Final Flashcards
Is accommodation accurate?
No
what to access with accommodation
relative amp, absolute amp, accuracy, facility
How to chance accommodation stimulus?
Lens or distance
What to look up with AA?
Does pt. have AA for near demands and for age
Does PRA have a normal distribution?
NO! Has a cut off. Normal standard evaluation will give false negatives!
What is accommodative test is the best predictor of symptoms?
NRA.
IS NRA a normal distribution?
No!
Tests for posture?
BCC or MEM
BCC
pre-clarity. Pt. must be spherical. High nest-start with excessive plus.
Mem
Don’t leave in longer than 1s.
Who has greater accommodation affect: lenses or near-far rock?
lenses
Monocular flipper cuttoff
Binocular flipper cuttoff
What is the most common symptom of accommodative disorder?
HA
SCCO 4+ System
Test fixation. Look at 20/80 for 10s. 5s or less=failure.
Line scanning laser opthamoloscope with fixation assessment
Use a machine to determine your fixation.
Fixation training examples
Hooping with golf tees. McDonald Chart. Tachiostopic. Any task with zero velocity.
How many sessions for Pursuit Dysfunction
8-24
Does pursuit dysfunction exist by itself?
Very rarely. There will be accommodative and mergence problems as well.
Should pursuit tasks be predictable?
YES!
Goals with pursuits
accuracy over speed. Minimize head movement. Monocular->binocular. Loading the task to encourage distraction. Want it to be hard but not too hard.
Modifying pursuits
Use a loading demand or a cognitive demand.
Pursuit training examples
Rolling ball. Can modify with a flash light. Can have a stationary target and a head movement. Thumb pursuits. Flashlight tag. Marsden ball and can hoop. Penny drop. Spear the picture.
Pursuit problems
Will likely also see basal ganglia disease, parkinsonism, and cerebellar disease. Commonage with others.
What do you need for 3D vision
Equal consistent input, equal monocular perception, perceptual integration, relative comparison of object distances. Accommodation and mergence consistency.
SILO
Perception change due to vergence changes.
What causes stereopsis symptoms to increase
Vestibular interaction and disorder, neuromuscular disorder, accommodation or vergence disorder, medications, sedentary lifestyle.
What causes stereopsis symptoms to decrease
Immersion and presbyopia.
Progressive of stereopsis training
Awareness of float, localization of lost, localization comparison of two objects, similar at far.
Training for awareness of float
Marsden ball and quoits juxtaposition. Use polarized glasses. Adjust BI until patient sees hooping.
localization of float
use a single vectogram and typically start with BO. Once pointer not needed can increase and go for
Compared localization of float
quoits preferred. Use polarized flippers to reverse BI and BO. Can also do matching float (adjust lower image to match).
Stereopsis training at far
Brewster: Use BO first. Change demand and depth with thromboning. Juxtapose with natural targets: any object farther than marsden ball. Projected vectograms, computer-based.
What lens should be used with VT?
Plus add if needed to limit phasic response, limits accommodation adaptive requirements, reduce AC/A influence.
Bioenginering VT approach
Stimulus Sensitivity, phasic training, specific skills, adaptive training.
Stimulus Sensitivity
Bring awareness to stimulus cues. I.e. how does it feel to accommodate.
Stimulus sensitivity examples with accommodation
Plus blur/lens sorting, plus and/or BO walk away. Mental minus/split pupil rock.
Stimulus sensitivity examples with vergence
Prism sorting, brock string, disparity sensitivity.
Why is phasic training important
Linked to asthenia, helps other steps, daily visual tasks need. Find minor deficiencies or OD/OS imblance
Phasic training
Facilities. Can use flipper with BIM/BOP.
Training Deficient Skills
Work more directly on the weak skill area but avoid training in only one direction. i.e. normalizing amplitudes
Adaptive training Importance
Linked to asthenia and can have return to VT without finishing with adaptive training
Problem with adaptive training
symptoms are normally gone by this time so patient is not as motivate.
How to train adaption
Large changes, all at once, hold activity for adaption.
EX: of adaption with accommodation
Read two minutes before changing flipper.
Feature for accommodative training
lenses, target distance, target features.
Is it better to do 20 minutes practice a week or do 4 days of 5 minutes?
Better to form a habit and do a little bit each day
Lens sorting
Sensitivity to blur. Monocular. Start with plan, +1, +2. Use smaller increments. With minus at first must be at least 1 from.
Minus lens activities
Sensitivity to blur. Monocular. Use target about 1.5 m away. Can do accommodation awareness and progress to mental minus
Accommodation awareness with minus lens
Start with -4. Patient feels sensation of changing clarity. Holds when lens inserted and removed. Used generally as intro to mental minus
Acc. awareness w/ Mental minus
Learn to voluntary control accommodation. Will voluntary increase or decrease prior to lens introduction.
Accommodative infacility
Typically 3-12 sessions. Facility alone often improves quickly. Do all the facilities with this patient.
Near far rocks
Use with accommodative in facility. Can also use metronome. Want 60-75 ppm with no errors or pauses. Can also do loading technique.
Split Pupil Rock
Do with accommodative in facility. Change vertex distance to alter distance. Prescribe 2-3 minutes each eye.
Split Pupil Rock Goals
-6 lens in spectacle with 15-20 cpm in 30s trial.
Bi-ocular Rock
Accommodative in facility. Same as split pupil rock but no occlusion. See double and shift between the two images. Do not use with those that may get sick.
Lens flippers goals
Put for 15 cpm average in 2 minutes. Stop at +2/-5. Can move to BIM/BOP.
Prescribing lens flippers
Determine power to reduce facility to 7-9 flips in 30 sec. When patient races 12 cpm increase the power until goal is reached.
Specific skills with accommodative infacility
Generally already accounted for.
Adaptive training with accommodative infacility
No adaptive training here.
Treatment for accommodative insufficency
Immediate help=plus add. VT for long term
Can you use CISS for AI
Yes
Length of VT for AI
3-12 sessions.
Phasic training for AI
Train facilities. Specifically use Jensen rock, split pupil rock, minus lens tromboning, minus lens walk up
Jensen rock
used with AI. Hold near chart a few CM further away than NPA. Near far rock as before.
Modified Jensen Rock
Can push up the near card while doing it.
Minus lens tromboning
Min=-4 Sustain at spectacle plane for 10s.
Minus lens walk up
Take one foot length forward when clear. Stop when too blurry. Can add minus once can do this.
Adaptive training for AI
Change large lens and hold. Can hold a large lens for 2 minutes and then change. Recommend 15 minutes per day total.
Ill Sustained Accommodation TX
VT. Maybe low plus for partial relief. 2-9 sessions.
Goals with ill sustained accommodation VT
improve amplitude, normalize facility, emphasis adaption. Very similar to AI sequence.
False CI
Low stimulus AC/A but more normal response. Lag.
False CI TX
Low plus may improve accommodation. VT. Typically 6-16 sessions.
BIM addition with False CI
Specific skills training with false CI to improve AA
Crossed Cylinder Focus
Improve pt. ability to regulate accommodation. Use crossed cylinder lens at 90 or 180. Use cross cylinder target. Have patient change to make vertical and then horizontal clear. This is likely a finishing technique.
AE
6-18 sessions.
BOP walkaway
Used for AE. Encourages reduction in accommodation. Plus lens greater than +1. RXN 6X per day.
Adaption with AE
Plus addition lens wear, sustain large lens change with two minutes of reading.
Pseudo myopia VT.
4-12 sessions. May do plus only facilities. Can do BOP walkaway as well.
Accommodative Spasm
DO plus only facilities! BOP the spasm.
DE TX
VT, overminused at distance with plus at near, prism.
How many sessions with DE
6-18
Goals for DE VT
Want to increase PRV without drawing on accommodation. Above 8 prism. Want to get to 20.
Phasic activities for DE
Distance facilities through prism (more BO). Near far with GTVT and minus at near, BO at far. Near sequence with BIM/BOP.
First step with DE for specific skills
Check near skills. Use plus and do brock string, analgphs, hectograms, etc.
BOP walkaways
Use with DE. Continue fusing while accommodation decreases. Can use prism with GTVT, chiastopic fusion tasks.
Steps in DE VT
Start at near, near with plus, move from near to far, simulated far point, true far point
Brewster with DE
Stimulated far point. Expand PRV ability. Trombone away.
What happens when you move card away
BOP effects
What happen when you move card closer
BIM
Optical far point with DE
Use distant anaglyph target. Can do BO prism pops or BOP walkaway. Can also do Near far with anaglyphs. Can also do prism bar.
Why are anaglyphs a good choice?
Suppression control and float.
Projected targets in DE
Use anaglyph or hectogram The same instruction as with near.
Adaptive for DE
Large prism change every 2 minutes, large change on stereoscopes.
Basic EXO VT
8-18 sessions. Phasic-see accommodative and mergence in facility. More emphasis on N-F. Basic Skill-combination of activities for CI and DE.
How hard is DI to treat
A very challenging case. 10-20 sessions
Phase 1 for DI
Pencil Push away. Brock string: bead push away, steps and jumps, lenses. Accommodative activities: distance rock and then flippers binocular.
Phase 2 for DI
Vectrograms, Transaglyphs, computer, brewster, prism. Start at near and then progress to far.
Most common symptom of DI
Diplopia.
Hectograms for DI
Work in one direction for 2-5 minutes. 4 times as much BI. Can project vector at far or add +2.50. Next add look aways and jumps. Then BIM/BOP
Tranaglyphs for DI
Smooth, step, BIM/BOP. For far can do walk aways, step demands, BIM demands
Computer for DI
Works in break/recovery zone. Can project in some programs.
Brewster
Bring the card closer for BIM affect. Can add look aways.
Phase 3 DI
Start with near-far. Aperture rule trainer and lifesaver/eccentric circles
ART for DI
Work divergence 4 times as much. Use double aperture for divergence. Step or jump mergence.
Dismissal from Active VT
RTC 1 month. Prescribe 1-2 HVT procedures. Progress at 1 month. RTC 2 months and continue HVT. Eval at 3 months and if okay RTC 6 months and discontinue HVT. Repeat at 9 months and if okay RTC 1 year for CVE.
Basic ESO Tx
Quick: full plus at all distances, BO prisms, Commonly associated with uncorrected hyperopia. Long term: VT
Difficulty of basic ESO VT
difficult. 10-20 sessions.
Signs of Vert. deviations
head tilt, vertical phobia, reduced vergence recoveries in both directions, unilateral eyebrow furrowing.
Finding vert. dissociated phoria
Maddox is great. Screen 9 positions of gaze.
Finding AP for vert.
Use saladin. Trial frame and look for adaption. If FD stays constant there is no adaption.
If no prism adaption is seen?
Prism may be better choice. VT only necessary if prism doesn’t work.
If prism adaption is seen?
VT is the best choice.
How long therapy for Vert.
4-24 (varies greatly) Non strab
Ways to train vert. fusion
Move target or move head (easier as we do this in life)
Do you train with or without compensating prism?
Start all activity with compensating prism so they now how to do it. May/may not use at home but eventually will use opposite prism.
Vertical facility
Use at least 3 prism in opposing direction with no compensating eventually. Can start with compensating prism with equal BD/BU facility. Find prism they can do by increasing compensating prism (Make so that values of compensating in flipper are increased)
Recommended vertical facility
12-15 cpm. Want 2 minutes of facility 3-5 times a day.
Other options for vertical facility
Use vertical anaglyphs with R/G flippers, vertical hectograms with polarizing filters.
Which is harder R/G flipper or prism flipper?
R/G as only a bit of eyes is stimulated to move up or down
Steps for vertical deviation training
compensating prism-no prism-opposite prism
Vertical fusion range approaches
step prism range, smooth prism range, modifications.
Smooth vertical fusion range
Want to expand FR to >3 D in opposite direction. Require responding to drift in panum’s fusion area
Smooth vertical fusion Activity
Use vertical hectogram, anaglyph, or rotation prism. Practice slow break/recovery. Can modify with head movement, target movement, both movement, tilting head, titling target, vestibular input.
Head rolling with horizontal analgyph
Smooth vertical fusion. Have patient move head and try to keep fused.
Drive a horizontal anaglph
Emphasize left and right turn.
Rotating prism
Fuse Small BO prism. Slowly rotate toward BU or BD to break/recovery. Increase prism by 1 when can rotate to bu?bd
Is there SILO with vertical fusion
NO silo.
Step Vergence
Use small step increments to practice fusion. Uses peri-macular stimulus. Can use fixed vertical analgphys. Adaption is a key to sucess
Step vergence with prism bar
Starting from no prism fuse each window for a few seconds before moving to the next.
Step vergence with fixed vertical anaglphys
Same procedure as with bars.
Vertical fusion adaption
Time, big change all at once
Adaption training activities
Can do prism while doing horizontal fusion activities, Can hold maximum right or left turn while driving, Can also do challenging vertical prism while on a computer, or can tilt head with TV
Post VT mgmt for vert
FU in 1 month, Follow up 3 months, at 6 months if still okay stop home. RTC only if VT needed
When to train horizontal before vertical
vertical only there when dissociated, vertical is small, horizontal deviation is large. If Vertical is large compensate during horizontal training.
What is computer VT not a substitute for
office VT or examinations and FU
Glasses in computer
R/B. Red over right.
Time with HTS iNET
5 times a week for 20 minutes for about 3 months
VTS3
use in office. Very expensive.
Dedicated VT practice
one or more ODs specializing in VT. Can be group therapy.
General optometric practice that provides VT
Limited to easily treatable conditions. Mostly home base with Evaluations. Mostly in rural settings.
General optometric practice that contracts VT
VT comes on site once a week or so and performs.
OD in opthamology
Help with amblyopia, pre/post surgical strap, CI/CE.
Discussing tx
Start and end with the best choice
Estimating number of sessions
Number of conditionsX5 +5
FU with VT
3-6-9
