When Refractive Amblyopia Doesn't Tell The Whole Story

Christopher’s Case

History:

Christopher (6.11) was referred by his occupational therapist with a previous ocular history of amblyopia of the left eye.  He had 1 year of occlusion therapy including atropine and corrective lenses. His previous Rx was: OD: +0.50, OS: +5.25- 0.75 X 007.  In spite of his previous treatment he still had many difficulties including poor handwriting, spatial disorganization up and down on the page, poor motor coordination and difficulty catching a ball. Even though Christopher was a capable reader, he read slowly, skipped words and used his finger as a marker.  Christopher would often experience frustration and emotional outbursts with visually demanding tasks. It was even thought that Christopher had an affect disorder.  Additionally, he had trouble riding a bike, and would experience easy motion sickness in the car.

Visual Assessment:

His initial evaluation revealed a corrected visual acuity of 20/20 OD, 20/100 OS.  His dry refraction showed OD: Plano 20/20, OS:+4.75 OS 20/100. Cover test was othophoria for distance and 8 exophoria at near. His NPC was 12”/16” (PLRG NPC).  He showed suppression OS on the vectographic slide.  Stereopsis: None at distance and near.  His oculomotor abilities were age appropriate on pursuits and saccades.  His accommodative amplitude was adequate OD and reduced in the amblyopic eye (as expected). While his VMI was 8.7, his Wold Sentence Copy Test revealed spatial disorganization.  In the area of visually directed gross motor, Christopher had poor bilateral integration and persistent primitive reflexes including a moderate Moro and Tonic Labyrinth Reflexes.

 
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Diagnosis:

1. Anisometroptia
2. Refractive amblyopia OS
3. Convergence Insufficiency
4. Suppression OS
5. Defective stereopsis.
6. Bilateral Integration Dysfunction including persistent primitive reflexes (Moro, TLR)
7. Visual spatial disorganization in paper pencil tasks

Plan:

1. Rx: OD: Plano, OS: +4.75 (Hi-index, aspheric lenses with Crizal A/R)

2. (35) 1-hour sessions of Office-Based Optometric Vision Therapy.

The therapeutic applications of office-based optometric vision therapy included: equating monocular skills,  antisuppression,  binocular vision development activities including a “heavy dose” of stereopsis experiences.  Included in the treatment was a strong emphasis on integrating both sides of his body to develop his reciprocal interweaving, balance and integration of primitive reflexes. 

Results:

1. Visual acuity: OD: 20/20 OD, 20/40-OS
2. Stereopsis: Distance: 120”, Near: 20”
3. NPC: nose (PLRG NPC)
4. Suppression: None
5. Handwriting neater and more organized
6. Able to ride a two-wheeler bicycle
7. No more motion sickness.
8. Happier kid!

 
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Clinician Comments:

While occlusion treatment, including atropine penalization is a common treatment regimen for amblyopia, for our patient Christopher,  this limited treatment approach fell short of what he truly needed.  Since amblyopia is the result of a disruption of development of binocular vision, treating him solely with occlusion therapy only re-enforced Christopher’s dysfunctional visual system. Through office-based optometric vision therapy Christopher had the opportunity for his visual brain to develop the use of both eyes (binocular vision) thus ridding need for his sensory adaptations. This not only improved Christopher’s visual acuity but also his stereo vision which, along with the development of his visual integrative skills,  enable his abilities in paper-pencil skills, riding his bike and other key areas of his life. This gave Christopher confidence and happiness.

Your questions or comments are welcome.

Nhin Nguyen, O.D.,

SCO Private Practice Resident 2011-2012

Wow Vision Therapy