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.
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.
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.
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
thanks for sharing. I would suggest one thing that we done for many years now that can make an amazing difference. Put this young person in contacts. Here are the reasons:
1. eliminates the anisometropic magnification of spectacle lenses. Sometimes we put the aniso in the contact with spectacles over top, sometimes we give full correction of both eyes in contacts, but any combination based on positioning and patient function works well.
2. eliminates the VOR gain differences induced by spectacles lenses (this has profound effects on the vestibular-ocular connections and sometimes immediate stereopsis)
3. You can blur the "dominant" eye to 20/30 or more or less as needed with a contact which is equivalent to patching with graded foils.
4. Kids are very motivated to get out of those spectacles.
5. I have found literally hundreds of these patients and they require very little therapy when you are able to manipulate visual functioning with contacts.
6. Stereopsis is often present immediately when you do this.
7. Mildly over plus-ing the dominant eye often leads to a rapid equalization of refraction. ie- more hyperopic eye drops, and less hyperopic eye increases.
8. I also find that these patients tend to have a higher exo at distance when you measure with the aniso difference gone.
Thanks Dr. Clopton for the great suggestion! I will keep it in mind and try it next time.