Asthenopia Ahmad M. Fahmy Presented at the Pediatric Ophthalmology & Optometry Symposium 17 19 March 2013 Riyadh, KSA
ASTHENOPIA PEDIATRIC OPTOMETRY SYMPOSIUM 17-19 MARCH 2013 NATIONAL GUARD- HEALTH AFFAIRS Ahmad M. Fahmy amfahmy@mneye.com
ASTHENOPIA Asthenopia Eye Strain FaOgue Photophobia Dull Ache Located round globe of the eye My friends tell me I have Tired Looking Eyes Difficulty sustaining near visual funcoon IntermiWent Diplopia at near FluctuaOng VA HA Prolonged Reading Computer Work Tedious Near Tasks : EMR
ASTHENOPIA - ASSOCIATIONS Low accommodaove amplitude relaove to age Reduced D/N accommodaove facility Reduced range of accommodaoon Abnormal lag of accommodaoon AccommodaOve instability Convergence excess CVS Convergence Insufficiency AccommodaOve Insufficiency
SCREENS ProtecOve sheet in reducing eye strain caused by unnecessary light reflecoon on portable liquid crystal display panels while playing Game Boy Blink rates of 24 normal volunteers Relaxed condioons Polyethylene terephthalate with AR coaong 10 minutes Tsubota. Am J Ophthalmol 2002;133:704 705
SCREENS RESULTS : The results showed a dramaoc increase From 5.6+3 to 9.1+4.9 [P <.0001] in blinks/minute with use of the protecove sheet CONCLUSION : The protecove sheet has shown the possibility of increasing the blink rate by making the screen easier to use Tsubota. Am J Ophthalmol 2002;133:704 705
CVS Most common CVS symptom : Eye Strain FBS Irritaion Decreased VA VA Instability DTS OSD AccommodaOve DysfuncOon Extraocular ( ergonomic ) Display rate and quality Refresh rate RadiaOon Blehm. Surv. Ophthalmol 50:253-262.2005
CVS Treatment requires MulOdirecOonal Approach RefracOve error Binocular Vision AccommodaOon DTS therapy Osmolarity. Interferometry. Careful SL assessment of the OSS Environmental adjustments LighOng AR filters Breaks Computer Glasses Blehm. Surv. Ophthalmol 50:253-262.2005
CVS
CVS
CONVERGENCE INSUFFICIENCY Treatment with home- based computer orthopoc exercise program 42 PaOents symptomaoc children ages 5-18 Asthenopia IntermiWent Binocular Diplopia Headaches with reading and near tasks CI defines as: NPC > 6cm Decreased PFV EP at N > D NPC > 50 cm began 4BI^ and Pencil Push- Ups x 2 weeks Serna. J AAPOS 2011;15:140-143
CONVERGENCE INSUFFICIENCY 35 / 42 Treated with OrthopOcs program and push- ups 7 / 42 Treated with OrthopOcs program only 12.6 week Treatment 8.5M Follow- up Serna. J AAPOS 2011;15:140-143
CONVERGENCE INSUFFICIENCY Baseline NPC = 24.2 cm Improved to 5.6 cm 92.8% achieved NPC < 6 cm 92.8% improved PVF 64.2% reported symptom resoluoon Serna. J AAPOS 2011;15:140-143
CONVERGENCE INSUFFICIENCY AND ADHD Carries a significant impact on children and their families Basic workup for ADHD includes careful eye examinaoon R/O Ocular condioons impacong performance Inability to converge the eyes or maintain adequate binocular convergence toward a near target without undue effort. Rowe 1997 Symptom overlap InaWenOon Granet. Strabismus, 13:163 168, 2005
ADHD SYMPTOMS 1. Oren doesn t give close awenoon to details or makes careless mistakes in schoolwork 2. Oren has trouble keeping awenoon on tasks or play acovioes 3. Oren does not follow instrucoons and fails to finish schoolwork, chores, duoes ( not due to opposioonal behavior of inability to understand ) 4. Oren avoids, dislikes, or does not want to do things that take a lot on mental effort for a long period of Ome ( homework avoidance ) 5. Easily distracted 5/9 Symptoms DSM- IV Criteria for ADHD Dx DiagnosOc Confusion Granet. Strabismus, 13:163 168, 2005
CONVERGENCE INSUFFICIENCY ADHD RetrospecOve review of 266 PaOents with CI. Mean age 11.6 26 (9.8%) diagnosed with ADHD at some point during the CI clinical course 20 (76.9%) were on medicaoon for ADHD at the Ome of diagnosis of CI Three- fold greater incidence of ADHD among paoents with CI compared to the general populaoon AddiOonal computer Dx code review UCSD 1705 paoents with Dx of ADHD 176 had eye evaluaoons CausaOve relaoonship? AssociaOon? Granet. Strabismus, 13:163 168, 2005
CONVERGENCE INSUFFICIENCY TREATMENT Lavrich. Current Opinion in Ophthalmology 2010,21:356 360
CONVERGENCE INSUFFICIENCY TREATMENT Intensive orthopoc therapy : Treatment of choice Pencil push- ups and use of accommodaove targets: Have a role in the treatment of convergence insufficiency when used as part of a more intensive orthopoc program Base- in prism glasses: Should be reserved for reducoon of symptoms in the presbyopic populaoon. Lavrich. Current Opinion in Ophthalmology 2010,21:356 360
ACCOMMODATIVE INSUFFICIENCY AI as the number one cause of asthenopia in school children Most common accommodaove dysfuncoon AI paoents also exhibit infacility and high lag Most common treatments are PLRA v. Flippers Helping Hand / Passive v. AcOve Systems PLRA: Remaining blur is recognizable and the image is cleared by the paoent s accommodaove capacity Flipper: ManipulaOon of blur reducoon (+) and blur inducoon (- ) Engaging the adapove mechanisms of the A system
ARE EXERCISES BETTER THAN READING GLASSES FOR AI?
ACCOMMODATIVE INSUFFICIENCY TREATMENT 24 Subjects Mean age 10.3 PLRA arm: 10 completed an 8 week program Improved from 3.58D to 4.25D Flipper arm: 9/14 completed an 8 week program Improved from 5.15D to 7.82D VAS : Asthenopic Symptoms PLRA: 4.7 Units lower arer treatment Flipper: 6.3 Units lower arer treatment
ASTHENOPIA Take into account the visual demands on children today Carefully invesogate signs and the paoent s visual environment Carefully assess accommodaoon and vergence on paoents with Dx of ADHD Flippers
THANK YOU amfahmy@mneye.com