prefi 1 Flashcards
BEST AMBLYOPIA MANAGEMENT (3)
Prescription lenses
Vision therapy
Patching
if the px has EOR, we must give this especially if refractive in origin
Prescription lenses
Types of Prescription lenses (2)
- Compensatory Lenses
- Treatment Lenses
is defined as a lens that restores standard (20/20, 6/6, 1.0) visual acuity at distance and in the case of a presbyope, includes an add.
Compensatory Lenses
- More on the grade of the patient
- THIS IS USUALLY PRESCRIBED to PX
COMPENSATORY LENS
- For example, patient has presbyopia, we give plus lenses or progressive, as long as the purpose is to clear the 20/20 best standard VA at near
COMPENSATORY LENSES
type of rx lens Any time a lens other than the compensatory lens is given
Treatment Lenses
treatment lenses is for: (3)
- Reduce visual stress
- Treatment of Visual conditions
- Any add that is not directly related to aging
reduce visual stress treatment lens (3)
prism
plus lens at near
anti fatigue lens
o Example, patient is 4 years old and you checked is near. 13A is ortho. The visual system is not okay, so it is better to give plus lenses at near or at all distance.
reduce visual stress (treatment lenses )
o For example, Px has CI so lack of convergence (there is divergence), we can give lenses or prisms. We can give plus lenses in order to treat insufficiency in accommodation
- Treatment of Visual conditions
o treatment lenses are not lenses alone but also prisms as long as it has a purpose that is different aside from VA
true
o Patients that are strabismus or amblyopic that need reading lenses.
o Best is Flat top and executive, and last is PAL.
o Flat Tops are difficult to prescribe because the patient might be bullied about it.
o Flat top is the best choice because the prism jump is lesser compared to Kryptok. If he looks at far and near, it won’t cause too much “lipong”
o Our bifocals have a “Prism Base Up” effect. If they look at the reading portion, they might get dizzy.
add that is not directly related to aging
Improve Amblyopia to 20/80 or better
Let’s say VA is worse than 20/80 without pathology.
Specific activities are prescribed to improve visual acuity in the amblyopic eye to at least 20/80 level
true
Usually in VT, we do _____ first because if we compare amblyopic and non-amblyopic eye, their visual system is not equal.
There is a tendency that the amblyopic eye fixation is poor, poor accommodation, poor pursuits and saccades, poor CS.
So our first goal is to ____the monocular skills of both eyes and we can do this by occluding one eye.
Next is _____, approximately equal. We teach the two eyes to work together.
Monocular Activity
equalize
Binocular Activity
improve ambly: monocular activities to improve ____
acuity
To Patch or Not to Patch?
To Patch carefully and Actively
- Always _____/ activate the amblyopic eye
stimulate
patching:
if we stimulate the amblyopic eye ___, we stimulate the good eye once.
__not strict rule.
Thrice
3:1
TREATMENT OPTIONS FOR STRABISMUS (6)
no treatment
lenses
prism
occlusion
surgery
referrals
There are cases in that we do not need to treat strab, like ____, no symptoms, no headache, no difficulty reading, and cosmetically okay eye position. There is no treatment needed, they are well-adapted due to ARC.
SMALL ANGLE CONSTANT STRABISMIC (MICROSTRAB)
o The idea alone that the patient has ARC, he reduces the prognosis already. Making it difficult to VT compared to double vision or suppression.
o Usually the patient suppresses when the deviation is big
o It is more difficult to treat small deviations rather than big deviation.
no treatment needed
o Check if Px has EOR because sometimes, it is only the grade that’s the problem. When we put lenses, there are cases that the eyes will be ortho.
- Lenses
o Plus lenses for eso? Not all the time. depending on the case because there are others that the visual system is already not normal.
true
o Hyperope - eso Myope- exo
-
o Example, amblyopic Px has a grade of +3.00 at near, and we add +1.00, we expect exo but the px went more eso. So different visual system.
o If EOR affects alignment, is it more exo or eso? It will depend.
-
o If the patient has diplopia or double vision we can give this based on
NEUTRALIZING LENS.
o Cosmetically straighten the eyes,
TRAINING PRISM.
prism are for (3)
Neutralizing
Measuring
Correcting
o if strab/ambly is an anatomical problem or paralytic
Surgery
Remember that ‘anti-suppression activities’ are part of the strabismic’s therapy program and diplopia is a ‘needed interim’ visual response.
___________must be achieved if binocular vision is to occur.
Sensorimotor fusion
goals for VT
px has strabismus. During the VT program, there must be improvement in intermittent and phoria.
-
Optical Correction
* It is not unusual for the lens correction alone to eliminate the strabismus and to stabilize binocularity
-
- Use the least amount of plus that gets the job done (especially for kids). Leave at least a single to a double buffer uncompensated _____, unless there is a state change with more plus
(+0.75 to +1.50)
o Do not give full prescription EXCEPT WHEN (3)
Px has strabismus (eso) and when we give +4.00, the patient becomes Ortho. That is the time we give full correction.
Also check the stereopsis of the patient with the prescription, if its result is 20-40 sec of an arc.
If there is no improvement in stereo fly, you can’t immediately give.
o For example, 4 y.o. His cyclo is +4.00 at 20/20
o We do not give the full amount of plus for young children. If we give the full amount, we disrupt the process of emmetropization. There is a possibility that we are not helping but making his condition worse.
o Usually, children have a buffer that is +0.50 or +0.75
o We can subtract +0.75 (single buffer) or +1.50 (double buffer).
o You can cut plus lenses +0.75 to +1.50
o Example, +4.00 - +1.50 = +2.50 (20/40) this is okay because the child doesn’t need to see 20/20.
o WE must weight clarity, VA and Buffer.
o During VT, you can freely do what you want because the prescription would change.
o If we give the full amount, we take some of the child’s buffer making them passive. So, what happens if we take their buffer, they create their own buffer which increases.
o Careful in prescribing plus lenses to children.
o Always check if there is an improvement in the deviation and check the stereopsis.
o Usually you can do this, after the emmetropization stage around 8-9
-
- Like a translucent tape.
- Usually used for patients with esotropia
- Difference with patching is that patching is whole eye, this one is only part of the eye
- can be monocularly
Bi-Nasal Sector Occluder/ Bi-Nasal Occlusion
To determine the amount of nasal occlusion to use. Sector occlusion is a simple and effective way to eliminate much of the _____which appears as a significant cause of patient confusion.
pre-fixation physiological diplopia
bi-temporal sector occluder
to be more eso
bi-nasal sector occluder
to be more exo
Expected Total Treatment Time
Constant strabismus to heterophore may be as short as
6 weeks but for some, 1 year
o 4-6 months (exotropia) and
o 6-12 months for esotropia
it is more difficult to diverge an eye compared to converge.
easier to train convergence rather than divergence because we all have small convergence
constant strabismus
o 1-2 months for intermittent exotropia and
o 2-4 months for intermittent esotropia
Intermittent deviation
VT session ______ only, not 2 hours
30-45 minutes
______ phototherapy’s colored lights are used to help stimulate the visual system while also changing the brain’s biochemistry. The result is an improved balance between two nervous systems: the sympathetic and parasympathetic nervous systems.
Syntonics
(Light therapy or Tints)
_________suggested that that red light at one end of the visible spectrum stimulated the _________________, and indigo activated the parasympathetic nervous system (rest and digest).
spitler’s model
sympathetic nervous system (fight and flight)
red light at one end of the visible spectrum stimulated the
sympathetic nervous system (fight and flight),
indigo activated the
parasympathetic nervous system (rest and digest).
can be used as support to other therapies to aid in the remediation of strabismus, amblyopia, accommodative/convergence problems, asthenopia, ametropia, visual attention deficit, vision-related learning and behavior problems, and visual field constrictions associated with visual stress, brain injury, degenerative ocular disorders, and emotional trauma
Syntonics
- Neurovisual stimulator
- Enhances the focusing mechanism
- Stimulates the photoreceptors in the retina.
- Usually we do this before proceeding to other procedures
Eye Relax
Equalize _______skills - cover the other eye (thru eye patch)
monocular
Biocular (monocular work in a binocular field)/ (Monocular Fixation in a Binocular Field) MFBF
- test for ______
- right and left eye are working,
- they are not occluded but the one eye sees one target and the other eye sees another target
ANTISUPPRESSION
Biocular (monocular work in a binocular field)/ (Monocular Fixation in a Binocular Field) MFBF
- test for ______
- right and left eye are working,
- they are not occluded but the one eye sees one target and the other eye sees another target
ANTISUPPRESSION
Binocular:
* 1st-degree fusion – _________
* 2nd-degree fusion – flat fusion
* 3rd-degree fusion – fusion with depth/stereo Build ranges
simultaneous perception
Provides an auditory component to therapy to maximize effectiveness. Variable speed control allows patients to build speed and accuracy over time
Electronic Metronome
- Controls the speed and accuracy of the patient
- New session - slow beat
- For a long time - faster beat
- Example, used in Saccades
Electronic Metronome
Improve Monocular Accommodative Skills:
- Not only pursuits and Saccades but also accommodation
- Accommodative inaccuracies are common in strabismus/ amblyopia (different in left and right)
- Improve thru monocular visual activities
-
Improve Monocular Motility Skills:
- Saccades and Pursuit
- We exercise more the amblyopic and strabismic eyes without forgetting the good eye.
- Motilities improved to their maximum level under monocular viewing conditions
- Initially, deviating eye exhibit limitation in pursuit ability – including fixation maintenance, pursuits and saccades – are improved monocularly
-
MONOCULAR SKILLS (6)
- DEM
- King Devick test
- Wayne Saccadic Fixator
- Groffman Visual Tracing
- Marsden ball
- Hart chart
- Improves fixation
- Train eye-hand coordination
- Train pursuit eye movements
- Dynamic visual acuity (because it is moving)
- Also helpful in training athletes
- Anti-suppression when it is used with R-G glasses
o When we use red-green glasses, it becomes anti-suppression
o green tees to green area (holes)
Pegboard Disc Rotator with red/green tees
- Central fixation to improve attention
- Improve eye-hand coordination
- Training saccadic movement
- Enhancing anticipation and reaction time
- Developing visual memory and response to an auditory and visual signal
- Sequencing, peripheral, saccades or pursuits
- it is like Dwayne-Saccadic but it has a different program or activities that can be performed.
Sanet Vision Integrator (SVI)
- Eye-hand coordination
- Sequence
- Saccade
- For kids
Peg Board - stationary
Threading/ stringing beads (4)
- Fine motor control
- Eye-hand coordination
- Fixation
- Depth perception
- Develop perceptual skills like discrimination
- figure ground
- visual memory
- Fine motor control
- Eye-hand coordination
- Fixation
Puzzles
Memory, spatial awareness, ADHD, coordination, visual perception, eye tracking, and visual sequencing and more.
Multi-matrix Brain Game
- has numbers and shape
- Eye-tracking
- Catching: Eye-hand coordination
- May occlude one eye, be creative in the procedure like right-left right-left
- 3 meters or 4 meters, no specific distance
Bean Bags
- distance-near distance-near
- Purpose: Accommodative Amplitude & Facility, Blur awareness
- Target: Distance Hart Chart or another accommodative target (HART CHART)
- can use with Metronome
- OD, OS, OU
- Choose a target in the distance and look at the center
- Procedure: Cover one eye w/patch (monocular), stand about 4 ft away from target & hold bull’s eye target in front of open eye. Clear distance target through clear area on Bull’s eye target then focus back on Bull’s eye target & keep rings clear
Bull’s Eye
Why do we need to exercise? Because the eyes lead the body. Especially in relation to the 4 circles of Skeffington.
Body Bilaterality
done monocularly @40cm
* Home Vision Therapy
* Fixation, depth perception
* accuracy
* eye-hand coordination
Pointer in the Straw
BALANCE VT PROGRAMS/PROCEDURES/TRAINING (4)
WALKING RAIL
BALANCE BOARD
ANGEL IN THE SNOW
CHALKBOARD CIRCLES
is useful for patients with tracking problems and/or perceptual difficulties. Starting with a military-type walk, the addition of a fixation target such as a Marsden ball and a metronome can increase the challenge Next, make the ball swing side to side and even around the patient as he walks, and the challenge increases. Walk forward and/or backward. The walking rail should be performed with shoes off to provide a challenge to balance and increase the tactile feedback in all parts of the foot.
- usually there is a narrower rail.
- forward and backward
- increase difficulty by using Marsden Ball. It is hang on the ceiling and the Px is looking at the wall i,e, HART Chart, patient walks thru the Marsden ball without getting hit.
Walking RaiL
- Balance board can be used to test and train spatial integration.
- Eye-body coordination. Body reaction time (weightshifting) and balance.
- The patient’s eyes should be directed to a specific visual target straight ahead, and at eye level, throughout the procedure
- balance is incorporated in saccades
Balance Board
- Primitive reflexes
- 1st stage both arms
- 2nd stage feet
- 3rd stage arm and feet
- The patient lies on his back on the floor with his hands at his sides and feet together. Hands and arms, feet and legs, should maintain contact with the floor throughout this procedure.
- Homolateral (right side/left side),
- Cross Pattern (right arm, left leg)
Angels in the Snow
Two large diameter chalks are used which should be held in a proper chalk grip, rather that with a pencil grip. The patient stands in front of the chalkboard at its center at a distance equal to the length from his knuckles to his elbow. The patient leans forward until his nose touches the board, straightens up, and makes an X at the spot where his nose touched. This X is his fixation target.
- let the patient almost touch his nose on the board before placing the ‘X’ to make sure that fixation is at center
- Direction of circle is out.
- px may be a bit far from the ‘X’
- let the patient make plenty circles
- observe the size of the circles
Chalkboard Circles
BIOCULAR (Monocular Fixation in a Binocular Field) (2)
Biocular Phase
Cheiroscope
- one eye at a target, the other eye on another target
- The stage when both eyes are used at the same time while viewing objects at different points in space.
- The transition from the monocular phase to the binocular phase of therapy sometimes can be a very difficult period.
- we cant easily proceed to biocular phase. We must consider that monocular skills are nearly equal. If we proceed earlier, px may disregard this or px may experience diplopia. Thus VT takes time
- Too often a mistake is made by moving too quickly from the monocular to the binocular phase without first attempting to bridge the gap. Since the patient has likely never seen the same object at the same point in space before in his life, a sudden introduction of this phenomenon at this point will likely be rejected
Biocular Phase
Cheiroscope
* Level of Fusion - _______
simultaneous perception
VT TRAINING CHARTS (6)
Red - green charts/ filters
Red/Green Hart Chart
Red-Green Bar Reading
GTVT Anti-Suppression Charts
Sherman Red/Green Playing Cards
Tranaglyph
usually for anti-suppression
These charts provide superior cancellation with Red/Green glasses.
The Single-Color charts are fantastic for the ever important Monocular in a Binocular Field training, and the Multi-Color charts provide exceptional suppression monitoring during binocular vision training procedures
Red - green charts/ filters -
- Near and Far Chart Set provides letter and number matrix for testing and accommodative vision training.
- Red filters (cancels out) the green, sees red
- Green filters (cancels out) the red, sees green
- We will know if the patient is suppressing
Red/Green Hart Chart
- Vision therapy at home
- Example. px is a bookworm, then we can incorporate this while the patient is reading. The patient must see all letters.
- We place this at any reading material
- Purpose: Anti-suppression
- Target: any reading material or screen of interest
- Procedure: Place bar reader over any reading material or screen vertically while wearing polarized or R/G glasses. Keep all bars visible at all times. If any set of bars ever turn black, blink
Red-Green Bar Reading
These charts monitor suppression when used with Red/Green glasses. Can be used together for near-far jumps
Red filter - red background
Green Filter - clear at white background
Right suppression - can’t see under red background
Left eye suppression - White background cannot be seen
Headache is prone if the Px is over-worked.
Uniformity: Red - right Left - green
GTVT Anti-Suppression Charts
For Adults. The cards make fusion therapy for the amblyopes, strabismics and suppressors fun instead of exercise
PURPOSE: anti suppression
Sherman Red/Green Playing Cards
Fusional Reserve Training.
* Base out demand – convergence
* Base in demand – divergence
* Anti suppression training
* Improve smoothness and range of eye alignment ability when looking at objects.
* has many cards to be used
Tranaglyph
1st plate (Test for peripheral fusion): ask the patient if he can see the first small circle, If yes, there is peripheral fusion. There are other tests that we find suppression. However, it is not all the time that whole eye is suppressed sometimes it is only central suppression and there is peripheral fusion. So binocularilty still because there is peripheral fusion.
2nd plate: Peripheral Fusion and Stereopsis
If px can see four circles and if there is a circle that is floating
3rd plate: Test for: Central, Peripheral, Stereopsis
tranaglyph
Only for tranaglyph
- If Px doesn’t see green - Right eye Suppress
- If Px doesn’t see red - Left eye Suppress
- If right eye is closed - see red
- if we close left eye - see green
- Red Filter at Right eye - sees green, if not seen green, then right suppression
- Green Filter at Left eye - sees red, if not seen red, there is left suppression.
- inverted with WORTH4DOT.
-
Procedure: Place non-variable tranaglyph in light box groove or holder, put on r/g glasses, red lens over OD. Read vergence demand as indicated on side of each picture
Has Prism - 4 prism, 8 prism, 10 prisms
If you can’t converge, then there is possible suppression.
tranaglyph
