EXCELerated Vision

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

Research in Vision Therapy...Now with Open Access to All

One of the most exciting aspects within the field of optometry is the continual contributions made by optometrists and researchers.  Their efforts create growth and advancements for the entire optometric profession.  Specifically in the area of binocular vision, optometric professionals depend on the research and information presented in the Optometry and Vision Development (OVD) journal to stay current on issues and studies being conducted.  The OVD is the official journal of the College of Optometrists in Vision Development (COVD), the international organization that board certifies optometrists and vision  therapists in the areas of behavioral and developmental optometry.

The OVD has just become the first optometry journal world-wide to be accepted by the Directory of Open Access Journals (DOAJ).  The DOAJ provides access to international quality controlled journals.  Dr. Dominick Maino, editor of  OVD notes that, "DOAJ wants to increase the visibility and ease of use of scientific and scholarly journals and to promote their overall positive affect upon the scientific and clinical care community."  Dr. Dan Fortenbacher, current president of COVD says, "OVD's acceptance by this prestigious online directory recognizes the tremendous need for easy access by the world community for high quality articles concerning binocular vision, optometric vision therapy and vision development."   Executive Director of COVD, Ms. Pamela Happ, says that, "This singular honor recognizes COVD's ongoing commitment to research and publication of an outstanding journal that is now easily available to an international audience of scholars, scientists, and clinicians."

With some of the finest vision researchers contributing to the journal, clinicians all over the world will be able to access articles, increasing their awareness of current information within the behavioral and developmental field of optometry.

Lindsey Stull, OD

Uncovering Causes for Learning Problems...the Importance of Visual Processing Testing in Children

  When a child struggles in the classroom, it is important to have a comprehensive developmental vision assessment.  When an evaluation is scheduled with a developmental optometrist there will often be additional testing of the child's competency on visual processing tasks. Visual-motor integration, visual-spatial perception, figure-ground, sequential memory, letter reversals and handwriting may all be a part of the testing in order to adequately assess a patient’s visual processing skills.

The areas being evaluated often correlate directly with difficulties demonstrated in the school setting.  In order to fully understand a patient’s visual needs this testing is essential.

The most recent Journal of the College of Optometrists in Vision Development includes a research article that discusses how enhancing certain components of the visual system can enhance the acquisition of basic arithmetic skills.

Math relies on competency in visual-spatial processing.  In regards to math, a child must have an understanding of what numbers mean and that they represent a quantity in order to make sense of the problem being presented.   Being able to utilize one’s visual memory is also necessary to retain certain patterns and basic math facts allowing for efficiency in this subject area.

Poor handwriting can be indicative of a deficiency in visual-motor integration and visual-spatial processing.  This is often demonstrated by a difficulty in keeping letters between the lines, writing uphill/downhill, or an irregularity of letter sizes and spacing.  Insufficient integration between the vision and motor systems, and the inability to link the visual input and motor output, often results in poor handwriting, difficulty with drawing and cutting with scissors.

Being able to easily find a pencil in a desk drawer provides an example of using figure-ground processing.  This may also be true for someone who often misplaces objects or has difficulty finding objects in crowded or busy environments.

Letter reversals, such as b, d, p, and q may occur until age 7.  However, significant letter reversals may indicate visual-spatial impairments, if they persist past age 7.  Visual-spatial processing occurs when the input from the visual system fails to provide the brain with accurate and consistent information about the environment.

The assessment of visual processing is a necessary step in determining the appropriate cause for certain visual deficiencies, and should not be dismissed or overlooked when difficulties in school are present.

Many of these topics are discussed in The Mislabeled Child, written by Drs. Brock and Fernette Eide. 

Lindsey Stull, O.D.

Clinic Director, Wow Vision Therapy

Identifying Convergence Insufficiency

Last week I saw a healthy, six year old little girl who presented for a general eye examination in a primary eyecare practice.  Her mom had specific concerns because her daughter had recently been complaining that words, "don't look right on the page" during near tasks. This was the patient's first eye exam, and her mom wanted to rule out any vision related issue.  After completing a few tests that check how the eyes are teaming together, I found that this patient had a common binocular vision disorder called convergence insufficiency, or CI.

Patients with CI often present with symptoms such as: eye strain, headaches, avoidance of near work, skipping words, complaints that letters or lines run together, difficulty with concentration and covering or closing an eye. However in young children they may not be complaining of any problems. It largely depends on the child's reading demands and if they are using large font text in their story books, the problem with "seeing double" can be overlooked.

CI affects approximately five percent of all school-age children, yet can be overlooked at routine eye examinations.  When the eyes do not work together efficiently, there is an inability for the eyes to maintain a clear, steady image. The signs and symptoms of CI can lead to a diagnosis of ADD/ADHD, when in fact the underlying problem may be a binocular vision issue.

When performing the history in an eye exam it's often difficult, especially for a child, to articulate what they are truly experiencing.  When asked if they see double they will often say "no", but after using the following demonstration they will often know what you are talking about.

Place both of your hands together, palm to palm.  Stand directly in front of the child, holding your hands up and say, "Do you ever notice, especially late in the school day, or if you're tired, that the letters on the page seem to do this...?" slide one hand slowly to one side to give the appearance of a double image.  You may also ask, "If you 're ever really tired, do you ever see the two images slide completely apart, like this?"  Slide your two hands slowly apart and have them separate by a few inches.

Another easy method is to ask the child, "Do you ever see words look like these when reading?"

 

Once diagnosed with CI, the next step would be to be schedule an evaluation by an optometrist that specializes in developmental optometry and can recommend the appropriate vision therapy treatment program.  Research has shown that vision therapy is more effective in decreasing signs and symptoms of CI compared to other treatment methods.  With early detection and treatment of binocular vision disorders, patients are given the opportunity to succeed without  having to overcome the unnecessary struggles caused by an untreated vision related issue.

Lindsey Stull, O.D. 

Oculomotor Dysfunction Following an Acquired Brain Injury

The term acquired brain injury (ABI) refers to traumatic brain injuries (TBI) and cerebral vascular accidents (CVA), or stroke.  Each year an estimated 8 million people will suffer a traumatic brain injury and 500,000 will suffer a CVA.  According to a study conducted through the State University of New York State College of Optometry and the Raymond J. Greenwald Rehabilitation Center in New York, the majority of all ABI patients will develop some degree of an oculomotor dysfunction.

The five areas of oculomotor dysfunction researched in this study were accommodation, version, vergence, strabismus and cranial nerve palsy.  Although all ABIs are unique to the individual, certain oculomotor dysfunctions were found to be more prevalent given the type of ABI.  The following statistics represent the trends found through this particular study.

• More than 40% of the TBI patients demonstrated an accommodative dysfunction while the amount of CVA patients with this deficit was only 12.5%.
• Convergence insufficiency was found to be the most frequent vergence dysfunction in both the TBI and CVA patients.
• Nystagmus, a version oculomotor dysfunction, was 30 times more prevalent in the CVA subgroup in comparison to the TBI patients.
• Approximately one fourth of TBI patients and 37% of CVA patients had acquired some form of strabismus.
• Ten percent of CVA patients had a cranial nerve palsy, primarily 3rd nerve palsies, while 7% of TBI patients had a cranial nerve palsy, primarily 3rd and 4th nerve palsies.

The study indicates that 90% of the TBI patients and 86.7% of the CVA patients manifest some form of oculomotor dysfunction.  Based on these significant statistics, it's imperative that these patients receive a comprehensive eye examination to adequately address any underlying binocular vision problem that may exist.  Each ABI case must be addressed on an individual basis, however there are certain trends that one should be aware of when determining the appropriate treatment plan for these patients.

To learn more about brain injuries and the effects they may have on the visual system, follow the links below.

Optometry Journal Article

Brain Injuries

Lindsey Stull, O.D.

Measuring Success in Vision Therapy

A recent study completed through the Illinois College of Optometry concluded that vision therapy can decrease patient symptoms and improve quality of life after only six office visits.  The Quality of Life Survey (QLS), developed by the College of Optometrists in Vision Development (COVD), was used as the tool for measurement.  The QLS takes into consideration visual symptoms such as binocular vision (eye teaming), accommodative (eye focusing), oculomotor (eye tracking), visual information processing disorders, as well as one's social and psychological well-being.

Success stories are a means for patients and/or parents of patients to share their personal experiences and accomplishments after vision therapy.  Although these stories are a powerful tool in sharing the message of  vision therapy, there is no way to statistically show progress.  This particular study assigned numeric values to the frequency of symptoms before, during and after vision therapy in order to quantify the results.  It was found that there was a statistically significant difference (p<0.05) between the scores on the QLS from the first, sixth and final visit of vision therapy.

Previous studies have already demonstrated the efficacy of vision therapy.  The unique feature of this study is that rather than relying on clinical data, or what is demonstrated in the exam room, the input comes from the patients and/or parents of patients and how they measure their success upon completion of therapy.

Please enjoy reading success stories from patients at wow vision therapy, as well as other vision therapy programs throughout the country at the links included below.

Download full_text_article.pdf

wow vision therapy success stories

Vision Therapy and the Autistic Child

A Quest for Luke--Misdiagnosis of ADHD opens family’s eyes

Lindsey Stull, O.D.