Tanya Polonenko, OD, FAAO

Residency Trained Optometrist in Vision Therapy and Rehabilitation

What is Vision Rehabilitation? o Definition

o Neuroplasticity

o Optometry’s Role

o Goals of Vision Therapy

o Improvements to expect & Prognosis Factors

Guidelines for Vision Rehabilitation o When working with TBI patients

o Key Concepts

o Vision Rehabilitation Sequence

Vision Rehabilitation Procedures

Does it work? o Current research

How to incorporate into your primary care practise

Resources

Occipital Lobe (primary

visual cortex)

Parietal Lobe (spatial

inattention, perception)

Temporal Lobe (spatial

organization, object

recognition)

Frontal Lobe (initiates

voluntary saccades and

pursuits)

Midbrain and Pons (cranial

nerves)

70% of our brain as

Something to do with

VISION

An individualized treatment regimen prescribed to a patient in order to:

o Provide medically necessary treatment to normalize diagnosed visual

dysfunctions • Vergence

• Accommodation

• Oculomotor

o Improve visual comfort, ease and efficiency

o Enhance visual performance to meet defined needs of the patient

o Improve visual information processing • Spatial organization

• Object perception

• Visual memory

• Visual attention

• Integration with other sensory modalities (motor, vestibular, auditory, etc)

Brain (visual system) is able to create new connections and fortify

old ones by experience

Learning and plasticity can occur by myelination formation or re-

modeling white matter

Neurogenesis continues throughout lifetimes

Examples:

o rapid functional plasticity in primary somatomotor cortex and perceptual

changes after nerve block through MRI

o Visual development in adult amblyopes

1-4

Optometrists can diagnose,

manage, and treat binocular

vision problems

o Strabismic

o Non-Strabismic

o Visual Perceptual

Without appropriate

treatment, we are ignoring

25-57% of our TBI

population needs

Dysfunction of: % of TBI

Accommodation 41%

Vergence 56%

Oculomotor 51-57%

Strabismus 25-36%

Cranial Nerve Palsy 7-10%

5

Alleviate signs and symptoms

Achieve desired visual outcomes

o Clear, comfortable, single binocular vision

o Efficient coordination of visual functional skills

o Efficient visual information processing

Meet the patient’s needs

Improve the patient’s quality of life

Return to daily activities

5-26

Oculomotor Skills o Improved accuracy and speed of pursuit and saccades

o Reduced number of re-fixations and regressions while reading

o Increased span of recognition

Vergence o Increased vergence ranges, speed, facility

o Reduced eyestrain, headache with near tasks

Accommodation o Increased amplitude, flexibility, facility

o Improved quality and stability of near vision

Comfort Efficiency Accuracy Performance

5-26

Most visual efficiency cases have a very good prognosis (72-90% in CITT 2008)

Important factors: o Accurate diagnosis (rule out disease/trauma)

o Age/understanding of patient

o Treatment appropriate for diagnosis

o Patient compliance and motivation

o Stage in the grieving process

o Degree of brain injury

Rehabilitation is a process that takes time

Initially program can cause symptoms to be exacerbated

Manage the increased symptoms while strength training

o Modify amount of time spent on exercises

o Slowly increase amount of exercises performed

o Monitor log for delayed symptoms

o Symptoms should not exceed 7 or 8/10

Working with Patients with TBI

Extent and severity of symptoms may not correlate directly

with degree of abnormality in clinical findings

May have certain ability but at expense of excessive effort

Visual hypersensitivity

o Real

o May not be over-reacting (most want to return to their normal life!)

Mechanisms that normally help to function efficiently and

comfortably are compromised

Quiet

Avoid Fluorescent lighting

Reduce clutter

Speak slowly

Soft voice

Slow movements

Ask for them to repeat

instructions

Gain their attention

Confirm they understand the task

Give instructions in small steps

Give breaks

Increase demand in small increments o Amount of time

o Level of difficulty

Key Concepts

Determine a level at which the patient can perform easily

Emphasize that changes must be made within their own visual system (we can’t do the work for them!)

Set goals (for both patient and doctor)

Use techniques that provide them with feedback (diplopia, blur, parallax, float….)

Relate how exercises will impact daily living

Classical/Structural

Visual processing as it relates to anatomy, neurophysiology, and sensorimotor substrates o Muscles and nerves

Mechanics of vergence, accommodative and oculomotor systems

Bring measurements into the “comfort zone” or “norms” o Sheard, Percival, Morgan

Functional/Developmental/

Behavioural

Emphasizes visual development, function and performance in the context of their total behaviour

Treatment is based on individual’s abilities, needs, and goals

A “visual stress test”

Looks into fatigue, variability, stamina

Functional

Develops visual functional skills and abilities o Oculomotor skills

o Accommodative rock

o Fusion range extension

Looks how the visual system develops and integrates visual information

Behavioural

Added holistic approach to underlying organismic processes to behaviour

Incorporates procedures related to: o Movement

o Awareness

o Stress reduction

o Visual information processing

o Central-peripheral organization

o Visuomotor function

Higher degree of holistic: o Syntonics

o Bates (natural vision improvement)

o Chinese Acupressure treatment

Work on functional visual skills classically while addressing the developmental

and visual perceptual processing

• Anti-suppression

• Awareness

Phase 1

• Monocular

Phase 2 • Bi-ocular

Phase 3

• Binocular

• Accomm

• Vergence

Phase 4 • Integration

• Flexibility

• Stamina

Phase 5

o Expand both but emphasize difficult area

o Build ability and stamina before flexibility

o Start with peripheral targets and work towards central targets

o Each eye has to learn how to work on its own before they are

expected to work equally to the partnership

o Can use lenses, prism

o Incorporate both free space and equipment

Begin therapy by slowly stressing the direction of

difficulty:

o Exophoria with low base out – emphasize BO

o Esophoria with low base in – emphasize BI

o Accommodative Insufficiency – minus lenses

o Accommodative Excess – plus lenses

To increase accommodative abilities:

o Begin by stressing direction of difficulty

o Later work on both relaxation and stimulation

o Emphasize the “feeling” of effort

o Equalize right and left eyes` skills

o Emphasize amplitude, then facility, fine control, and stamina

To increase fusional vergence ranges:

o Maintain accommodation at the plane of regard and change the

stimulus to the vergence system

o Maintain vergence at the plane of regard and change the

stimulus to accommodation

o Emphasize amplitude, then facility, fine control, and stamina

Chief Complaint: 33 year old male lawyer sustained concussion from MVC;

since has had headaches, double vision with reading, eye strain and

discomfort at near, words moving on the page, dizziness with movement.

Dx: Convergence Insufficiency and Accommodative Insufficiency

Your

Findings

Exam results Interpretation

Phoria Distance: 2 XP

Near: 14 XP

Higher exo at near

NPC 15/20, 18/25, 20/30 Low, Recedes with repetition

AC/A 2:1 Low

PFV/NFV

(40cm)

BO: 4/8/6 , BI: x/8/6 Low PFV

NRA/PRA +1.00/-1.00 Low NRA and PRA

AA OD 3D, OS 3.5D Low

MEM OD +1.25, OS +1.25 High accommodative lag

BAF 5 cpm (- longer) Low

MAF OD 7 cpm , OS 7.5 cpm Low

Goal: Anti-Suppression

and Awareness

o Discussion of Vision

Problem and Goals

o Marsden Ball Tracking

o Space Fixator

o VO Star

o Batwing

o Cheiroscope

PHASE 1:

ANTI-SUPPRESSION

& AWARENESS

Goal: Equalize the skills between both eyes

Strategies: distances or lenses

o Monocular Accommodative Rocks

(+/-)

o Hart Chart Saccades

o Near-Far Hart Chart Saccades

o Monocular Lens Sorting

o Mental Minus (clear-blur-clear)

PHASE 2:

MONOCULAR

Goal: Develop monocular skills with binocular awareness

o Monocular Fixation in a Bi-

Ocular Field (Red Acetate with R/G glasses)

o Split Prism Techniques

o Split Vectograms

o R/G tracking/workbooks

o Red Rock

o GTVT Chart

PHASE 3:

BI-OCULAR

o Brock String

o Vectograms

o Tranaglyphs (Stationary and Sliding)

o Bernellscope

o Batwing

o Computerized Vergence Program

o Eccentric Circles

o Lifesaver Cards

o Aperture Rule

o Binocular Accommodative Flippers

PHASE 4:

BINOCULAR

Goal: Integrate both eye together and improve Fusional Ranges and Accommodation

BROCK STRING

Correct

- If you want to look at the

green bead, it is single

- String “X” indicates you

are paying attention to

both eyes

- Where the strings meet

is where you are looking

- Bead is in the middle of

the “X”

Incorrect

- You are looking farther

away than you want to

- Must look closer

- Look towards your nose

- Move your eyes together

so they “touch”

Incorrect

- You are looking closer

than you want to

- Must look farther away

- Look farther down the

string

- Imagine looking down a

tunnel

Incorrect

- Means you are suppressing or

ignoring information received by

one eye

- You want to see 2 full strings

- You need to make your brain

pay attention to both eyes again

- Do either:

- Blinking

- Tapping the bead you

want to look at

- Lightly tapping your

forhead

Ensure that you see all the shapes:

For CONVERGENCE: Slowly move the slider out from the thumb tag until you see double or something disappears. Stop, and try to re-fuse the images or make images appear. If you are able to, continue to move the slider out until you are unable to fuse the two images any longer.

Note what the number is on the top (called the “break” – when your binocular system breaks apart)

Nudge the slider in slightly and try again to re-fuse. If you are unable to do so for a few seconds, continue to nudge the slider inward a little bit and re-attempt

Once you are able to re-fuse the images, hold the image single for 5-10 seconds, then rest.

Note what number is on the top (called the “recovery” – when you are able to recover your binocular vision)

FOR DIVERGENCE: Repeat, but turn the tranaglyph upside down so that the thumb tag is now on the left side.

TIPS: To help with re-fusing, use the red stick, by slowly moving the stick towards you (for convergence) or behind the tranaglyph (for divergence)

Remove the fogged sleeve to help with divergence (which allows you to look past the tranaglyph to a distant target)

Convergence:

Divergence:

Numbers to record

SLIDING TRANAGLYPH

o Fixation Stability

o Mazes/Groffman Tracings

o Marsden Ball

o Pegboard Rotator

o Four-corner saccades

o Hart Chart saccades

o Computer Training Techniques

o Michigan Letter Tracking

o Kirschner Arrows

o PBQD slap tap

o Saccadic Workbook

PHASE 4:

OCULOMOTOR

Goal: Integrate both eye together and improve Oculomotor skills

There are many areas of brain needed for tracking: o Pursuits/Saccades:

Brainstem (Pons, Midbrain)

o Fixation: FEF, Parietal lobe & \Prefrontal cortex (for attention)

o Different pathways

o Both need to know where objects are in space

•Control of saccades and pursuits

Cerebral

•Horizontal and Vertical Gaze Centers

Brainstem

•Control of eye muscles

Cranial Nuclei

•Execute the eye movements

Extra-ocular Muscles

MICHIGAN LETTER

TRACKING

GROFFMAN MAZES

PHONETIC FOCUS

HART CHART

SACCADIC WORKBOOK

Goal: Improve stamina, enhance skills, achieve accommodation-convergence flexibility

o Any Binocular Technique with +/- Lenses

(BIM/BOP)

o Vectrograms/Tranaglyphs with Jumps

o Binocular Prism Jumps with Saccades

o Computerized Vergence Program with Jumps

o Eccentric Circles or Lifesaver with Tromboning

o Load activities, adding: • Speed

• Metronome

• Balance board

PHASE 5:

INTEGRATION,

FLEXIBILITY, STAMINA

Goal: Improve processing

visual information

o Visual Memory

o Figure Ground

o Visualization

o Visual-Motor Integration

PHASE 5:

VISUAL PERCEPTUAL

Improvement in Convergence Insufficiency Symptoms (double vision, eye strain and discomfort at near, words moving on the page, etc.)

Final Results

Pre VT results Post VT results

Phoria Distance: 2 XP

Near: 10 XP

Distance: tr XP

Near: 8 XP

NPC 10/15, 13/15, 15/17 3/5, 3/5, 4/6

AC/A 2:1 2:1

PFV/NFV

(40cm)

BO: 4/8/6 , BI: x/8/6 BO: 12/25/18

BI: 12/20/16

NRA/PRA +1.00/-1.00 +2.00/-3.00

AA OD 3, OS 3.5 OD 10, OS 10

MEM OD +1.25, OS

+1.25

OD +0.50, OS

+0.50

BAF 5 cpm 9 cpm

MAF OD 7 cpm

OS 7.5 cpm

OD 12 cpm

OS 12 cpm

Interpretation Norms

Higher exo at near

Well compensated

Ortho – 2XP

Normal, stable At least 5/10

Low 4:1

Normal BO: 9/19/10

BI: x/7/4

Normal +2.00/-2.25

Normal Min = 15 - (Age/4)

Normal lag +0.50 to +0.75

Normal 8 cpm

Normal

12 cpm

3 month re-check, giving them homework 2-3 times a

week

Then, if needed, wean the procedures to once a week

(or biweekly) for another 3 months

Yearly exams

12 non-strabismic individuals with mTBI and diagnosed vergence and accommodative disorders participated

6 weeks (2 sessions/wk, 3 hours each); half did oculomotor training (OMT) and half did placebo (P) training

Results: o Improved amplitude and peak velocity of

• vergence (pfv and nvf)

• accommodation (monocular and binocular)

o Improved stereoacuity

o Improved visual attention

o Reduced near symptoms (CISS score)

o No change in patients that did placebo VT

Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on vergence

responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2013: 50(9): 1223-40.

Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2014; 51(2): 175-92.

12 subjects with mTBI participated in either oculomotor training (OMT) or sham training (ST).

6 weeks, 2 sessions a week. Trained vergence, accommodation, version in randomized order across sessions.

Visual attention assessed by VSAT

Results: o Over 80% of abnormal parameters significantly improved

o Reading rate improved

o Amplitudes of vergence, accommodation improved

o Saccadic eye movements improved in rhythmicity and accuracy

o Improved visual attention and CISS score

Thiagarajan P, el al. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (TBI): An integrative approach. NeuroRehabilitation. 2014. 34: 129-146.

5 adults with stroke and 9 adults with TBI

8 weeks of training, 2 sessions/week

Training included single- and multiple-line simulated reading, as well as basic versional tracking (fixation, saccade, and pursuit) using infra-red eye movement recording technology

Internal oculomotor visual feedback in isolation (4 weeks) or concurrent with external oculomotor auditory feedback (4 weeks)

Results: o Improved objective accuracy with versional tracking

o Improved reading ability

Ciuffreda KJ, et al. Oculomotor rehabilitation for reading in acquired brain injury. NeuroRehabilitation. 2006. 21: 9-21.

13 control normal BV adults; 4 convergence insufficiency

adults

All participated in 18 hours of VT

Results:

o Reduction in NPC and NPC recovery point

o Reduction in Near Phoria

o Improved PFV, average peak velocity of convergence

o Significant increased functional activity within the frontal areas,

cerebellum, and brain stem significantly

Alvarez TL, et al. Vision Therapy in Adults with Convergence Insufficiency:

Clinical and fMRI Measures. Optom Vis Sci. 2010; 87(12): E985–1002.

Functional activity and vergence eye movements were quantified from 7 BV normal and 4 CI patients before and after 18 h of vergence training.

Results: CI patient measurements after vergence training were more similar to levels observed with BV normal

o Increased fMRI activity levels

o Increased speed in convergence response

o Improvement in CISS score

Alvarez TL et al. Functional activity within the frontal eye fields, posterior parietal

cortex, and cerebellar vermis significantly correlates to symmetrical vergence peak velocity: an ROI-based, fMRI study of vergence training. Front. Integr. Neurosci., 2014; http://dx.doi.org/10.3389/fnint.2014.00050

12 BV normal patients and 4 CI patients. CI patients

underwent 18 hours of VT.

Results: After VT, peak velocity and exophoria

magnitude improved significantly in CI patients

Alvarez TL. A pilot study of disparity vergence and near dissociated phoria in

convergence insufficiency patients before vs. after vergence therapy. Front. Hum.

Neurosci. 2015; http://dx.doi.org/10.3389/fnhum.2015.00419

The NIH funded a study to determine the best treatment

protocol for Convergence Insufficiency.

The results indicated that in-office VT is the treatment of

choice as it is the most effective treatment for

convergence insufficiency.

Randomized, multi-centered clinical trial

221 children ages 9-17 years with CI

Subjects subdivided into 4 groups and underwent 12 weeks of either:

Results: o Remained symptom free 1 year later

o ~90% of those CI subjects who initially had reduced accommodative amplitudes and facilities also developed normalized accommodative skills with the VT program

VT Reduced symptoms by:

Office based VT 73%

Home-based pencil push-up (PPU) VT 43%

Home-based computerized VT + PPU 33%

Office-based placebo therapy 35%

Decide what conditions you are comfortable treating

and what tools you will need.

Compose written instructions to hand out.

Schedule an instructional session to review the

techniques together.

Sell or rent the required equipment to your patient.

Equipment Cost

Instructions Photocopy

Brock String $2

Sliding Tranaglyph $15

Red/Green Bar Reader $10

Flippers (+/-2.00) $19

Near and Far Hart Charts Photocopy

Barrel Card $3

Total Cost $50

Your office registers for an institutional account (free)

Purchase DVD/codes for each patient, which will be

linked to your account

Software, Glasses, and Flipper Set: $110 USD (Your

cost)

What is “In-Office” VT: o Usually weekly sessions of 45 minutes

o Homework to be completed at least 4 times between sessions

o Activities progress week by week

o The patient’s progression is monitored and the program can be individualized for optimal results

Can get in touch with local clinics offering VT for specific info: o Do they have a referral form?

o What kind of patients do they treat?

o What is their background/training?

o What is their fee?

Canadian Optometrists in Vision Therapy and Rehabilitation (COVT&R) o Annual Meeting (August)

College of Optometrists in Vision Therapy and Rehabilitation (COVD) o Tour d’Optometry for students

o Annual Meeting for students and optometrist (April)

o Can become a fellow (essays, clinical experience, exam, and interview)

Optometric Extension Program (OEP) o Courses available

Vision Therapy Courses by Robert Sanet o Courses available

Neuro-Optometric Rehabilitation Association o Annual Meeting

Websites:

o Bernell - www.bernell.com

o Optego - www.optego.com

o McCray Optical - www.mccrayoptical.com

o Fresnel Prisms (prisms and bangerter foils) - www.fresnel-

prism.com

o GoodLite - www.good-lite.com

o HTS Inc - www.visiontherapysolutions.net

Can discover more at the annual meetings and exhibits

1. Weiss T, Miltner WHR, Liepert J, Meissner W, and Taub E. Rapid functional plasticity in the primary somatomotor cortex and perceptual changes after nerve block. European Journal of Neuroscience; 20: 3413–3423

2. Levi DM and Polat U. Neural plasticity in adults with amblyopia. Proc Natl Acad Sci U S A. 1996; 93(13): 6830–6834.

3. Levi DM. Perceptual learning in adults with amblyopia: a re-evaluation of critical periods in human vision. Developmental Psychobiology. 2005; 46 (3): 222-232.

4. Zhou J, Reynaud A, and Hess RF. Real-time modulation of perceptual eye dominance in humans. Proc Biol Sci. 2014 22;281(1795).

5. Ciufredda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, and Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry 2007; 78: 155-161.

6. Ciufredda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, and Han ME. Vision therapy for oculomotor dysfunctions in acquired brain injuries: A retrospective analysis. Optometry. 2008. 79;18-22.

7. Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in traumatic brain injury. Optom Vis Dev 2009;40(1):16-23.

8. Aksionoff EB, Falk NS. Optometric therapy for the left brain injured patient. J Am Optom Assoc 1992;63:564-8.

9. Cohen AH. Optometric management of binocular dysfunctions secondary to head trauma: case reports. J Am Optom Assoc 1992;63:569-75.

10. Ciuffreda KJ, Suchoff IB, Marrone MA, et al. Oculomotor rehabilitation in traumatic brain-injured patients. J Behav Optom 1996;7(2):31-8.

11. Gottleib DD, Fuhr A, Hatch WV, et al. Neuro-optometric facilitation of vision recovery after acquired brain injury. Neuro-rehabilitation 1998;11:175-99.

12. Hellerstein LF, Freed S. Rehabilitative optometric management of a traumatic brain injury patient. J Behav Opt 1994;5(6):143-8.

13. Ludlam WM. Rehabilitation of traumatic brain injury with associated visual dysfunction—a case report. Neuro-rehabilitation 1996;6:183-92.

14. Thiagarajan P and Ciuffreda KJ. Effect of oculomotor rehabilitation on accommodative responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2014;51(2):175–92.

15. Thiagarajan P, Ciuffreda KJ. Effect of oculomotor rehabilitation on vergence responsivity in mild traumatic brain injury. J Rehabil Res Dev. 2013;50(9):1223–40.

16. Thiagarajan P, el al. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (TBI): An integrative approach. NeuroRehabilitation. 2014. 34: 129-146.

17. Ciuffreda KJ, et al. Oculomotor rehabilitation for reading in acquired brain injury. NeuroRehabilitation. 2006. 21: 9-21.

18. Kapoor N, Ciuffreda KJ, Han Y. Oculomotor rehabilitation in acquired brain injury: a case series. Arch Phys Med Rehabil 2004;85:1667-78.

19. Thiagarajan P and Ciuffreda KJ. Versional eye tracking in mild traumatic brain injury (mTBI): Effects of oculomotor training (OMT), Brain Injury, 2014; 28(7): 930-943

20. Ciurfredda KJ. The scientific basis for and efficacy of optometric vision therapy in nonstrabismic accommodative and vergence disorders. Optometry 2002;73:735-62.

21. Liu JS, Lee M, Jang J, et al. Objective assessment of accommodation orthoptics: dynamic insufficiency. Am J Optom Physiol Optics 1979;56:285-94

22. Bobier WR, Sivak JG. Orthoptic treatment of subjects showing slow accommodative response. Am J Optom Physiol Optics 1983;60:678-87

23. Hung GK, Ciuffreda KJ, Semmlow JL. Static vergence and accommodation: population norms and orthoptics effect. Doc Ophthalmol 1986;62:165-79.

24. Cooper J, Feldman J, Selenow A, et al. Reduction of asthenopia after accommodative facility training. Am J Optom Physiol Opt 1987;64:430-6

25. Grisham JD, Bowman MC, Owyang LA, et al. Vergence orthoptics: validity and persistence of the training effect. Optom Vis Sci 1991;68:441-51

26. North R, Henson DB. The effect of orthoptic treatment upon the vergence adaptation mechanism. Optom Vis Sci 1992;69:294-9.

Tanya Polonenko, OD, FAAO

tpolonenko@hotmail.com