EXCELerated Vision: The Wow Vision Therapy Blog

A look at convergence insufficiency and tracking problems...before and after vision therapy

Just as so many other children are affected (research shows 1 in 12) by this vision problem known as Convergence Insufficiency (CI), Josh also struggled. The impact on him was that he had double vision and loss of interest for reading. It also made it difficult for him to play baseball or most any ball sport. As a result Josh lacked confidence at school and on the playground. Now after successful completion of his office-based optometric vision therapy Josh no longer sees double when reading, his comprehension and reading speed has significantly improved and he is gaining skill and confidence in sports. Now that he has good binocular vision, Josh no longer struggles and is a happy kid!

A Call for Advocacy on Vision and Learning

From time to time there is a patient advocate who steps up and says, “enough is enough”! …meaning, more has to be done to help recognize children with vision related learning problems!

In this video provided from Dr. Robert Lederman on YouTube, a family member speaks out about the importance of early recognition of children with vision related learning problems.

 

At Wow Vision Therapy we recognize the vital role that parents and patients make to help educate the public about the serious impact vision problems involving binocular vision (eye teaming), accommodation (eye focusing), oculomotor abilities (eye movement control) and visual processing can have on reading and learning. For more examples, check out Wow Vision Therapy on Facebook.

Dan L. Fortenbacher, O.D., FCOVD

Progress in Vision Therapy...Patients lives tell the story

Over the last 3 decades I have worked with thousands of children and adults with binocular vision dysfunction and other visual brain related problems. Some of the most common conditions I have treated are the visual problems that involve poor eye coordination and visual processing ability. The impact of these visual conditions on a patients life can be significant. The overall impact of poor visual abilities in some of the key areas of visual acquisitions skills such as binocular vision, accommodation and oculomotor function can be very stressful causing reduced individual performance and even emotional side effects.

I wrote about one such syndrome coined BAOD and published it on The VisionHelp Blog entitled: A new visual syndrome- BAOD...it's more than a feeling.

The emotional fallout of these visual conditions can take a significant toll on the child and the family. The following video by P.A.V.E. (Parents Active for Vision Education) describes the impact of an unaddressed vision related learning problem as well as the positive changes that occur when visual problems are identified and properly treated.

 

 

As a regional referral practice that specializing in developmental vision and therapy, most of our patients find their way to us through a doctor, occupational therapist, teacher, other professional or proactive parents who recognize and recommend us.

In the video below our patient Matthew was referred by his family primary care Optometrist with a binocular vision problem known as Convergence Insufficiency. Prior to treatment he was seeing double when trying to read or view anything within 20 inches. This caused Matthew, a bright boy, to struggle to keep-up in school. It was also beginning to have emotional side-effects on his self esteem.

This video shows how much better Matthew is doing within only 10 sessions of office-based optometric vision therapy in conjunction with home oriented activities...the evidenced-based proven standard of care for this diagnosis. Not only is Matthew no longer seeing double, his confidence is growing. Matthews response below sums it up!

 

Progress in vision therapy is not only about improving symptoms...it's about improving lives!

Dan L. Fortenbacher, O.D. FCOVD

Accommodative Dysfunction - The 3 A's of Eye Focusing that impact reading

The following is an abridged article written by Dr. Fortenbacher and recently published on The VisionHelp Blog. In the original post Dr. Fortenbacher describes a true story of one of his patients  "Jenny" who was referred for treatment for an Accommodative Dysfunction by her primary care optometrist.

Accommodation, otherwise known as "eye focusing",  is a vital visual function that provides the ability to adjust the lens system of the eye to see detail as an object is brought closer to the eyes.  To read this article requires your eyes to accommodate (focus) on the print. In addition, to read your eyes must stay "in focus" on the printed material for an extended period of time. What's more you must do this with a high degree of precision in order to see the print clearly. And let's not forget that we must periodically look away and then back to the printed material. Therefore,  for efficient reading and learning, a child's eyes must engage in the "triple play" of eye focusing or what can be called the 3 "A's" of Accommodation:

A # 1. Amplitude of Accommodation.This refers to the strength ability of focus. The greater the amplitude of accommodation means an object can be held closer to the eyes and sustained in focus for a longer period  of time.

A # 2. Accuracy of Accommodation: This refers to the ability to adjust the lens system of the eyes with precision to maintain optimal clarity of the viewed object.

A #3. Agility of Accommodation: This refers to the ability to adjust and change focus from near to far rapidly and without effort.

Symptoms of  Accommodative Dysfunction usually involves some of the following:

• Eye discomfort and/or headaches (often frontal headaches) with sustained close work like reading
• Squinting, blinking and rubbing eyes
• Trouble copying from the chalkboard
• Blurred vision when reading small print
• Vision becomes worse by the end of the day
• Reduced attention for reading
• Poor reading comprehension

 Accommodative Dysfunction has been studied and linked to an array of symptoms  associated with near visual work such as reading or computer based tasks.  It has also been linked to reading problems in children. Below are two interesting studies done within the last 5 years that shows there is scientific evidence to link Accommodative Dysfunction with serious negative consequences on the lives of children:

• Accommodative Insufficiency Is the Primary Source of Symptoms in Children Diagnosed With Convergence Insufficiency. Optom Vis Sci Vol 83, No. 5, May 2006 

 

Accommodative Function in School Children with Reading Difficulties. Graefes Arch Clin Exp Ophthalmol (2008), 1769-1774

Therefore research shows that good eye focusing (accommodation function) is essential to reading, yet too often this area of visual dysfunction gains very little notoriety.   Currently the rave is all about 3-D vision, 3-D movies, 3-D  TV and 3-D games, but  there are no cool digital media devices like 3-D video games and movies that shed light on public awareness on Accommodation Dysfunction. What's more, school vision screenings will typically exclude testing of this vital visual function, even though it is one of the most important "players" in your child's "vision abilities team" for reading and learning.

What can be done to help children with Accommodative Dysfunction?The best approach is usually a combination approach of vision therapy to develop the visual brain learn which means the development of the essential "neural-software" for effective and effortless coordination of the accommodative system andproperly prescribed reading glasses.  The best practices in  vision therapy approach is office-based, doctor supervised optometric vision therapy. The best prescription for reading glasses are lenses with high-definition optics to maximize the patients ability to not only focus but also to expand peripheral visual awareness. The importance of  prescription lenses plus office-based vision therapy is to develop a patient's 3-As of accommodation so that visual-stress related side effects involving frontal headaches go away and the act of reading and doing classroom learning becomes a visually effortless process.

And yes with this approach, the patient will have a happy ending; but only when a child is first identified, usually by the primary care optometrist,  who then makes the initial determination that a referral for treatment is required. If left to the public provided visual screenings children all around the country will still have to endure the headaches and eye discomfort because an unidentified accommodative dysfunction.

What if these kids didn't have to struggle with an unaddressed visual deficiency of Accommodative Dysfunction? There is help available from doctors around the US and internationally, in private practice and University Clinics where optometric developmental vision and therapy services are provided.  But first,  the primary care eye doctor is usually where the patient with Accommodative Dysfunction is diagnosed and then referred for proper vision therapy care.

Will you help? If you are a doctor, occupational therapist or other professional who works with children and have ideas or suggestions to  increase public awareness I welcome your thoughts and comments on my post. If you are a patient, concerned family member, or public advocate who is  interested in getting involved with others on this cause of vision advocacy, I encourage you to join Sovoto- The Vision Advocacy Network, take a look and contribute your thoughts to the discussion groups. Your involvement could make the difference in a child's life!

Dan L. Fortenbacher, O.D., FCOVD

Asking the right questions critical to the right care in children's vision

Have you ever wondered if what you see is really the right way of visually seeing the world? If you find all of your visual tasks to be pretty easy to accomplish, then you may never have thought that there is anything besides just being able to "see clearly". Now, imagine being a child who in fact sees print overlap or move while reading and yet not knowing that "doubling letters" is not the right way of seeing. A child wouldn't  know that overlapping print is a sign of a problem since they have no reference to what is actually normal vision.

My name is Amanda Hodge, 4th Optometry Student at Michigan's College of Optometry at Ferris State University  and I have just completed my 2nd rotation with Dr. Dan Fortenbacher and the team at at Wow Vision Therapy. As a doctor in training, this experience has opened my eyes to many aspects optometric care that I was literally not aware of until I saw the vision therapy patient in action.  For example, I have heard several children say, "I didn't know I wasn't suppose to see like that." What occurred to me is that this may be the main reason why younger children often do not have complaints about their vision. What I've learned is that a child can have a significant visual problem but never announce anything to their parents because they don't know any different.

This is true for doctors too!  Doctors who work with children's vision must be aware of the behaviors which can be signs and symptoms of a problem that requires the necessary testing to make the right diagnosis. Often a parent may see a behavior in their child and just assume that it is something else, but in fact be a sign of a significant vision problem.

Some examples of questions parents can ask their children or themselves are:

• Do you notice one eye turns in or out, up or down?
• Do you squint trying to see things?
• Do you close or cover one eye?
• Do you avoid near work such as reading?
• Do you use your finger to keep your place when reading?
• Do you have a short attention span?
• Do you have sloppy handwriting?
• Do you have trouble with reversals such as bdpq's?
• Do words appear double or move while reading?

Other symptoms can be found on the College of Optometrists in Vision Development (COVD) website Vision and Learning Symptoms checklist. Another good resource for children and vision is the American Optometric Association (AOA) Good Vision Throughout Life. This section breaks down what to be aware of for different age groups.

If you as the parent or your child answered "yes" to any of the above questions (or those on the COVD or AOA website) it is important to make the time to schedule  your child for a comprehensive vision examination. Make sure you tell the doctor what your concerns are and specifically ask the doctor if he/she offers vision therapy or has a referral protocol with a vision therapy provider if your child requires VT care. Simply ask, "Do you ever recommend vision therapy for your patients?" If the answer is no, then your doctor may also overlook the vision problems that are only detected by running the correct vision tests.

Now you might be saying to yourself, I don't have a doctor and don't know where to begin? Well a good place to get started would be to visit the Doctor Locator via the COVD website and/or the AOA website  by locating an optometrist who works in pediatrics.

Don't let your child fall through the cracks of having to deal with an undiagnosed vision related learning problem. Schedule a comprehensive vision examination for your child if you are concerned that vision may be playing a part in your child's struggles. But, most importantly be sure that you ask the right questions.

Amanda Hodge

4th Year Intern, Michigan College of Optometry

Connor's Story expressed in a Matthew West song...leads to Fox and Friends Sunday

What an amazing year it has been for Connor Caple. The Doctors and Staff at Wow Vision Therapy would like to congratulate Connor for all of his accomplishments and to his parents for staying strong throughout Connors years of frustration as a result of his reading and learning difficulties. Especially we would like to recognize Connor's mother, Michelle who expressed her story of sadness in a letter to musical artist Matthew West who in turn composed a song entitled: To Me

About 1 year ago, at age 15,  Connor presented for care to Wow Vision Therapy as a recommendation from his reading teacher who recognized many of the visual symptoms that Connor was experiencing. Connor's symptoms were significant for poor concentration for reading, letter reversals, difficulty keeping his place when reading and avoidance of reading. On the COVD Quality of Life Symptom Checklist he scored 47!

Connor was identified with delays in visual development particularly in eye movement skill, visual processing and visual imagery ability.

Connor completed his vision therapy treatment plan with us at Wow Vision Therapy in July 2010. He was reading everyday, but because it was the middle of the summer it was not known how well we was actually going to do in school.

Connor came in for his 3 month progress evaluation this week  and is reporting 3 grade levels improvment in reading and doing much better in spelling.  His Quality of Life Symptom Checklist is nearly all "0's" ...only a few "1's" (total score 7).

We are thrilled with Connor's success and thankful to have had the opportunity to play a role in the progress of  his life's journey. Connor's next stop is New York City on the weekend of November 13-14, 2010  where he and his parents will be interviewed on the Fox and Friends Sunday Morning Show. This should be a wonderful interview where his story of struggle that lead to his mother's letter that lead to...To Me

To Me by Matthew West (The Story Behind The Song) from emicmg on Vimeo.

 

*Thank you to Steve and Michelle Caple who gave us permission to share Connor's story*

Early intervention critically important in children's vision problems

When is it OK to "wait and see" if the problem goes away on it's own?

What if your 6 year old child has been diagnosed with a binocular vision problem that appears to be interfering with her learning to read? You are seeing behaviors that look like she can't concentrate on books. Her teacher is spotting some signs of trouble but can't be sure that it is "her eyes". You take her to an eye doctor who makes the diagnosis of a binocular vision problem called convergence insufficiency but dismisses treatment "for now" and opts for monitoring the problem. But, is it really ok to just wait and see?

As strange as it may sound, an outdated approach often recommended by many eye doctors when faced with a young patient (often 4-7 years old) diagnosed with certain forms of eye coordination problems, such as convergence insufficiency, is to simply monitor the condition and see if it goes away it's own. In other words, no treatment is recommended.

In response to this and other vision problems in children, the University of Oregon Brain Development Lab has just produced this video on vision and the developing brain. See what the neuroscientists and the research is showing about the importance of early intervention.

Then check out the story of a mom (below) who wouldn't accept "NO" for an answer when told that her 6 year old daughter (with convergence insufficiency) was too young to be treated.

Find out how a persistent mom dealt with this problem with her own 6 year old daughter. Read the heartwarming and inspirational story from Paige Melendres in Albuquerque, who was not comfortable with the "wait and see" recommendation by her first doctor.  Her story can be found by clicking on  CI:The Private Eye Goes Public -Part 1 and scroll down to comment #8. Her story has a happy ending and good advice for parents who may have a child who is struggling.

CI: The Private Eye Goes Public is a  VisionHelp Blog investigational series written by Dr. Leonard Press and Dr. Dan Fortenbacher dedicated to uncovering the important public health and patient care issues surrounding convergence insufficiency.

Dan L. Fortenbacher, O.D., FCOVD

Back to School Vision Checklist - An Interview with Dr. Carl Hillier

One of the leading experts on children's vision, Dr. Carl Hillier, is interviewed and provides a helpfull list of things for parents to look for that are important cues of a vision-related learning problem.

Find more videos like this on Sovoto - The Vision Therapy Connection

A Hidden Epidemic? Parent Back-to-School Oversights – by an MCO Intern

The summer is winding down, and back-to-school is on almost every parent’s thoughts.  As a “doctor in training”, I’ve been thinking about my amazing summer internship at The Michigan College of Optometry externship site, Wow Vision Therapy in St. Joseph, Michigan.  What especially amazed me was the number of children that we see in this clinic that have learning-related component to their vision problem.  At the beginning of each child’s treatment plan, we ask the parent what they expect vision therapy will do to help their child.  Almost every patient has school-related goals.  In optometry school, we talk about the fact that 1 in 4 children suffers from an undiagnosed vision problem and that 1 in 8 children suffers from a binocular vision problem known as Convergence Insufficiency, but until I came to this practice, I didn’t realize just how many families are affected by this.  When a child struggles in school, it’s not just a problem for them; the entire family is affected.

 

Seeing so many children with vision problems causing them to struggle in school  made me start thinking about how these children even began to realize that they had a vision problem.  I have had the opportunity to speak with a number of our patients’ parents.  It’s amazing how often I hear that the visual system was the last thing on their minds when their child started to have problems in school.  Vision-related learning problems can often manifest in ways that don’t always suggest that the visual system is at the root of the problem.  Common symptoms include problems with reading comprehension or fluency, avoidance of reading, headaches or eyestrain after near work, poor handwriting, or attention problems.  It’s easy to think that these problems could be academic or behavioral, but a visual dysfunction can be all-too-often to blame.  Imagine how hard it would be to pay attention or to be interested in reading if the words were doubled on the page or looked like they were moving around!  It would be hard to read efficiently or have neat hand writing if everything you see up close is blurry! 

 

Detecting vision-related learning problems can be a difficult task for parents.  I often hear that the child had a school vision screening, but they passed with 20/20 vision!  Now I’m starting to remind parents that 20/20 vision is only a small piece of the puzzle.  Most people think of 20/20 as “perfect vision,” but there are a whopping 17 skills that are necessary for efficient learning!  A list of these skills can be found at the COVD website on Children's Vision and Learning Month.  Children who struggle with these skills may not realize that they have a problem.  They don’t know how other people see, so they may not realize that they should not have to struggle to keep their vision clear, comfortable, and single. 

 

The best way to make sure that you child does not have a learning-related vision problem is to have a comprehensive eye exam from an optometrist who is trained to identify and recommend the necessary treatment for vision-related learning problems.  The American Optometric Association has outlined the best practices for this in a Clinical Practice Guideline (CPG) entitled Care of the Patient with Learning Related Vision Problems. In this CPG, under Early Detection (pg 8-9) it says, “because the evidence that learning related vision problems can be prevented to any substantial degree is inconclusive, the emphasis is on early detection. It is recommended that vision examinations be scheduled at 6 months, 3 years of age and at the entry into school…” Too often, parents rely on school vision screenings to tell them if their child has a vision problem.  These, however, may not be enough.  School screenings usually test for only distance visual acuity and possibly any overt eye muscle problem. This leaves out the vast majority of the 17 necessary skills.  Even with the screenings in place, 1 in 4 children suffer from undiagnosed vision problems!  A comprehensive vision examination with a focus on the vision problems that can affect learning will detect these problems before your child begins to struggle in school.  It is with these insights that I hope will lead to fewer parent oversights. For those parents who read this story, make sure your child is seen by an optometrist who knows how to recognize the 17 vision skills! Make a comprehensive vision exam a priority to your back-to-school checklist this year!

 

To find out if your optometrist will recognize a vision-related learning problem simply use the 17 skills checklist and ask before making your appointment. You can also contact the American Optometric Association at www.aoa.orgor  College of Optometrists in Vision Development at www.covd.org for assistance.

 

April A. Jones

4th Year Intern, Michigan College of Optometry

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