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Visual Symptoms in Traumatic Brain Injury

Brain Eye2

A traumatic brain injury occurs as a result of forces from impact disrupting the functioning of brain cells and their ability to effectively transmit signals. As a result, changes in physical, cognitive, and emotional aspects may be observed. Physical symptoms include headaches, dizziness, nausea, vomiting, drowsiness and sensitivity to noise and light. Furthermore, there may be cognitive deficits in memory, attention, concentration, processing, reaction time and the feeling of one’s brain being in a “fog”. Emotional changes such as irritability, depression, anxiety and changes in sleeping patterns may also be noted. Depending on the severity of the injury, these symptoms may be seen within a day following the event and resolve as early as several weeks. However, in other cases the symptoms of the brain injury persist for longer periods of time and may never truly resolve.

The visual system comprises a large amount of space in the brain and has many components that must be intact in order to effectively take in, process and apply visual information. In traumatic brain injury, many aspects of the visual system may be affected and this results in visual symptoms including losing one’s place or skipping lines when reading, reduced reading speed and accuracy, occasional or constant blurry vision, double vision, eyestrain or fatigue, as well as increased sensitivity to motion and light. This can make previously simple tasks unbearable, such as going to the grocery store, driving a car, or doing computer work. The brightness of fluorescent lights may suddenly become debilitating and the noise and activity of the workplace may become overwhelming. Symptoms of dizziness or nausea may ensue when found in similar situations.

Rehabilitation of patients with traumatic brain injury is a multidisciplinary approach involving optometry, ophthalmology, psychiatry, neurology, occupational therapy, physical therapy and speech therapy, as many neurological systems may be affected. To complicate matters further, no two injuries are the same and the symptoms and effective treatments may vary between individuals. Appropriate therapy requires an individualized approach to training with the goal of utilizing the brain’s plasticity to maximize brain functioning, reduce patient symptoms and improve overall quality of life.

Vision therapy has been shown to effectively restore appropriate eye movements and binocular function at a level of 90% or greater1 in patients suffering from mild acquired brain injury. Symptoms of blur, difficulty reading, eyestrain, or double vision are eliminated. For patients with more severe brain injury, prescription spectacle lenses with prism have been shown to reduce symptoms of double vision and enhance previously restricted vision due to visual field defects2. As a result, better spatial awareness is possible thereby improving stability and mobility and reducing incidences of running into unseen objects. For the patient suffering from traumatic brain injury, this means a significant reduction or complete resolution of visual symptoms negatively impacting life and a renewed ability to carry out daily activities.

By Monica Bell and Debbie Luk, OD, FCOVD

References:

  1. Vision therapy for oculomotor dysfunction in acquired brain injury: A retrospective analysis. Ciuffreda, K., et al. Optometry (2008) 79:18-22.
  2. Field Expansion for Homonymous Hemianopia by Optically Induced Peripheral Exotropia. Peli, E. Optometry and Vision Science (2000) 77:453-464.
  3. Visual Profile of Patients Presenting with Brain Trauma. Hellerstein, L., Kadet, T. Journal of Optometric Vision Development, (1999) 30:51-53.
  4. Assessment, Management and Knowledge of Sport Related Concussion: Systematic Review. King, D., et al. Sports Med (2014) 44:449-471.
  5. Neuroptometric Rehabilitation For Persons with a TBI or CVA. Padulla, W. Journal of Optometric Vision Development, (1992) 23:4-8.

Optometric Treatment for Post-TBI Patients

Tinted Lenses TBI

By: Yi Zheng, Optometry Intern, Class of 2016

Traumatic brain injuries (TBIs) such as concussions, strokes and whiplash injuries frequently result in oculomotor dysfunction and visual disturbances. Common vision disorders associated with TBIs include deficits in accommodation, version, vergence, visual field, and photosensitivity.1 The intimate interactions between these visual systems can produce symptoms that significantly affect the patient’s ability to function in the workplace and at home. Effective treatment methods are discussed in this article.

Post-TBI patients will often have difficulty functioning in environments with rich visual stimulus; this is sometimes referred to as “supermarket syndrome.” The use of bi-nasal occlusion often works well to alleviate symptoms of visual discomfort, imbalance and vertigo. This treatment method restricts the field of overlapping vision shared between the eyes and reduces visual confusion. A small vertical strip of semi-transparent tape or Bangerter foil is applied to the nasal side of both spectacle lenses. The width of the occlusion is determined by maximizing comfort and mobility.3 Electively, a Streff Wedge can be used to trial the occlusion and for accurate measurement the occluder width.

Visual field inattention is also common in patients that have suffered a TBI. These patients experience symptoms such as bumping into objects or missing words on the affected side when reading.1 Base in prisms have been used to treat these visual field deficits with good success. A 2-3^ BI of ground-in prism is incorporated into the patient’s spectacles. By increasing the divergence demand, the visual system is encouraged to become more aware of the peripheral field of vision.

Padula et al. propose that the visual dysfunction caused by TBIs is caused by impaired ambient (magnocellular) processing. Their study showed that treatment with bi-nasal occlusion and base in prism increases the amplitude on VEP (P100) for post-TBI patients, which suggests improved function in the binocular cortical cells. In addition, the symptoms improved for patients subjectively.2

Further, solid tints are useful to help relieve photosensitivity that some patients experience. Colours are selected by subjective trialing. Popular choices include brown, grey, amber and blue.1 The above treatment options have had lots of success in the management of post-TBI associated visual dysfunction. They can be easily incorporated into eye exams and trialed.

Finally, vision therapy is an excellent option to explore to address the underlying problem. A customized vision therapy program can work to mend accommodative, oculomotor, visual field (scanning therapy), and visual processing dysfunction at a patient-specific pace and minimize the rehabilitation process after a TBI. For more information, go to www.covd.org

References

  1. Kapoor, Neera, and Kenneth J. Ciuffreda. “Vision disturbances following traumatic brain injury.” Current

Treatment Options in Neurology 4.4 (2002): 271-280.

  1. Padula, William V., S. Argyris, and J. Ray. “Visual evoked potentials (VEP) evaluating treatment for

Post-trauma vision syndrome (PTVS) in patients with traumatic brain injuries (TBI).” Brain Injury 8.2 (1994): 125-133.

  1. Proctor, Alissa. “Traumatic Brain Injury and Binasal Occlusion.” Optometry & Vision Development40.1

Vision Therapy Myth Busters

By: Evelyn Zhang, University of Waterloo Senior Optometry Intern

Vision therapy may be a foreign concept to many. What is it? How does it work? Will I benefit from it?

Brock String

Vision therapy is used to improve eye movement control and eye coordination. It is often used to treat strabismus (eye turn), amblyopia (lazy eye), oculomotor dysfunction (eye tracking deficits), and other binocular vision disorders. Vision therapy also promotes better visualization, visual perception, and eye-hand coordination skills. Vision therapy involves a series of exercises and procedures carried out under the supervision of an optometrist or vision therapist. It works by strengthening existing neural connections or build new connections between the eyes and the brain to streamline eye coordination and visual processing.

Below we will learn more about vision therapy and discuss a few misconceptions of vision therapy.

Myth #1 – Vision therapy only works for kids.

Vision therapy is effective for people of all ages, not just children. Vision therapy works by strengthening the neural connections between the eyes and the brain to allow the two eyes to work more effectively and comfortably in coordination. Studies have shown that adult brains are plastic and is capable of changes and improvements, which provides the basis for vision therapy.

Whether you have a longstanding strabismus (eye turn) or binocular vision deficiency, or you are experiencing headaches and discomfort with reading or computer work, you will benefit from a thorough binocular vision assessment by an optometrist who may recommend vision therapy to improve your visual function. Adults with acquired brain injuries and concussions will also benefit from vision therapy. Since majority of the brain is involved with vision, visual symptoms such as visual fatigue, light sensitivity, and blur often appear or worsen after a brain injury. Vision therapy will re-teach the brain to better process visual information by strengthening the neural connections that were affected by the concussion.

Myth #2 – The effects of vision therapy is not life long

When vision therapy is performed under the direction of an experienced optometrist or vision therapist and with adequate practice of the visual skills by the patient, the benefits of vision therapy will last a lifetime. Vision therapy works through building new and strengthening existing neural connections between the two eyes and the brain, effectively re-teaching the brain to use the two eyes more efficiently. Changes in the brain are long lasting, allowing skills gained through vision therapy to last for a lifetime. As well, the newly gained skills is practiced and solidified through everyday tasks. Similar to learning how to ride a bike, the visual skills learned through vision therapy is not something your eyes can easily “forget.”

Myth #3 – I don’t need an eye exam or vision therapy if I can see well.

Many people believe that if you’re seeing 20/20, it means your eyes are perfectly healthy and visits to the optometrist are not needed – but that is not the case. In fact, many serious eye diseases, such as glaucoma and diabetic retinopathy, won’t start to affect your vision until the end stages of the disease. Regular eye exams by an optometrist will ensure that your eyes are not only seeing well, but they are healthy as well. An optometrist will also thoroughly assess binocular vision functions, which tells you how well the two eyes are working together as a team. It is possible to have binocular vision deficiencies even if your vision is 20/20. As a matter of fact, many of our vision therapy patients have 20/20 vision and don’t wear glasses.

Deficits in binocular vision may present as discomfort and difficulties with reading or computer work; symptoms include eye strain, fatigue, headaches, double vision, lack of attention, and blurry vision. Majority of those symptoms can be eliminated or reduced with vision therapy. Although it is important to have good vision, it is equally important to assess all aspects of ocular health and binocular vision by an optometrist to ensure your eyes are free from disease and are working optimally as a team.

Myth #4 – Vision training won’t help if my child has a learning disability.

Since so much of learning is done visually, the improved visual function and visual processing achieved through vision therapy may in fact enhance learning in children who have been labelled “learning disabled.” Many common ocular conditions, such as convergence insufficiency, accommodative dysfunction and oculomotor dysfunction (eye tracking deficiency), will cause discomfort and difficulties while reading. The child may avoid school work or lose attention easily as a result. The symptoms of binocular vision disorders actually overlap with the symptoms commonly associated with ADHD and learning disorders. Therefore, it is important to see a developmental optometrist to identify these visual issues.

Convergence insufficiency, the inability to keep one’s eyes turned in while reading, is a common binocular vision disorder that can cause double vision, eye strain, fatigue, lack of attention, poor comprehension, and the feeling that “words are moving on the page.” Oculomotor dysfunction, or eye tracking deficit, will cause the child to lose their place while reading, skip words or lines, re-read lines, and poor reading comprehension. Accommodative dysfunction often cause blurry vision, headaches, difficulty switching focus between far and near objects, eye strain, and difficulty concentrating.

Vision therapy can treat all of the binocular vision deficiencies mentioned above. Vision therapy will help the child improve their visual skills, which better prepares them for the academic environment. Vision therapy teaches the child to better coordinate their two eyes, and allow them to read more comfortably for longer periods of time. It is important to note that visual function is not the sole factor in learning, so parents may still need to pursue other avenues to encourage better learning for their child.

Myth #5 – There is no need for in-office therapy, doing exercises at home is just as effective.

Even though vision therapy exercises performed at home can be effective, studies have shown that in-office therapy sessions result in the greatest improvements. The Convergence Insufficiency Treatment Trial (CITT) compared the efficacy between in-office vision therapy, at home vision therapy and placebo for the treatment of children with symptomatic convergence insufficiency. The results of the study showed that in-office therapy is drastically more effective than other treatment options.

In-office vision therapy allows the vision therapist and the optometrist to better monitor each patient’s progress from week to week in order to tailor the exercises appropriately. The patient is reinforced on the proper technique for each exercise and receives constructive feedback at every in-office session to help further improve their visual skills. Also, a variety of therapy equipment and computer based programs are available only in office. With regular monitoring and support from the vision therapist or the optometrist, it’s no wonder that in-office vision therapy is a more effective way to treat a variety of binocular vision disorders!

 

References

Seiderman AS. Overlooked: 20/20 is Not Enough. Optometric Extension Program Foundation; 2012.

Scheiman M, Cotter S, Mitchell GL, Cooper J, Kulp M, Rouse M, et al. A Randomized Clinical Trial of Treatment for convergence Insufficiency in Children. Arch Ophthalmol. 2005; 123: 14-24.

Scheiman M, Wick B. Clinical Management of Binocular Vision, 4th Ed. Philadelphia: Wolters Kluwer; 2014.

 

What’s So Important About Doing My Homework?

 

Home Vision Therapy Program 2 copy

By: Paul Harris, OD, FCOVD, FAAO, FABCO

Home activities have been an integral part of our vision therapy program. The pioneer clinicians in the field noticed that when home practice was done on a regular basis, more profound and lasting changes in behavior were noted. This was passed on to me through my education, but with little scientific backup. The old sages told us it would work and it matched my observations.

I ask my patients to do their home practice on the days that they do not come in for their in-office session, allowing one other day off per week. Thus, the plan for patients coming in once a week was for five days of home therapy to be done between in-office sessions. Over the years my observation has been that patients who regularly got at least three days of practice between their once-weekly in-office sessions made the progress as expected and in many cases did so towards the short end of my estimate of their length of treatment. Those patients who worked less often than this moved through the program more slowly and made fewer overall gains from the program. Some tried to compensate for missing several home sessions by practicing at one or two longer home practice sessions. I found that this was not as productive as the regularly spaced short practice sessions.

Once in a while a piece of good scientific work comes along that provides the proof to understand why such a thing is so. I recently ran across the article, “Adult Cortical Plasticity and Reorganization” by the Israeli neurologist Avi Karni. Traditional thought is that we become less plastic (changeable or moldable) as we get older and that in particular our cortices (the gray matter on the outside of the brain) is much less changeable than some other parts of our ‘higher’ brain functions. Without getting too technical, I relay the portions relative to regular home practice.

Karni found that there were two types of learning that he was able to measure at the level of changes in the cortexes of his subjects. His research was done primarily in areas of vision. He showed that “A fast improvement, occurring early in training, can be induced by a limited number of trials, on a time scale of a few minutes or less, but only if high-quality sensory input is provided.” This is what we are doing in your in-office session. Each activity we do in the office is programmed for 8-10 minutes. It is an intense, highly-controlled environment where we expose you to a specific aspect of vision that we want to help you improve. You perform that action several times in those few minutes. What he found, and which we find in the vision therapy room, is that people make very rapid

improvement over a short period of time and then it levels out. It may actually be counter productive to push for more progress in that particular activity in the session in which the plateau was reached.

Then Karni found that the person would retain that new level of ability learned in the short practice session, for a period of about 8 hours. He continues, “After this latent period, large and long-lasting improvements in performance were found.” And here is the key that is relative to your vision therapy homework: “Performance continued to improve over days and was maximal after 5 to 10 consecutive training sessions spaced 1 to 3 days apart. Once a maximal level of performance was reached, most of the gain was retained over months and even years.”

The key to embedding the new behavior or skill is the 5-10 consecutive practice sessions with no more than 3 days between each of the practice sessions. You may note that during your vision therapy some activities are assigned for only one week. This is rare in the program. Most activities will be assigned for two or more weeks. Those activities that are done for much longer are modified as you proceed through your treatment.

In vision therapy we arrange conditions to provide you with the opportunity to have the necessary meaningful experiences to acquire the new skills you need to do the things you want to do. We hope that the activities are made meaningful to you and that you can see the reason why the activities are being done. With the proper support of regular home practice you can make huge changes which will last a very long time.

 

Reference: Karni, Avi, “Adult Cortical Plasticity and Reorganization”, Science & Medicine, January February 1997, PP 24-33.

Source: What’s So Important About Doing My Homework article by Paul Harris, OD, FCOVD, FAAO, FACBO. © Dr. Paul Harris, Optometrist 2013. All rights reserved. Reproduction other than for one-time personal use is strictly prohibited.

 

How To Tell If Your Child Is Suffering From Pediatric Retinoblastoma

By Amanda Duffy

More than 300 children in the U.S. suffer from Retinoblastoma, an eye cancer affecting one or both eyes of the children. 95 percent of these cases occur in children ages five years and below according to the National Cancer Institute which is why early diagnosis is important. Manifestations of retinoblastoma in children can differ depending on the type of retinoblastoma which is either hereditary or non-hereditary.

Hereditary Retinoblastoma

About 10%-15% of children suffer from hereditary retinoblastoma which is caused by a mutation of a gene called RB1 in both parents. The RB1 mutation occurs in one of the cells of the retina which leads to retinoblastoma tumor. Children suffering from hereditary retinoblastoma usually have both sides of the eyes affected.

Non-hereditary Retinoblastoma

Also called sporadic or familial retinoblastoma, this type affects one eye. Cases of this type of eye cancer affect more children compared to hereditary retinoblastoma. and unlike the latter, symptoms of non-hereditary retinoblastoma are seen at a later stage of a child’s growth.

As parents or guardians, it is important to equip yourself with knowledge on retinoblastoma in children which can cause vision problems and permanent complications when not diagnosed and treated early.Below are symptoms which tell if your child is suffering from retinoblastoma:

● Leukocoria

This is a condition wherein the pupil of the eye appears white or pink in color when exposed to bright lights. Parents may also notice a white glare in the eye of their child when exposed to camera flash. Leukocoria can also be caused by other primary cases like intraocular infection, cataract and retina malformation.

Swollen pupil

Because of the growing tumor in the retina, it can cause the pupil to enlarge and swell leading to poor vision and blindness when the tumor is fully developed.

Lazy Eye

The lazy eye is a loss of vision that affects both children and adults. This condition cannot be treated with correctable eyeglasses or lenses and is common to children below six years old. The lazy eye could also cause blurred eyesight.

Sore Eye

Besides the usual sore eyes that happen when there is infection, children suffering from retinoblastoma may experience inflammation of the eye for no particular reason.

Strabismus

Strabismus is a misalignment of the eyes. Both eyes could be farther apart each other or could not follow the same direction wherever the child focuses on a specific thing or person. Parents can ask the child to play a game of staring contest or hold a stick and ask them to focus on the movement of the stick to see how their eyes respond. An indicator of strabismus is if their eyes move in and out, up and down or in a crossed direction.

 

Diagnosis and Treatment

There are a couple of eye exams and laboratory tests needed to diagnose eye cancer and necessary steps for treatment. Early detection can spare financial and emotional crisis arising from retinoblastoma, but before deciding on performing these tests, make sure you have background knowledge on such tests and you trust the doctor or organization.

 

Here are some of the tools used in diagnosing retinoblastoma:

Biopsy – This means sampling of a tissue of the tumor for further study. This will help doctors recommend a better procedure for treatment.

Blood Sampling – Blood samples of the child will be taken for examination to determine dysfunctional or missing genes that may have caused the eye disease.

Magnetic Resonance Imaging (MRI) – The MRI detects almost any kind of cancer including the eye, it utilizes electromagnetic waves that captures images of the spinal column and brain to know the development of the eye tumor and whether or not it has spread to other parts of the body. The doctor may administer medicine to sedate the child when performing this method to prevent the child from moving, which generates inaccurate images.

Spinal Tap – If the MRI results state that there is abnormality in spine or brain activity linked to the eye, then the spinal tap test is performed which involves a needle inserted at the child’s back to determine the status of cancer cells. The child is also given anesthesia before the spinal tap is performed.

Bone Marrow Aspiration – A tiny amount of the bone marrow is taken through a needle on your child’s hip to see if the cancer cells have spread to the bones.

 

Update on Irlen Lenses

Windmill

There is much controversy when it comes to whether Irlen/Scotopic Sensitivity Syndrome (IS or SSS) exists or not and if its proposed treatment of coloured filters is effective for treating reading difficulties.

Irlen Syndrome is described as a perceptual condition where individuals experience sensitivity to certain wavelengths of light thus causing reading-related visual stress. The elimination of those wavelengths using coloured lenses or overlays while reading are the basis for treatment of IS, which is proposed to alleviate visual stress and make reading less difficult.1

Optometrists are hesitant to jump on board with diagnosing IS as they believe there is an underlying vision deficit that is contributing to the reading difficulties, of which can be treated by proper lenses, prisms, and/or vision therapy. The described symptoms of IS are very similar to those symptoms associated with accommodative, binocular vision, and ocular motility disorders (such as fatigue, words moving on the page, etc.). Supporters of IS stress that it is a distinct condition separate from vision problems that could be diagnosed during a visual examination. They propose that although IS and visual problems may have similar symptomatology, similar symptomatology may have dissimilar etiology. They believe that those with IS have a dysfunction of the major visual pathways in the brain which are unrelated to vision problems.1

The Irlen Institute states that all clients receive comprehensive assessment of their visual system, and if any vision problems are found they are treated prior to testing for IS.1 But a study performed by Scheiman et al reported that 95% of subjects identified as being a good candidate for Irlen lenses also had a readily identifiable vision anomaly. There were 57% of those Irlen candidates that reported they had an eye examination within a year of the study, and yet in 90% of those subjects it was found that they had significant uncorrected visual efficiency problems. This suggests that the appropriate testing to identify oculomotor, accommodative, and binocular vision anomalies had not been carried out during those examinations.2

Much of the controversy around IS and the treatments they suggest stems from the lack of validity of the research they provide. Irlen has only one published article7 in a scientific journal, with much of her other work8 being found in newspapers and non-published journals5. Systematic reviews of the studies on coloured filters and reading disabilities suggest that the existing research is inconclusive and not sufficient to direct current treatment of learning disabilities.5, 6 There is a need for long-term randomized control trials with appropriate placebo and masking.5

A recent, well designed study addresses these concerns and completed the first investigation of Irlen colored overlays in which the participants had no explicit knowledge of their prescribed color before being tested (masked) with an adequate sample size to make valid conclusions. Their results suggested that Irlen coloured overlays had no immediate effect on children with reading difficulties, even in those who had been diagnosed with IS.3

It is important for full eye examinations of those identified with learning difficulties to specifically look at whether there are any visual deficits in the areas of ocular motility (saccades or pursuits), accommodation, binocularity and/or depth perception, and that the appropriate treatment be carried out. It may be that a large proportion of those with reading difficulties that also have vision deficits that have not been appropriately detected and managed by optometrists and thus have turned to the Irlen treatment approach for help that they failed to receive otherwise.1

In another study by Blaskey, Scheiman et al, it showed that the subjects’ use of Irlen filters had a reduction in visual symptoms (increase in comfort), but all 11 of the subjects still had clinically significant vision anomalies after treatment with the filters. Whereas in the vision therapy treatment group, where the subjects also reported significant improvement in comfort after vision therapy, the subjects were no longer considered candidates for Irlen filters, suggesting that the optometric intervention alone was sufficient for treating the symptoms. There was a subdivision of the vision therapy group (two subjects) that reported they received additional benefit from coloured lenses after their visual anomalies have been treated by vision therapy.4

It seems that the general consensus from an optometric viewpoint is that it is critical for those identified with reading difficulties to be properly assessed for any visual anomalies before considering diagnosing IS and the prescribing of Irlen filters or overlays. It is highly possible that appropriate glasses, prism, and/or vision therapy for people with visual efficiency deficits will alleviate their visual symptoms, thus improving concentration and efficiency while reading. There may be an additional benefit for a select group of people with use of coloured lenses after having been treated with glasses and vision therapy, but it is critical to diagnose and manage the underlying vision problem prior to taking this controversial approach.

It is therefore important, for those with reading difficulties, to be properly examined by an optometrist, to determine the etiology of their reading difficulty. A referral to a developmental optometrist may be required. A developmental optometrist spends years in post- doctoral education to master the diagnosis and treatment of visual efficiency and visual perceptual disorders through therapeutic glasses, prisms and vision therapy. Recent studies9, 10, 11 on vision therapy have shown that there is great remediation in visual efficiency symptoms when vision therapy is used to treat convergence insufficiency and accommodative dysfunction. Not only do symptoms improve, but their clinical measures of accommodation and binocular vergence, greatly improve if not normalize after the visual therapy program. These treatments usually alleviate the majority of visual symptoms and improve reading ability and efficiency in patients with reading difficulties. If there are no detected vision anomalies or there are residual symptoms after optometric treatment, the phenomenon of IS could be considered and if indicated, coloured lenses may be prescribed for increased relief of symptoms.

By Debbie Luk, BSc(Hons), OD, FCOVD, and Shannon Pennifold, BSc.

Reference

1 Irlen HL, Scheiman M. Scotopic sensitivity syndrome, Irlen filters and reading disability. Journal of Behavioral Optometry 1994: 5;31: 62-66.

2 Scheiman M, Blaskey P, et al. Vision characteristics of individuals identified as Irlen filter candidates. Journal of the American Optometric Association 1990: 600-604.

3 Ritchie SJ, Sala SD, & McIntosh RD. Irlen colored overlays do not alleviate reading difficulties. Pediatrics 2011: 128; e932.

4 Blaskey P, Scheiman M. The effectiveness of Irlen filters for improving reading performance: a pilot study. Journal of Learning Disabilities 1990: 23: 604-610.

5 Albon E, Adi Y, Hyde C. The Effectiveness and Cost-effectiveness of Colored Filters for Reading Disability: A Systematic Review. Birmingham, United Kingdom: University of Birmingham Department of Public Health and Epidemiology; 2008.

6 Dohnert M, Englert ED. The Irlen syndrome–are there pathophysiologic correlates and scientific evidence for “reading with colors”? Z Kinder Jugendpsychiatr Psychother 2003; 31(4):305-309.

7 Irlen H, Lass MJ. Improving reading problems due to symptoms of scotopic sensitivity syndrome using Irlen lenses and overlays. Education 1989; 109(4):413-417.

8 Irlen, H. Successful treatment of learning disabilities. 1983, paper presented at the 91st Annual Convention of the American Psychological Association, Anaheim, California.

9 Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126(10):1336-1349.

10 Lavrich JB. Convergence Insufficiency and its current treatment. Current Opinion in Ophthal 2010; 356-360.

11 Convergence Insufficiency Treatment Trial Study Group. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci 2001; 88:1343-1352.

Sports Vision Eye Protection

 

Gift suggestions from your OD?

This time of year many patients are considering sports-related gifts, which could include visors and protective eye wear. Dr. Debbie Luk has put together an excellent summary to help ODs introduce the safety aspect with patients.

Consider the impact of visors on eye and orbital.

Eye trauma, often occurring through physical activity, is the leading cause of noncongenital monocular blindness in children. An optometrist has a crucial role in reinforcing eye safety in sports-related activities. This is especially because over 90% of ocular injuries are preventable with appropriate eye protection. However, studies show low rates of use among athletes.1

A recent article revealed amongst NHL hockey players, 34 out of 640 are without a visor. Vancouver defenceman Erik Gudbranson is one of them. After suffering from a broken orbital bone, he continues to play without proper protection and explains that his decision is unwise, but is due to being comfortable. According to a 2014 retrospective study, a total of 149 eye or orbital injuries over the last 10 seasons in the NHL. Most injuries were a result of being hit by a deflected or direct puck (37%) followed by being struck by a high stick (28%).2

Visor use among NHL players grew from 32% in 2002-2003 to 73% in 2012-2013 as the NHL Players’ Association made it mandatory for inexperienced players to wear visors. In Canada, the evolution of facial protection and implementation of mandatory full-face shields in minor hockey led to a significant decline in ocular injuries. Mandatory helmets and facial protection reduced the number of ocular injuries in 1974–1975 to half of that in 1983–1984. Additionally, hockey players were 10 times more likely to sustain an ocular injury with no facial protection and four times as likely with partial facial protection, whereas no injuries were found with full-face protection. Implementation of mandatory full-face protection for minor hockey players has led to a decline in ocular injuries.1,2

In the United States, 84.6% of children do not wear protective eyewear despite engaging in a sports that risk eye injury.1 As part of a comprehensive eye examination, optometrists should discuss hobbies, including sports and therefore have the opportunity to discuss the importance of eye protection. One of these discussions could save an eye.

1. Luong M, Dang V and Hanson C. Traumatic hyphema in badminton players: Should eye protection be mandatory? Can J Ophthalmol. 2017; 4: 143-6.

2. Micieli JA, Zurakowski D, Ahmed II. Impact of visorts on eye and orbital injuries in the National Hockey League. Can J Ophthalmol. 2014; 49:243-8.

Top 5 Reasons to Perform Cycloplegic Refraction

Why use dilating eye-drops in a child’s eye exam? It may be performed to detect vision disorders, especially in young children who cannot verbally provide a clear and accurate description of their vision problems, and are frequently unaware of the presence of those problems. The following article is geared towards optometrists, and for patients who want to be more informed.


Original article found on the Alberta Association of Optometrists’website.

Top 5 reasons to perform a cycloplegic refraction

By Dr. Debbie Luk, OD

Sometimes when people see an OD for an eye examination things are not always what they seem, which is why a cycloplegic refraction is important. Be sure to explain the procedure to your patient and why it is important to their eye health.

  1. Hyperopia. Uncorrected hypermetropia can result in accommodative esotropia, strabismic amblyopia and isometropic amblyopia. Children with >3.50ds of hypermetropia have a 13 times greater risk of developing strabismus or amblyopia.
  2. Esotropia. New onset of/ previously well-controlled accommodative esotrope is an indication for cycloplegic refraction. This allows us to determine whether the eye turn has an accommodative component.
  3. Anisometropia is a very powerful amblyogenic risk factor. Over +1.00ds difference between two eyes can put a child at risk of developing anisometropic amblopia. It is not surprising to find a much larger difference in refractive error between the two eyes after cyclodilation. If you don’t prescribe the full anisometropic difference between the two eyes, the amblyopia/reduced acuity may not fully resolve despite occlusion therapy/patching. Treatment of anisometropia should consist of symmetric reduction of hypermetropia of up to 2.00 D.
  4. Accommodative Spasm. In older children and young adults, cycloplegic refraction can confirm the diagnosis of accommodative spasm, which is a constant or intermittent, involuntary increase in ciliary contraction. Patients with low hyperopia may present as myopic during examination; this so-called pseudomyopia can be identified by cycloplegic evaluation.
  5. Asthenopia with near work. This applies for children and young adults. A study of young adults18-21 years old showed that they possessed +1 to +2 D of latent hypermetropia. Should they complain of headaches with near work and asthenopia, cycloplegic refraction is indicated.

References

  1. Arthur L. Rosenbaum MD, J. Bronwyn Bateman MD, Don L. Bremer MD, P.Y. Liu PhD. Cycloplegic Refraction in Esotropic Children: Cyclopentolate versus Atropine. Ophthalmology, 1981; Volume 88, Issue 10, Pages 1031-1034
  2. Michaels DD: Accommodation: Clinical aspects. In Smith RE (ed): Focal Points 1987: Clinical Modules for Ophthalmologists 5, Module 1:1. San Francisco: American Academy of Ophthalmology, 1987.
  3. Mimouni M, Zoller L, Horowitz J, Wygnanski-Jaffe T, Morad Y, Mezer E. Cycloplegic auto refraction in young adults: is it mandatory? Graefes Arch Clin Exp Ophthalmol. 2016 Feb; 254(2):395-8. doi: 10.1007/s00417-015-3246-1. Epub 2015 Dec 21.

WICKFEST! Wickenheiser Female World Hockey Festival

 

Sports Vision Training

By: Debbie Luk

We had the wonderful opportunity to participate at an empowering and inspiring hockey event for girls. This special weekend is the dream come-to-life of six-time Olympian Hayley Wickenheiser. Hayley is pleased to host her seventh festival in this exciting city and venue, in partnership with Girls Hockey Calgary and Rocky Mountain Female Hockey League. Over the course of two four day weekends in November 1,500+ players will compete and connect while building positive female hockey experiences across all levels.

At the event, we had a Sports Vision Training station to highlight how important vision and perception can give you the extra edge to become a better athlete. To learn more, take a look at this Sports Vision Training Handout composed by our exceptional intern, Monica Bell. Also, much thanks to Drs. Jillian Yeaman, Cassandra Biro and Monica for showing the athletes the fun vision training tools!

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In between hockey games, the athletes are working to improve visual skills such as tracking, eye hand coordination, peripheral vision, depth perception and dynamic visual acuity.

Sports Vision Eye Hand
The girls are eager to find the all the numbers on the rotation visual scanning board as fast as they can!

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Catching and throwing a tennis ball with Strobe sports vision training glasses. After training with them, athletes describe seeing the world in slow motion, hence improving their reaction time!

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Congrats to Brooklyn Hill from Prince George Cougars for beating Hayley’s high score on our eye-hand reaction/peripheral vision training program! Well done!!

 

 

ADHD or Vision Problem?

We have previously blogged about how vision problems have similar symptoms as AD(H)D, and how to tell the difference between the two. A recent study discusses how treating convergence insufficiency, a common eye-teaming dysfunction, can result in reduction of attention deficit symptoms.

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Behavioral and Emotional Problems Associated With Convergence Insufficiency in Children: An Open Trial. The paper is co-authored by Eric Borsting, G. Lynn Mitchell, L. Eugene Arnold, Mitchell Scheiman, Christopher Chase, Marjean Kulp, Susan Cotter, and the CITT-RS Group (CITT-RS stands for “CITT-Reading Study”).

Objective: This study investigated behavioral and emotional characteristics of children with convergence insufficiency (CI), before and after treatment with office-based vergence accommodative therapy (OBVAT). Method: Parents of 44 children ages 9 to 17 years with symptomatic CI completed the Conners 3 ADHD Index and the Child Behavior Checklist (CBCL) before and after OBVAT. Pre-treatment scores were compared with normative data and post-treatment scores were compared with baseline using the Wilcoxon sign rank test. Results: Following OBVAT, CI children showed a significant mean improvement (p < .0001, effect size of 0.58) on the Conners 3 ADHD Index with the largest changes occurring in the 23 children who scored the highest at baseline. On the CBCL, anxious/depressed, somatic, and internalizing problems improved significantly (p < .001, effect sizes of −0.36, −1.15, and −0.67, respectively). Conclusion: In an open trial, attention and internalizing problems improved significantly following treatment for CI.

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