EXCELerated Vision

Convergence Insufficiency or ADD/ADHD?

Convergence Insufficiency is a vision disorder that affects nearly 1 in 12 children and has consequences to a child's quality of life. This serious vision problem does not cause blindness, but it's impact can be nearly as severe as shown by this video on The VisionHelp Channel...

A real live example of this is told by Aiden's Success Story. His behaviors before treatment looked like ADD/ADHD.

To see what has been published in the professional journals, Optometry Times published it's lead story in March 2009 showing the evidenced-based research.

Click here to see what Doctors are being taught about the most effective treatment for Convergence Insufficiency.

For more information on Convergence Insufficiency, go the The VisionHelp Blog

Dan L. Fortenbacher, O.D., FCOVD

MFBF treatment for amblyopia shows patching alone is not enough

MFBF is a technique we use to accelerate vision development through office-based treatment of our patients with amblyopia. This latest research (October 2010), from Current Biology, shows that this MFBF(monocular fixations in a binocular field) treatment methods are evidenced based in Neuroscience. Read more in this interesting VisionHelp Blog post written by Dr. Leonard Press.

Research Support for MFBF Amblyopia Optometric Vision Therapy

The significance of this research is that occlusion therapy (eye patching) the "good eye", when utilized as the sole treatment, does not address critical aspects of binocular vision development for patients with amblyopia.

Dr. Fortenbacher has previously blogged on this topic and explains why eye patching alone is not enough to treat amblyopia. Parents need to be aware of this advancement in amblyopia treatment which is based on solid research. If you have a child who has amblyopia and the only treatment recommended is an eye patch, consider finding a doctor who will provide office-based vision therapy and the MFBF technique.   

Read Dr. Fortenbacher's previous VisionHelp post here: Amblyopia treatment – Eye patching alone is no longer the standard of care

Help your child become a piano virtuoso with simple finger exercises!

What if your child is struggling to play the piano? Let say he is a bright 10 year-old boy who finds playing the piano difficult.  He just doesn’t get it! You ask yourself, why is he having this difficulty…he just seems to be unable to coordinate his fingers to play?   So, as any concerned parent, you seek professional help. But first,  you go on-line to research the possibilities for a solution to this problem and stumble across a website that says,   “Help your child become a piano virtuoso with simple finger exercises!”

Now wait a minute, that’s hard to believe right!? We all know that is illogical.  Doing simple finger exercises will not teach anyone how to become a skilled piano player! His fingers are strong enough to move the keys on the piano, his brain just does not know how to coordinate his fingers to play the music. The answer to his problem is found when you locate a good piano “coach” who can guide him along a process of learning the skills for playing the piano. Then with practice he will improve.  So, you dismiss the internet offer as another example of someone trying to promote an unproven and implausible self-help program.

Now let’s consider another scenario.  This time it is your 10-year-old son who is struggling to read and keep up in school. He  loses his  place easily when reading. He is  having trouble concentrating on a reading task and become very frustrated. He says his eyes hurt and sometimes he gets a headache when he reads. It sounds like he could be having a vision problem.

So you seek professional help and schedule him to have his eyes examined by your family optometrist, Dr. A.  Your son has his eye exam with Dr. A. and what you learn from the doctor is that his eyes are healthy and he has normal 20/20 eye sight. But,  he is having difficulty with coordinating his eyes together as a team when he tries to look at a book to read. Specifically he has trouble with his binocular vision (eye teaming). The doctor called it Convergence Insufficiency(CI). As it turns out, Convergence Insufficiency occurs in about 8-12% of children; affecting about 21.5 million people in the US (adults included).  Often times a person with CI (especially children) will experience symptoms involving  stress and strain around the eyes and have occasional double vision and avoidance behaviors. Often these symptoms look like ADD (Attention Deficit Disorder) too.

Doctor A. turns to you and says your child has a problem with proper eye coordination. His visual brain has not developed the correct neuromotor coordination abilities resulting in poor eye teaming when he attempts to do near vision work. This condition is treatable with 25-30 hours of office-based, doctor supervised, optometric vision therapy. While Dr. A.  does not provide this service in his office, he recommends another doctor whose practice is dedicated to treating patients with office-based optometric vision therapy and makes the referral.

Gosh, you were hoping for an easy fix like a new pair of glasses!  But what you are hearing is that it is much more complicated and will take several trips to another doctor over an extended period of time.

In the mean time, you think about it and decide to check around on your own and take your son to another doctor, Dr. B. for a second eye examination.  Dr. B. completes his eye exam of your son and agrees with the diagnosis…yes, he has CI. But this doctor’s approach is entirely different.  Dr. B. describes the problem with your son’s eyes is that he just has “weak eye muscles”  which need to be strengthened. He advises you that  your child’s problem can be solved  with some simple “eye exercises”! All you have to do is make his eye muscles stronger by asking him  to look at the tip of a  pencil as you move it closer to his nose.  In addition you are given some “work books” that have your son doing “tracking exercises”. You are puzzled by the lack of consistent treatment recommendations between the two doctors but since the recommendation is coming from a doctor, it must be true…right? Besides he accepts the minimal payment by your insurance and the treatment plan sounds a lot easier than what Dr. A was recommending. 

So…who do you believe? Why if both doctors agree on the diagnosis, don’t  they agree on the method of treatment? Who has got it right, Dr. A or Dr. B?

First, let’s remember the first example of the 10-year-old boy who was having trouble playing the piano. Is it logical to think that doing simple finger exercises will help him learn how to successfully play the piano? The answer seems pretty obvious right?

Surely the coordination of a person’s eyes is equally as complex as coordinating ones fingers to play a piano. So it would seem illogical that doing simple eye exercises would be effective at treating a problem with both eyes coordinating when attempting to read. However, over 50 years ago, many doctors were  taught that Convergence Insufficiency (CI) was a problem with eye muscle strength. While techniques in the area of visual rehabilitation were also beginning to emerge about that time, there were still some text books that the had the old-fashioned remedy for CI as just  a “series of simple eye exercises”. The problem was that the eye-exercise model of treatment was based on an assumption and not based on research.  Therefore, many doctors to this day still hang on to an old outdated model of treatment that was never based on proven research. 

 Therefore the answer to the question, “Who has got it right, Dr. A. or Dr. B”,  can only be answered based on double-blind multicenter research. What’s more, the research on the best methods to treat CI  was completed in 2008. It is a landmark study called the Convergence Insufficiency Treatment Trial (CITT). The CITT was funded with a $6.1 million grant  by the National Institute of Health and conducted through the National Eye Institute along with several sites around the country including Mayo Clinic and Bascom Palmer plus 6 Colleges of Optometry.

What this double-blind, multicenter research did was to compare office-based doctor supervised vision therapy (OBVT) to home based eye exercises called “pencil push-up therapy” as well as compared to a placebo, called “placebo therapy”

What did the research prove? It found that the “eye exercise therapy” had about the same effectiveness as the placebo. In fact the research proved that both the “eye exercise therapy” and the placebo therapy were found to be ineffective in treating Convergence Insufficiency.

However, office-based vision therapy was found to be effective and in subsequent research found to be the cure for convergence insufficiency. Dr A was correct!

The research is clear. So why do some doctors persist to advise patients about old-fashioned and ineffective treatment for Convergence Insufficiency? This can be difficult to answer in each case, but certainly when this condition, Convergence Insufficiency (CI) is accepted by the entire optometric and medical community as an important public health issue, then and only then will the majority of doctors get it right.

To address this fundamental public health problem and its realitive importance in the eye-care community, I wrote an article that was published in the Journal of Behavioral Optometry (Vol 21/2010/#2) entitled:  "Does Convergence Insufficiency Really Matter"(download)

Dan L. Fortenbacher, O.D.,FCOVD

Amblyopia treatment – Eye patching alone is no longer the standard of care

Amblyopia, other wise known as "lazy eye",  is the most common cause of preventable blindness in children. While the loss of vision usually occurs in one eye, rarer forms of bilateral amblyopia do exist. This type of  "blindness" occurs in approximately 2 out of 100 healthy children.   In amblyopia the loss of vision is not from a disease of the eye but rather the lack of development of the visual brain. Therefore, by definition, a child with amblyopia has healthy eyes, yet the brain can not see.

Therefore, the cause of amblyopia is not due to a disease process. Instead the cause of amblyopia is when there is interference in the infant's binocular visual development.  This means that amblyopia occurs when the visual brain of the baby stops developing normally from the lack of proper "two-eyed" visual input.  As a result, even with healthy eye structure, the child is not able to see clearly from the affected eye.  So, a child with amblyopia will typically have 20/20 eye sight in one eye and the other eye will be poor.  The severity of the amblyopia will be measured by how poor the eye sight is in the affected eye. In addition to poor sight, the child with amblyopia will also have "stereo blindness" or poor depth perception. This only adds to the visual difficulty since the child who is "stereo blind" will not be able to experience the benefits of three dimensional vision.

There can be many causes for amblyopia. But, the underlying mechanism for amblyopia is when something prevents a developing child from seeing with both eyes simultaneously. The most common causes are strabismus (eye teaming failure, such as crossed eyes) and unequal refractive error (example: high farsightedness in one eye while the other eye is normal). 

Debunking old myths and practices:

Over the years amblyopia was thought to be only treatable if caught before age 6. This myth has been disproven. Current research shows that amblyopia can be treated even in 18 year olds. More research needs to be done, but what we know is that there is "plasticity" in the human visual brain at nearly any age. I have personally successfully treated amblyopes well into their 60's.

A commonly prescribed form of treatment for  amblyopia, yet insufficient by today's standards (based on Clinical Practice Guidelines), is what is called "occlusion therapy". Occlusion therapy or "patching" is where the patient wears an eye patch on the "good eye" for typically hours at a time during their waking hours. While the research shows that a child's visual brain will show improvement in their amblyopic eye sight with a patching regimen, this "old school" approach (when used alone) can be very difficult and disruptive for the developing child to handle. It creates visual disorientation and confusion in spatial judgements. This in turn creates frustration and often emotional upset in the patient. Furthermore,  unilateral patching therapy only teaches a patient how to be a "one eyed person" since it does not address the underlying cause for the amblyopia which is the lack of  binocular (two-eyed) vision development. 

Therefore today's "best practices" approach for the treatment of amblyopia involves  a combination of monocular and binocular training of the visual brain through office-based vision therapy. This is done with a vision therapist  under the direct supervision of a Doctor of Optometry along with prescribed home-oriented visual activities to complement the weekly or bi-weekly in-office procedures.

This treatment approach yields the best outcomes, often resulting in normalization of eye sight in the amblyopic eye and the development of stereo vision (3-D vision) for the child. Eye patching alone is no longer the standard of care.

Read more about Amblyopia from the College of Optometrists in Vision Development (COVD). Click here!

Read about the Clinical Practice Guidelines established by the American Optometric Association. Click here!

Dan L. Fortenbacher, O.D., FCOVD

Research shows link...eye movement predictor of academic success

"Eye movement is a predictor of academic success". This month marks the 10 year anniversary when the Harvard University Graduate School of Education made this announcement. The research clearly shows that there is important association between effective eye movement control and academic success.

Ever since this breaking news a decade ago, further evidence of the association between eye movement and academic success continues to be recognized. For example, in Volume 27 Issue 8 of the Journal of Brain Development in 2005 the titled research is, the Voluntary Control of Saccadic and Smooth-Pursuit Eye Movement in Children with Learning Disorders.

While the testing of eye movement is relatively easy, the clinical presentation of poor eye movement control can often be missed and misunderstood. For example the testing of smooth-pursuit  eye movement control can be easily performed with a bead on a stick or the tip of a pencil or pen. The examiner simply asks the child to look at the target (held about 10 inches from the nose) and follow it with their eyes as the target is slowly moved horizontally, vertically (on the midline) and in a rotation. The child should be able watch the moving target with minimal head movement. Furthermore, the child who is years and older, should be able to "visually track" the target with a minimal amount of distraction such as asking simple questions (cognitive loading).

With the advent of web-based professional networking sites, like Sovoto, a platform now exists to help doctors and other professionals who work with children to see an example of a child with oculomotor dysfunction. To see an example of a child with oculomotor difficulty that was associated with his reading difficulty click here.

The American Optometric Association has published the symptoms of eye movement disorders in the Optometric Clinical Practice Guideline (CPG) Care of the Patient with Learning Related Vision Problems. They are:

• Moving head excessively when reading
• Skipping lines when reading
• Omitting words and transposing when reading
• Losing place easily when reading
• Requiring a finger or marker to keep place when reading
• Experiencing confusion on return sweep phase when reading
• Experiencing illusionary text movement
• Having deficient ball playing skills

More importantly, once identified, the child who is diagnosed with a problem in eye movement, such as smooth-pursuits, can be treated with vision therapy. Specifically office-based optometric vision therapy provided by a vision therapist (supervised by the doctor), can effectively treat disorders of voluntary eye movement. The results can often be a dramatic improvement in the child's reading efficiency.

To see the same patient after 24 sessions of office-based vision therapy click here. His reading efficiency and fluency has improved and he is enjoying reading!

To learn more about optometric vision therapy  and find a doctor who provides office-based vision therapy visit the COVD website at www.covd.org

Dan L. Fortenbacher, O.D.,FCOVD

 

 

 

Home schooling mom learns impact of vision problems on her struggling 17 yr old daughter

Last week I saw a 17 year old girl for a new patient comprehensive vision evaluation. While most patients find their way to our practice as a referral from an eye doctor or an occupational therapist, this patient landed in my exam chair due to the determination of her mother to find an answer.

You see, our patient - lets call her Mary, is a  bright, articulate high school senior who wants to go to college next year, but due to her difficulty reading, she and her family are concerned that she will be unable to handle the college work load. What's more, her avoidance behaviors and mannerisms started to make her mother suspect something was "a miss" with Mary's eyes, even though she had had previous eye exams and was fit with contact lenses for nearsightedness. Mary complained of words overlapping and would turn her head or cover an eye when trying to read.

Thanks to the persistence of her mother through her own personal research,  she began to find the answers to her troubling questions.  Why was her bright daughter complaining of words moving on the page when reading? Why did she turn her head or furrow her brow when doing her paper pencil tasks? What she learned was that there exists specific types of vision problems that can cause bright kids to demonstrate reading and learning performance problems. One thing led to another and the family found our specialty practice; dedicated to the diagnosis and treatment of the vision related learning problems.

My examination revealed that Mary's eyes were healthy and her existing contacts properly corrected her eyes for a mild condition of nearsightedness. But, in spite of her 20/20 corrected eye sight, Mary was unable to coordinate her two eyes at near. She in fact had double vision for objects within 18-20 inches from her face! To further complicate this, Mary demonstrated poor eye tracking, eye focusing and poor visual processing skills. The diagnosis for Mary was convergence insufficiency, accommodative dysfunction,oculomotor dysfunction plus delays in visual information processing.

In spite of having the diagnosis, which explained why Mary struggled with reading and learning, it was painful for Mary's mother when she realized that Mary had been struggling with these symptoms since she was in 3rd grade.  Thanks  only to the determination of her mother through home schooling, Mary received the individual attention which enabled her to progress academically, albeit in spite of many compensatory strategies.

To restate the case, Mary's vision problems are not eye sight problems or eye health problems. Her eye muscles are normal and strong. Her neurology is normal. Instead, her vision problems are developmental. That means at age 17, Mary had simply not acquired the expected eye coordination and visual processing abilities that most us gain naturally through a process of normal childhood experiences.

The treatment required for Mary is  office-based optometric vision therapy (VT). VT is scientifically validated and proven safe and effective. Once Mary receives this treatment protocol, research has shown that she will not require any further treatment for these problems of eye coordination. Yes, there actually is a cure!

What makes Mary's case disheartening is that her visual issues could have been recognized early on. Mary should never have had to struggle for years with this binocular vision problem - convergence insufficiency. As a consequence of her binocular vision problem, Mary and her family have unnecessarily gone through years of frustration. They had to adjust their family around a home school model to support Mary's needs for individual attention primarily because she could not use her vision to apply herself academically.

On a positive note, Mary will soon be starting treatment...office-based vision therapy. And while she has had to tolerate her symptoms associated with these vision problems for years, within 4-5 months of treatment, I'm confident that Mary's binocular and other related "eye-coordination problems" will be resolved. What's more because she is bright and capable, once Mary no longer has near point double vision, she will be better prepared for the visual demands of college!

Fortunately, more eye doctors are becoming aware of the critical importance to recognize, diagnose and properly manage patients like Mary. For example, Dr. Dominick M. Maino, Editor of the journal Optometry and Vision Development and Professor of Pediatrics/Binocular Vision at the Illinois Eye Institute/Illinois College of Optometry has recently written a compelling journal editorial emphasizing this to the profession entitled, The Binocular Vision Pandemic.

Dr. Rochelle Mozlin, Associate Professor at State University of New York, State College of Optometry with a Masters Degree in Public Health also recently wrote on the COVD Blog, Vision Therapy — Where is the Evidence?, listing the evidence based Clinical Practice Guidelines, written by a team of optometric experts, and published by the American Optometric Association.

With greater professional and public awareness of the impact of binocular vision problems on reading performance, fewer children like Mary will have to struggle for years without getting the help that they truly need. For more information go to www.covd.org

Dan L. Fortenbacher, O.D.,FCOVD

Reading and Attention Problems Found with Common Eye Condition in Children ...A Proven Treatment for Convergence Insufficiency

Parents, teachers and health care professionals should see this video by the National Eye Institute. Too often children with reading and attention problems are overlooked in the healthcare delivery system, labeled with ADHD, learning disabilities and/or behavior problems when instead they have a common undiagnosed eye condition known as convergence insufficiency (CI).

Watch this video and see what the director of the National Eye Institute (NEI), researchers as well as a mother of a child who had CI, have to say. The results of the National Institute of Health (NIH) "double blind" multicenter research project completed in 2008 found that the only proven treatment for CI is office-based vision therapy. Other approaches such as home based remedies or prism glasses are not effective.

Children with CI often have symptoms that can impact reading, learning and attention. After treatment the patient will often show dramatic improvement in reading, learning and attention and concentration for near vision visual tasks.

At Wow Vision Therapy, office-based vision therapy is provided by a Doctor supervised Board Certified Vision Therapist along with vision therapy assistants.  Once successfully treated, the results are life long without the need for further maintenance treatment.

Dan L. Fortenbacher, O.D., FCOVD

New England Journal of Medicine ringing endorsement of Sue Barry's book and vision therapy

From the latest issue of the New England Journal of Medicine (7-2-09) - Book Review- provides an unqualified and ringing endorsement of Dr. Sue Barry's book (Fixing My Gaze), and of the specially trained and imaginative optometrists who provide vision therapy, in part:

"Capitalizing probably more on latent neuronal connections than on the creation of new ones, Barry benefited from orthoptics — a hidden corner of restorative medicine. With contrived ocular exercises, specially trained and imaginative optometrists treat patients whose eyes are cosmetically aligned but imperfectly foveated.  The simplicity of the exercises and of the apparatus (such as beads on a string, papers taped to walls, and strips of film) is bracing for a profession enamored with technology.

The book’s main contribution, however, is exposing the wrong-headed dogma that acuity and binocular vision can be restored only during a critical developmental period. Surgical correction of strabismus is dominated by this notion, first posited by Claud Worth in his landmark 1903 book, Squint: Its Causes, Pathology, and Treatment, and set at a hard stop at 2 years of age by his student Francis Chavasse. The experiments of Hubel and Wiesel are often cited as confirming the lost malleability of the adult brain, but Barry points out that they did no such thing because there was no attempt at restoration of fusion. Her experiences and those she recounts from others belie the “nothing else can be done” message that ophthalmologists gave to her and to her mother throughout her childhood.

Several visual scientists have now demonstrated the reversibility of infantile loss of vision and stereopsis, but blindness to these findings and under appreciation of the solutions offered by orthoptics still persist."

 

This is one more example of the growing scientific and medical support for office-based vision therapy in the treatment of binocular vision problems like strabismus.

 

Dan L. Fortenbacher, O.D., FCOVD

Vision Therapy IS NOT Eye Exercises

For the patient who suffers from the symptoms of double vision, headaches, fatigue and poor reading performance due to a binocular vision problem like convergence insufficiency, now there is scientific proof that office-based vision therapy is the only viable and effective treatment. When compared to all of the other commonly prescribed treatments recommended by doctors in the past, research has now proven that office-based therapy is effective but, pencil push-up eye exercises or computer based home therapy (used alone) are no better than a placebo.

Yes, office-based vision therapyis effective because IT IS NOT eye exercises. Why?

To understand the difference, one must understand that vision problems such as poor binocular control (like convergence insufficiency), accommodation problems (poor eye focusing), oculomotor dysfunction (poor eye tracking), problems in visual processing or visual motor integration (eye-hand coordination) are not typically problems with muscle weakness. 

A child that has double vision when reading is not having that problem because their eye muscles are too weak to turn their eyes in the orbit. If you think of any person with double vision like a "computer", the problem is not with the "hardware" (eye muscles), the problem exists in the "software" (the brain). The visual problem is a "brain coordination problem" not an eye muscle weakness problem.

Thus exercising eyes or eye muscles is no more effective in learning binocular "two-eyed" vision skill than exercising ones fingers in an attempt to learn how to play the piano. Doing finger exercises will not result in becoming a piano virtuoso. The same is true with eye exercises and vision.

Office-based vision therapy is effective because it IS NOT eye exercises. Office-based vision therapy is a process of helping the patient to develop the "brain skills" for proper binocular vision (and much more). This brain skill is a learned ability that, once learned, is like riding a bike...it is not forgotten.

The results of a successful office-based vision therapy treatment programis that the patient will learn proper vision skills and enjoy the lifelong benefit of good binocular vision, symptom free and more productive and competent in the rigorous visual demands of school and work.

Dan L. Fortenbacher, O.D., FCOVD

Latest Research Proves Office-based Vision Therapy is Effective

The United States Department of Health and Human Services, National Eye Institute just released the results of the landmark $6.1 million multicenter Convergence Insufficiency Treatment Trial (CITT) on October 13, 2008. According to the National Institute of Health, scientists have now proven that office-based vision therapy is the only effective treatment for convergence insufficiency (CI) compared to the other common methods used by doctors to treat CI.

Convergence Insufficiency (CI) is a public health concern due to the relative high incidence among children. Studys have shown that CI occurs as often as 5-18% within children of elementary school age in the US.

The CITT research investigators tested the efficicacy of 4 approaches to treatment of Convergence Insufficiency.

1. Pencil Push-ups Therapy (PPT). This form of treatment has been a commonly prescribed by eye doctors to parents for their children with CI and involves looking at the letters on a pencil while the pencil is brought closer to the end of the child's nose. The goal is for the patient to try to maintain convergence on the pencil while the target is progressively brought closer to the eyes. PPT is a home based eye-exercise approach to treating CI.
2. Home-based computer programs along with pencil push-up therapy (HBCVAT+). This approach uses computer based programs to help with convergence and eye focusing along with pencil push-ups.
3. Office-based Placebo Therapy (OBPT). This treatment was the placebo group in the research project who "thought" they were receiving regular vision therapy along with home reenforcement activities. In this case while the patient thought they were getting vision therapy, instead they were being provided a series of drills that mimicked vision therapy and therefore served as the "control group".
4. Office-based Vision Therapy (OBVT). This treatment group received weekly sessions of 60 minute in-office therapy (following a standardized approach) along with home reenforcement activities.

The research was conducted by a team of investigators at the following sites:

• Bascom Palmer Eye Institute - Miami Florida
• Mayo Clinic - Rochester, Minnesota
• University of California - San Diego Ratner Children's Eye Center
• State University of New York College of Optometry
• University of Alabama at Birmingham School of Optometry
• NOVA Southeastern University - Fort Lauderdale, Florida
• Pennsylvania College of Optometry - Philadelphia, Pennsylvania
• The Ohio State University- Columbus, Ohio
• Southern California College of Optometry - Fullerton, California

The results found that only Office-based Vision Therapy (OBVT) was effective in treating convergence insufficiency in children and that "pencil push-up" therapy, as well as the home based computer programs plus pencil push-up therapy, was no more effective than placebo therapy.

The public health conclusion from this research is that children who have been diagnosed with Convergence Insufficiency should be sure to work with a doctor who provides or will refer to a doctor who provides office based vision therapy. To find a doctor who provides vision therapy, be sure to contact the doctor locator at the College of Optometrists in Vision Development (COVD). Those who are Fellows are Board Certified in Vision Therapy.

Dan L. Fortenbacher, O.D., FCOVD