufredda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, and Craig S. Occurrence of
oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2007; 78:
155-161.
6. Ciufredda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, and Han ME. Vision therapy for
oculomotor dysfunctions in acquired brain injuries: A retrospective analysis. Optometry. 2008.
79;18-22.
7. Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury.
Optom Vis Dev 2009;40(1):16-23.
8. Aksionoff EB, Falk NS. Optometric therapy for the left brain injured patient. J Am Optom
Assoc 1992;63:564-8.
9. Cohen AH. Optometric management of binocular dysfunctions secondary to head trauma:
case reports. J Am Optom Assoc 1992;63:569-75.
10. Ciuffreda KJ, Suchoff IB, Marrone MA, et al. Oculomotor rehabilitation in traumatic braininjured patients. J Behav Optom 1996;7(2):31-8.
11. Gottleib DD, Fuhr A, Hatch WV, et al. Neuro-optometric facilitation of vision recovery after
acquired brain injury. Neuro-rehabilitation 1998;11:175-99.
12. Hellerstein LF, Freed S. Rehabilitative optometric management of a traumatic brain injury
patient. J Behav Opt 1994;5(6):143-8.
13. Ludlam WM. Rehabilitation of traumatic brain injury with associated visual dysfunction—a
case report. Neuro-rehabilitation 1996;6:183-92.
14. Thiagarajan P and Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative
responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2014;51(2):175–92.
15. Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on vergence responsivity in
mild traumatic brain injury. J Rehabil Res Dev. 2013;50(9):1223–40.
16. Thiagarajan P, el al. Oculomotor neurorehabilitation for reading in mild traumatic brain injury
(TBI): An integrative approach. NeuroRehabilitation. 2014. 34: 129-146.
17. Ciuffreda KJ, et al. Oculomotor rehabilitation for reading in acquired brain injury.
NeuroRehabilitation. 2006. 21: 9-21.
18. Kapoor N, Ciuffreda KJ, Han Y. Oculomotor rehabilitation in acquired brain injury: a case
series. Arch Phys Med Rehabil 2004;85:1667-78.
19. Thiagarajan P and Ciuffreda KJ. Versional eye tracking in mild traumatic brain injury
(mTBI): Effects of oculomotor training (OMT), Brain Injury, 2014; 28(7): 930-943
20. Ciurfredda KJ. The scientific basis for and efficacy of optometric vision therapy in
nonstrabismic accommodative and vergence disorders. Optometry 2002;73:735-62.
21. Liu JS, Lee M, Jang J, et al. Objective assessment of
accommodation orthoptics: dynamic insufficiency. Am J Optom Physiol
Optics 1979;56:285-94
22. Bobier WR, Sivak JG. Orthoptic treatment of subjects showing slow
accommodative response. Am J Optom Physiol Optics 1983;60:678-87
23. Hung GK, Ciuffreda KJ, Semmlow JL. Static vergence and
accommodation: population norms and orthoptics effect. Doc
Ophthalmol 1986;62:165-79.
24. Cooper J, Feldman J, Selenow A, et al. Reduction of asthenopia
after accommodative facility training. Am J Optom Physiol Opt
1987;64:430-6
25. Grisham JD, Bowman MC, Owyang LA, et al. Vergence orthoptics:
validity and persistence of the training effect. Optom Vis Sci
1991;68:441-51
26. North R, Henson DB. The effect of orthoptic treatment upon the
vergence adaptation mechanism. Optom Vis Sci 1992;69:294-9.


Tanya Polonenko, OD, FAAO
[email protected]