Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Tanya Polonenko, OD, FAAO Residency Trained Optometrist in Vision Therapy and Rehabilitation What is Vision Rehabilitation? o o o o o Definition Neuroplasticity Optometry’s Role Goals of Vision Therapy Improvements to expect & Prognosis Factors Guidelines for Vision Rehabilitation o o o When working with TBI patients Key Concepts Vision Rehabilitation Sequence Vision Rehabilitation Procedures Does it work? o Current research How to incorporate into your primary care practise 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 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 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 Alleviate signs and symptoms Achieve desired visual outcomes o Clear, comfortable, single binocular vision o Efficient coordination of visual functional skills o Efficient visual information processing Meet the patient’s needs Improve the patient’s quality of life Return to daily activities 5-26 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 Vergence o Increased vergence ranges, speed, facility o Reduced eyestrain, headache with near tasks Accommodation o Increased amplitude, flexibility, facility o Improved quality and stability of near vision Comfort Efficiency Accuracy Performance Most visual efficiency cases have a very good prognosis (7290% in CITT 2008) 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 Rehabilitation is a process that takes time Initially program can cause symptoms to be exacerbated 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 Working with Patients with TBI Extent and severity of symptoms may not correlate directly with degree of abnormality in clinical findings May have certain ability but at expense of excessive effort Visual hypersensitivity o Real o May not be over-reacting (most want to return to their normal life!) Mechanisms that normally help to function efficiently and comfortably are compromised Quiet Avoid Fluorescent lighting Reduce clutter Speak Soft voice Slow Ask slowly movements for them to repeat instructions Gain their attention Confirm they understand the task Give instructions in small steps Give breaks Increase demand in small increments o Amount of time o Level of difficulty Key Concepts Determine a level at which the patient can perform easily Emphasize that changes must be made within their own visual system (we can’t do the work for them!) Set goals (for both patient and doctor) Use techniques that provide them with feedback (diplopia, blur, parallax, float….) Relate how exercises will impact daily living Functional/Developmental/ Behavioural Classical/Structural Visual processing as it relates to anatomy, neurophysiology, and sensorimotor substrates Emphasizes visual development, function and performance in the context of their total behaviour Treatment is based on individual’s abilities, needs, and goals A “visual stress test” Looks into fatigue, variability, stamina o Muscles and nerves Mechanics of vergence, accommodative and oculomotor systems Bring measurements into the “comfort zone” or “norms” o Sheard, Percival, Morgan Functional Develops visual functional skills and abilities Behavioural o Oculomotor skills o o o o o o o Accommodative rock o Fusion range extension 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 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 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 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 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 Your Findings 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 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 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 Improvement in Convergence Insufficiency Symptoms (double vision, eye strain and discomfort at near, words moving on the page, etc.) 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 Yearly exams 12 non-strabismic individuals with mTBI and diagnosed vergence and accommodative disorders participated 6 weeks (2 sessions/wk, 3 hours each); half did oculomotor training (OMT) and half did placebo (P) training Results: o Improved amplitude and peak velocity of • vergence (pfv and nvf) • accommodation (monocular and binocular) 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. 12 subjects with mTBI participated in either oculomotor training (OMT) or sham training (ST). 6 weeks, 2 sessions a week. Trained vergence, accommodation, version in randomized order across sessions. Visual attention assessed by VSAT Results: o o o o o 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. 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 Internal oculomotor visual feedback in isolation (4 weeks) or concurrent with external oculomotor auditory feedback (4 weeks) Results: o Improved objective accuracy with versional tracking o Improved reading ability 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 Results: 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 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 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. 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 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 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]