Advanced Amblyopia Treatment. Learning Objectives: Learn about vision training for amblyopia to: Amblyopia. September 2015
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1 September 2015 Advanced Amblyopia Treatment Jen Simonson, OD, FCOVD Boulder, Colorado USA Learning Objectives: Learn about vision training for amblyopia to: 1. Decrease suppression 2. Improve fixation 3. Improve accuracy of accommodation 4. Develop depth perception 5. Improve acuity All lecture slides and links are available on Is our best treatment patching an eye? Amblyopia New research is validating that a binocular model of treatment is superior to occlusion therapy. Is our best treatment patching an eye? Potential Benefits of a Binocular Approach: 1. Improved treatment compliance 2. More functional improvement than patching especially in the development of stereopsis 3. Less regression 4. No harm to better seeing eye (reverse amblyopia) 1
2 The prevalence of amblyopia is approximately 3.5% of the population. Common Causes of Amblyopia: 1. Misalignment of the eyes (strabismus) Is our best treatment patching an eye? Mild 20/40 (6/12) or better Moderate 20/40-20/80 (6/12-6/24) Severe 20/80-20/200 (6/24 6/60) Is our best treatment patching an eye? 2. A refractive error (anisometropia) 3. Form deprivation (ptosis/cataract) Strabismus 13:93, 2005 S.E. Loudon, H.J. Simons, The History of the Treatment of Amblyopia Assumed these conditions interfered with the architecture of the developing brain. Patients with amblyopia were assumed to be anatomically monocular and lacked the capacity for functional binocularity SUPPRESSION: THE CAUSE OF AMBLYOPIA Robert F. Hess, PhD Director of Vision Research, Department of Ophthalmology McGill University, Canada Recent findings have provided strong evidence that amblyopes actually have an intact binocular infrastructure including binocular processes, even in the adult amblyope. However, what appears to have been lost is only a sign of suppression under binocular viewing conditions. Current evidence indicates that suppression plays a primary role in both the binocular and monocular deficits. 2
3 WHY is suppression Developed?? AMBLYOPIA TREATMENT STUDY -18 BACKGROUND Double Vision Doble La visión doble es muy dificil cuando la impresión es pequeña y poco espaciados. Supresión arregla. Blurry Vision Supresión hace que sea más fácil de procesar la imagen más clara. Visual Confusion Confusión Visual Confusión visual es cuando La visión doble es muy dificil dos cosas diferentes cuando la impresión es aparencen en el mismo pequeña y poco espaciados. lugar. Supresión arregla. Amblyopia affects more than acuity! Contrast sensitivity Binocular vision dysfunction Poor stereopsis Accommodation dysfunction Fixation dysfunction Vergence dysfunction Poor visual information processing Poor reading fluency Reduced visual-motor integration AMBLYOPIA TREATMENT STUDY (ATS-18) Binocular ipod treatment for amblyopia MONOCULAR DICHOPTIC treatment Compare binocular game play for 1 hour/day to Occlusion for 2 hours/day. Ages 5-13 and bert/clinicaltrial/clinical trial.html 3
4 Monocular Traditional treatment Use one eye at a time Goal: Equalize ocular skills Occlusion Types Complete: pirate patch, Band-Aid patch, cover, hand Fixation Pursuit Saccades Focusing Abilities Occlusion Types Translucent: light, but no detail Occlusion Types Blur: Bangerter foils, tape, contact lens, nail polish and atropine 4
5 Occlusion Types Partial: bi-nasal or bi-temporal Occlusion Types Liquid Crystal Glasses: Amblyz, Eyetronix (M) Activities Fixationability of the eye to accurately aim to one point in space. (M) Activities Saccades- the ability to swiftly and smoothly jump accurately from one point to the next. 5
6 (M) Activities Pursuits: the ability to smoothly and accurately follow a moving object. (M) Activities Accommodation - ability to focus clearly and accurately. (M) Activities Anti-suppression After-image Line scrubbing Macula Integrity Tester (M) Activities Detail recognition: Resolution 6
7 (M) Activities Detail recognition: Recognition (M) Activities Detail recognition: Vernier Acuity (M) Activities Detail recognition: Crowding (M) Activities Prism Training Monocular Prism Jumps Awareness of eye movements Localize direction and amount of movement Smaller amounts of prism are more difficult 7
8 MONOCULAR FIXATION IN A BINOCULAR FIELD Monocular Fixation in a Binocular Field (MFBF) One eye sees detail and the other eye sees the background in the same space. MONOCULAR FIXATION IN A BINOCULAR FIELD Anti-suppression Detail recognition 1. Hide and Seek (pom poms on black felt) 8
9 (MFBF) Activities Hide and Seek Monocular Fixation in a Binocular Field (MFBF) Monocular Fixation in a Binocular Field (MFBF) Goal: accurate perception of details with one eye and the perception of the background with the other eye. 2. ipad Activities: 2. Image set to Red 3. Can change SIZE and SPEED 1. Background set to Black 9
10 Both eyes see the ipad, but only the left eye can follow the red bear: (MFBF) Activities 3. Button Boards: Sanet Vision Integrator (SVI)- Eye Hand, Rotations, Saccades with Red patch or Red/Blue Glasses With a white background, the eye covered by the blue lens sees the target. Use the blue lens on the amblyopic eye 10
11 (MFBF) Activities The red light is blocked by the green filter. Use the red lens on the amblyopic eye. Saccadic Fixator with R/G glasses Saccadic Fixator with red/green glasses: (MFBF) Activities Acuvision with Red and Green Glasses (MFBF) Activities 4. Red- Ink Coloring books/letter tracking 11
12 Red letter charts Red letter charts (MFBF) Activities (MFBF) Activities 5. Red/White/Black Cards: Sherman Cards- separated to use one color only Rotating Pegboard with red numbers Carl s Cardsseparated to use one color only 12
13 (MFBF) Activities (MFBF) Activities Colored overlays BIOCULAR (BIOC) BIOCULAR 13
14 Biocular (Bioc) The ability to see information from both eyes, although the images are in different spaces. Biocular (Bioc) Goal: to improve the ability of both eyes to alternately shift focus in an un-fused situation, which will facilitate antisuppression and prepare the patients for simultaneous perception. (Bioc) Activities 1. Vertical Prism dissociation with ball on string (Bioc) Activities 2. Squinchel 14
15 (Bioc) Activities 3. Red/Red Rock (Bioc) Activities 4. Red/Green filters placed side-by-side (Bioc) Activities Anaglyphic projection (Bioc) Activities Red Green filters placed side-by-side on reading material, crossword puzzle, hidden pictures etc. Polarized or Red/Green bar readers with the appropriate glasses 15
16 (Bioc) Activities Split Vectograms 5. Spilt Vectograms Polaroid- Mirror Activity ANTI-SUPPRESSION ACTIVITIES ANTI-SUPPRESSION 16
17 ANTI-Suppression Activities ANTI-Suppression Activities Sherman Cardsentire deck ANTI-Suppression Activities ANTI-Suppression Activities 17
18 ANTI-Suppression Activities ANTI-Suppression Activities ANTI-Suppression Activities BINOCULAR 18
19 Binocular (B) Binocular The ability of the brain to fuse information from both eyes into one image. Degrees of Binocular: First Degree Fusion/ Simultaneous perception Second Degree/ Flat Fusion Third Degree/ Stereopsis Single, Clear Binocular Vision First Degree: Simultaneous Perception First Degree Activities Simultaneous awareness of dissimilar targets In the SAME place (vs. biocular, which is NOT fused into the same space) Goal: To see images from each eye in the same space. 19
20 First Degree Activities Luster-The perception of information from both eyes simultaneously; with Red/Green glasses this is a shimmery color. Activities: White toys, Flashlight activities First Degree Activities 1. Flashlight Activities: Press Lites Press Lites First Degree Activities 2. Cheiroscopic tracing 20
21 Cheiroscopic tracing - OPTO First Degree Activities 3. Hole in Hand First Degree Activities Cook s Rings First Degree Activities 4. Red Light/Red Ring: Red print circle on a paper placed over a red filter with a penlight behind both. Patient wears Red/Green glasses. Can also use a red laser pointer and a red circle drawn on a white board. 21
22 9/22/2015 First Degree Activities Mirror Superimposition: Bird in Cage First Degree Activities Bird in Cage 22
23 First Degree Activities Mixed Vectograms Second Degree/ Flat Fusion Goal: Use both the eyes to combine common borders and to align two images received from each eye into a single perception. 1. Mirror superimposition Second Degree Activities Mirror Superimposition 23
24 2. Stereoscope cards 3. Fusion Cards Morganstern s Visicare cards- Pre-fusion through Basic fusion 4. Computer activities: VTS3/4 Flat fusion 1 & 2 24
25 Third Degree Fusion/ Stereopsis The ability to perceive float and localize a target using binocular depth perception THIRD DEGREE FUSION/ STEREOPSIS Stereopsis Stereopsis Integration of similar objects with some disparity that causes stereopsis 25
26 SILO= small-in and large-out Accurate perception is of closer targets becoming smaller and further targets becoming larger Third Degree Activities In-instrument Techniques: Stereoscope with Convergence/ Divergence Cards Aperture Rule Amblyoscope, Synoptophore W-Cheiroscope In-instrument Third Degree 26
27 Stereoscope for ipad Third Degree Activities Anaglyphic or Polarized Lens Techniques Alphabet fusion book Keystone Cards Vectograms Tranaglyphs Vectograms Projected vectograms 27
28 Fixed Anaglyphs Variable Anaglyphs Third Degree Activities- Free Space Fusion Techniques Brock String 3-Dot/Barrel card Thumbs BI/BO Lifesaver card Mountain card Star cards Eccentric circles String and Dowel Yardstick and Pins Brock String Prism flippers Prism Bar Magic Eye books 28
29 Modified Brock String: Convergence & Divergence Third Degree Activities- Computer Fusion Techniques VTS3/4- Near and projected stereopsis Vision Builder- Random Dot Stereopsis, Vergence, Jump Vergence HTS- Random Dot Stereopsis Third Degree Activities- Computer Fusion Techniques Vision Tap OPTO 29
30 Treatment Calendar Improving patient compliance Improving Patient Compliance 1. Provide a written prescription 2. Present reading material on the diagnoses 3. Provide an office policy sheet regarding vision training Improving Patient Compliance 4. Give written instructions and goals 5. Be available for questions 6. Track progress with logs and reports 7. Schedule follow-up evaluations Graph the patient s progress in developing normal: Acuity Focusing skills Tracking skills Depth Perception Vergence skills 30
31 Sample Patching Prescription Your doctor has prescribed patching for the treatment of amblyopia. Please follow these instructions as directed. Remember to wear glasses or contact lenses when patching, so a clear image is on your amblyopic eye. Type(s) of Patch recommended: Adhesive bandage (Opticlude, Coverlet) Blur foil (Bangerter), clear contact paper or transparent magic tape Patch (Pirate-style or patchworks) Spectacle clip Frosted lens Opaque contact lens Over-plus optical lens (spectacle or contact lens) Atropine penalization Your amblyopic eye is the: Patch this eye: Hours per day: Days per week: Lazy Eye Tetris Vp7hfacpBp0 Examples of activities to complete while patched: References Fortenbacker, OD, FCOVD Advanced Amblyopia Treatment for Better Results 2015 COVD Annual Meeting. S.E. Loudon, H.J. Simonsz, The History of the Treatment of Amblyopia. Strabismus, 13:93, Amblyopia Treatment Study (ATS18) Study of Binocular Computer Activities for Treatment of Amblyopia Bateman, R., Danner, R., Dowis, R., et al. (1985). Manual of Esotropia Therapy. Colorado Vision Consultants: Colorado. Press, L. Press lites procedures for visual field awareness. Optom Vis Perf 2013;1(2): COVD. (2009, July). COVD fact sheets. Retrieved from Headline, T. C., Wahlmeler, I., & Bedes, V. (2005). The Vision Therapist's Toolkit. San Jose: California. Press, L. J. (1997). Applied Concepts in Vision Therapy. Mosby: Birch, Eileen E. Amblyopia and Binocular Vision. Prog Retin Eye Res March; 33: Doi: /j.preteyeres Simonson, J. Optometric Management, Volume: 48, Issue: December 2013, page(s):
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