This is the handout for my 2012 AOA presentation on Binocular Vision and Optometric Vision Therapy for the primary eye care doctor.

1. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor, Pediatrics/Binocular Vision
To BV or Not to BV: Illinois Eye Institute
Illinois College of Optometry
That is No Longer the Chicago, Il
Question,
Q i Lyons Family Eye Care
Chicago, Il
But Rather the Answer!
To BV or Not to BV: That is No Longer the Question,
But Rather the Answer!
• ..Whether 'tis nobler in the mind to suffer the slings and
arrows of outrageous economics, or to take arms against a
sea of troubles with binocular vision and optometric vision
therapy. To grunt and sweat under a weary life, But that
the dread of something unknown....the undiscovered
country of BV and VT whose bourn all travelers prosper,
doth not puzzle the will and makes us rather bear those
joys we have...than those ills of 3rd party payers that we
know not of? (With apologies to The Bard). This course
reviews the diagnostic and evidence-based therapeutic
procedures the primary care optometrist can use to
improve patient care while supporting the fiscal stability of
their practice.
Executive Summary Executive Summary
• Binocular vision in the news • Amblyopia can be treated at any age
• 3D Vision Syndrome in the news
y • Learning related vision p
g problems
• High incidence of BV problems optometric intervention supported by
• Evidence based medicine/research research
supports optometric vision therapy • Attention and binocular vision
problems related

2. Executive Summary Executive Summary
• Our patients are in pain • The myths of OVT wrong
• Proven examination techniques • Expand your patient base
available • Be unique
• Proven intervention/therapy • Offer more
available
BV Dx & Tx in the News!! BV Dx & Tx in the News!!
BV Dx & Tx in the News!! BV Dx & Tx in the News!!
10/97

3. Non-strabismic BV disorders Non-strabismic BV disorders
Prevalence/Incidence
• Convergence Insufficiency: 1.3% to 37% of
• Convergence Insufficiency: 1.3% to 37% of the population; most report 3-5%
the population; most report 3-5%
• Convergence Excess: ~6% • 309,000,000 people in USA (2010 Census)
• Accommodative disorders: 3-5% at 5% = 15 million +
Non-strabismic BV disorders Non-strabismic BV disorders
• Convergence Excess: ~6%
6% • Accommodative disorders: 3-5%
3 5%
• 18 million + • 15 million +
Subjective Complaints of
Non-strabismic BV disorders
Patients with BV Disorders
• If any other disease had this • Blur
• Headache
prevalence, it would be
l i ld b
• Aesthenopia
considered an epidemic…if • Diplopia
not a pandemic! • These complaints are usually
associated with near work

4. Subjective Complaints of Subjective Complaints of
Patients with BV Disorders Patients with BV Disorders
• Blur
• Blur
• Headache • Headache
H d h
• Aesthenopia • Aesthenopia
• Diplopia • Diplopia
• These complaints are usually • These complaints are usually
associated with near work associated with near work
Subjective Complaints of Visual Efficiency Examination:
Patients with BV Disorders Basic Tests
• Blur
• History
• Headache
H d h
• Aesthenopia
• Visual Acuity
i lA i
• Diplopia
• These complaints are usually
associated with near work
20/97
Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
• Oculomotor
– Cover Test, Hirschberg,
• R f ti E l ti
Refractive Evaluation
– Kappa, Krimsky, Bruckner
(Objective/Subjective)
– EOMs
– NPC (with red lens)
20/97 20/97

5. Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
• Heterophoria • Accommodative Tests
• Vergences –Minimum amplitude =
Minimum
–Sheard’s criteria 15 - (0.25) age
• Need twice your phoria in reserve
(10 pd exophore at near needs
• So a 20 year old should have at
20 pd BO reserves) least 10 diopters of
accommodation
Visual Efficiency Examination: Visual Efficiency Examination:
Basic Tests Basic Tests
–NRA/PRA, –Push Up/Pull Away
Minus Lens Amplitudes,
A lit d MEM
Amplitudes –Facility
Basic tests Basic tests
• Stereopsis
• Worth 4 Dot
• Random Dot,,
• Fi ti Disparity Testing
Fixation Di it T ti
• Stereo Fly – Wesson Card,
• Less than
– Bernell Fixation
70 seconds of arc
Disparity (Associated Phoria),
Disparometer

6. Common BV Syndromes Convergence Insufficiency
• Convergence Insufficiency • Signs:
– Most common syndrome – An exodeviation at near
– Symptoms: aesthenopia, • C even be an i
Can b intermittent exotropia at near
i i
headaches, blur, diplopia, loss of – Receded NPC value
concentration • NPC larger than 10 cm
• associated with near work – Reduced BO vergences at near
• often occur near the end of the day • Often fail to meet Sheard’s criterion
Convergence Excess Convergence Excess
• Signs
• Symptoms: Diplopia, headaches,
aesthenopia – Dynamic Retinoscopy
– almost always near related • May be the most significant test
• Signs: • Typically a high lag of accommodation
– Esophoria at near • Lag may be +1.00 to +2.00 DS at 40
• Use detailed accommodative target or you may miss cm
the esophoria
– Vergences
• Lags greater than +2.50 D at 40 cm
• BI vergences at near may not compensate
should suggest uncorrected hyperopia
Fusional Vergence Dysfunction Accommodative Disorders
• Symptoms: aesthenopia, headaches, • Symptoms: blur,
blurred vision (Binocular Vision/Visual headache,
Discomfort Dx) aesthenopia,
aesthenopia fatigue
when reading,
– Associated with reading or near work
difficulty changing
• Signs: focus from one
– Phorias: Normal at distance and near distance to another
– Reduced BI and BO vergences at
distance and/or near

7. Accommodative Disorders Other BV Disorders
• Signs
– Accommodative Insufficiency: • Divergence Excess
• Reduced amplitude of accommodation
p – Prevalence of ~0.5 to 4%
• Minimum Accommodation: – Exophoria greater at distance than
15 - (0.25) (age) near
– Accommodative Infacility – Frequently first discovered in grade
• Failure of monocular facility testing school
• Expected value: 11 cpm
30/97
Other BV Disorders Strabismus & Amblyopia
• Divergence Insufficiency 3-5% of the population
– Very rare!
– Esophoria greater at distance than near Tx
T appropriate at all ages
i ll
– Be careful to rule out lateral rectus May do out of office VT
palsy!
and achieve success!
30/97
Amblyopia Amblyopia
Legal Consultant
Pathological until Amblyogenic
p
proven otherwise Factors Amblyopia
Infants/Toddlers Anisometropia Malpractice case was not because of missing
Young Children Bilateral Refractive Error an eye disease…But rather due to alleged
inappropriate management/treatment
Busy Adults Strabismus (Constant)

8. Treatment for BV Disorders Treatment for BV Disorders
Evidence Based Medicine Evidence Based Medicine
Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in Scheimann M et al. Randomised clinical trial of the effectiveness of base-
non-strabismic
non strabismic accommodative and vergence disorders. Optometry.
disorders Optometry in i
i prism reading glasses versus placebo reading glasses for
di l l b di l f
2002;73(12):735-62 symptomatic convergence insufficiency in children. Br J Ophthal
2005;89(10):1318-23.
Base-in prism reading glasses were found to be no more effective in
Scheimann M et al. A randomized clinical trial of vision therapy/orthoptics versus
pencil pushups for the treatment of convergence insufficiency in young adults. alleviating symptoms, improving the near point of convergence, or
Optom Vis Sci. 2005 Jul;82(7):583-95. improving positive fusional vergence at near than placebo reading
…vision therapy/orthoptics was the only treatment that produced clinically glasses for the treatment of children aged 9 to <18 years with
significant improvements in the near point of convergence and positive symptomatic CI.
fusional vergence.
Treatment for BV Disorders Treatment for BV Disorders
Evidence Based Medicine Evidence Based Medicine
Solan H et al. M-cell deficit and reading disability: a preliminary study of the Solan H et al. Is there a common linkage among reading comprehension, visual
effects of temporal vision processing therapy. Optometry. 2004 Oct;75(10):640-
vision-processing Oct;75(10):640 attention, and magnocellular processing? J Learn Disabil. 2007 May-
50. Jun;40(3):270-8.
Solan H et al. Role of visual attention in cognitive control of oculomotor readiness in
This research supports the value of rendering temporal vision therapy to children students with reading disabilities. Learn Disabil. 2001 Mar-Apr;34(2):107-18.
identified as moderately reading disabled (RD). The diagnostic procedures and
the dynamic therapeutic techniques discussed in this article have not been
previously used for the specific purpose of ameliorating an M-cell deficit. Eye movement therapy improved eye movements
Improved temporal visual-processing skills and enhanced visual motion
discrimination appear to have a salutary effect on magnocellular processing and and also resulted in significant gains in reading
reading comprehension in RD children with M-cell deficits. comprehension.
Treatment for BV Disorders Treatment for BV Disorders
Evidence Based Medicine Evidence Based Medicine
Scheimann M et al. Randomized trial of treatment of amblyopia in children
Cotter S et al Treatment of strabismic amblyopia with
al. aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47.
g y p p ( )
refractive correction. Am J Ophthalmol. 2007 Amblyopia improves with optical correction alone in about one fourth of
Jun;143(6):1060-3. patients aged 7 to 17 years, although most patients who are initially treated
with optical correction alone will require additional treatment for amblyopia.
For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching
These results support the suggestion from a prior study that with near visual activities and atropine can improve visual acuity even if the
strabismic amblyopia can improve and even resolve with amblyopia has been previously treated. For patients 13 to 17 years,
spectacle correction alone. prescribing patching 2 to 6 hours per day with near visual activities may
improve visual acuity when amblyopia has not been previously treated

9. Adult Amblyopia
Levi DM. Prentice award lecture 2011: removing the
DM. Treatment for BV Disorders
brakes on plasticity in the amblyopic brain.
Optom Vis Sci. 2012 Jun;89(6):827-38.
Jun;89(6):827- • Treatment modalities
Video-
Video-game play induces plasticity in the visual system of – Lenses
adults with amblyopia.
amblyopia. – Prisms
Li RW, Ngo C, Nguyen J, Levi DM.
PLoS Biol. 2011 Aug;9(8):e1001135. Epub 2011 Aug 30.
– Vision therapy
• Traditional therapy
Prolonged perceptual learning of positional acuity in adult • Computer therapy
amblyopia:
amblyopia: perceptual template retuning dynamics.
Li RW, Klein SA, Levi DM.
J Neurosci. 2008 Dec 24;28(52):14223-9.
Neurosci. 24;28(52):14223-
40/97
Lenses as Treatment
Best Rx (clarity, comfort, function)
Lenses as Treatment
Refractive Error Amblyopia Binocularity Interference Rx if….
Concern Concerns with
Learning
• Best Rx (clarity, comfort,
Myopia >5.00D Under correct Depends >5.00D (any age) function)
eso/Fully o child’s
on c d s >3.00D @>1yr
correct exo • Accommodative disorders
age
– Can prescribe reading only Rx or an
Hyperopia >2.00D Under correct >2.50D >2.00D
exo/Fully add
correct eso • Exodeviations
Astigmatism >1.25D Depends >1.25D – Overminusing (DE)
on VA
– Not usually a first choice! Give add
Anisometropia >1.00D Monitor >1.00D >1.00D
BV/Stereo
Bifocals for Kids Bifocals for Kids
Bifocal Seg Height Bifocal Seg Height
3-5 Years
Infants/Toddlers Bottom 1/3 of Pupil
Pre-schoolers
Bi-sect pupil

10. Bifocals for Kids Bifocals for Myopia Progression
Bifocal Seg Height Gwiazda JE, Hyman L, Norton TT, Hussein ME,
Marsh-Tootle W, Manny R, Wang Y, Everett D;
COMET Grouup.
> 5yrs Accommodation and related risk factors associated
with myopia progression and their interaction with
Bottom of Pupil treatment in COMET children.
Invest Ophthalmol Vis Sci. 2004 Jul;45(7):2143-
51.
Bifocals for Myopia Progression Polycarbonate/Trivex Lenses
PALs were effective in slowing progression in these
children, with statistically significant 3-year
treatment effects The results support the COMET
effects.
rationale (i.e., a role for retinal defocus in myopia
progression). In clinical practice in the United States
children with large lags of accommodation and near
esophoria often are prescribed PALs or bifocals to
improve visual performance. Results of this study
suggest that such children, if myopic, may have an
additional benefit of slowed progression of myopia.
Optometric Vision Therapy
Prism as Treatment as Treatment
• Can be used with CI, CE, DI, DE, Vertical • The approach of choice for CI, Fusional
Deviations Vergence Dysfunctions, accommodative
• Prescribe the least amount of prism needed disorders,
disorders and Amblyopia
– Determine the associated phoria with a Wesson – High chance of success with these disorders
Card or Bernell Box – Results are typically long lasting
• Fresnel Prism trial, then Rx – Often can treat these disorders using primarily
home VT with in-office check-ups
50/97

11. Vision Therapy for Amblyopia
Vision Therapy as Treatment
• Traditional therapy • Prescribe Rx
– Hand-eye, Vergence and Accommodative • Implement occlusion therapy
procedures
• Active optometric vision therapy
• Computer Therapy
– Can attack hand-eye, vergence, accommodative • Monitor
and oculomotor problems (Vision information
processing anomalies?) • Change Rx/Tx as needed
Period of Sensitivity Atropine
vs Repka MX, Cotter SA, Beck RW, Kraker RT,
Birch EE, Everett DF, Hertle RW, Holmes
Period of Plasticity JM, Quinn GE, Sala NA, Scheiman MM,
Stager DR Sr, Wallace DK; A randomized
trial of atropine regimens for treatment of
moderate amblyopia in children.
Ophthalmology. 2004 Nov;111(11):2076-
85.
Atropine Atropine
Pediatric Eye Disease Investigator Group. The
course of moderate amblyopia treated with
CONCLUSIONS: Weekend atropine atropine in children: experience of the
provides an i
id improvement in VA of a
ti f
magnitude similar to that of the amblyopia treatment study.
improvement provided by daily Am J Ophthalmol. 2003 Oct;136(4):630-9.
atropine in treating moderate
amblyopia in children 3 to 7 years old.

12. Atropine
Occlusion Therapy
Age (yrs) Per Day Schedule Minimum Exam
Frequency
A beneficial effect of atropine is present 1 4 60min periods 1 day on/1 day off Weekly
throughout the age range of 3 years old to
g g g y 2 3 30min periods 2 day on/1 day off Every 2 wks
younger than 7 years old, and with an
acuity range of 20/40 to 20/100. A shift in near 3 3 30min periods 3 day on/1 day off Every 3 wks
fixation to the amblyopic eye is not essential for atropine to be effective
in all cases. Sound eye acuity should be monitored when a plano 4 2 60min periods 4 day on/1 day off Every 4 wks
spectacle lens is prescribed for the sound eye to augment the treatment
effect of atropine. 2 60min periods 5 day on/1 day off
5 Every 5 wks
6 2 60min periods 6 day on/1 day off Every 6 wks
Amblyopia Therapy Active Vision Therapy
What do we know about amblyopia? Hand-eye
– More than decreased VA Oculomotor
– Visual-Spatial affects
Accommodation
– Accommodation
– Hand-eye
– Stereopsis Have child “Do Stuff”
Interact with environment
60/97
Vision Therapy as Treatment
Phases of Therapy
Roberts CJ, Adams GG. Contact lenses in the management of high anisometropic
amblyopia. EYE. 2004;18(1):109-10 • Monocular (HE, OM, ACC)
High anisometropic amblyopia is
CONCLUSIONS:
• Biocular (HE, OM, ACC, Anti-suppression)
challenging to treat. In our study contact • Binocular (Vergence, Acc)
lenses improved visual acuity in myopic
anisometropia of up to 9 dioptres. • Integration/Stabilization
Do it all at the same time!

13. Vision Therapy as Treatment Vision Therapy as Treatment
Phases of Therapy Phases of Therapy
• Monocular (HE, OM, ACC) • Monocular (HE, OM, ACC)
• Biocular (HE, OM, ACC, Anti-suppression) • Biocular (HE, OM, ACC, Anti-suppression)
• Binocular (Vergence, Acc) • Binocular (Vergence, Acc)
• Integration/Stabilization • Integration/Stabilization
Do it all at the same time! Do it all at the same time!
Vision Therapy as Treatment Vision Therapy as Treatment
Phases of Therapy Phases of Therapy
• Monocular (HE, OM, ACC) • Monocular (HE, OM, ACC)
• Biocular (HE, OM, ACC, Anti-suppression) • Biocular (HE, OM, ACC, Anti-suppression)
• Binocular (Vergence, Acc) • Binocular (Vergence, Acc)
• Integration/Stabilization • Integration/Stabilization
Do it all at the same time! Do it all at the same time!
Traditional Therapy Procedures Traditional Therapy Procedures
• Hand-Eye Procedures • Vergence procedures
– mazes – Brock String
– dot to dot – Lifesaver card
– cutting – Anaglyph Series (BC920, others)
– coloring • Accommodative Procedures
– filling in O’s – Minus lens dips
– Flippers
– Hart Chart

14. Vergence Procedures Vergence Procedures
Brock String Life Saver Cards
Simple BO and BI
d
Inexpensive Good fusion
Easy Anti-suppression
Effective Inexpensive
Effective
70/97
Vergence Procedures Vergence Procedures
Fusion Cards Aperture Rule
Random dot
targets “Flying W”
BC 920, BC 50
Anaglyph series Stereoscopes
Accommodative Procedures Accommodative Procedures
Rock Card Hart Chart
Flippers the old
standby
Anti-suppression

15. Computer Vision Therapy
Computer Vision Therapy
• Can attack vergence, accommodative, and
oculomotor problems
• Patient can use at home, work,
• Most programs are set up to record patient’s wherever they have access to
performance each session computer
– Removes the problem of compliance!
• Trains eye movements,
• Different products on the market vergences, accommodation,
– Home Therapy System and perceptual skills
– Computer Aided Vision Therapy
– Psychological Software Services
Why use Computer Aided VT? How do you incorporate
Computer Aided Vision
• “I’d like to do VT in my practice, but...” Therapy in your practice ?
• Patients who cannot afford office VT
• P ti t who cannot make a time
Patients h t k ti • Diagnose the patient!!!
commitment for office VT • Assign a therapy protocol
• Patient compliance problems • Computer aided VT in the office
• Insurance or Third Party Problems • Schedule follow-up appointments
• Evaluate the patient’s progress/Follow-up
Computer Aided VT Resources Computer Aided VT Resources
Neuroscience Center of Indianapolis Computer Orthoptics
http://www.neuroscience.cnter.com/ HTS (Home Therapy System)
http://www.homevisiontherapy.com/
80/97

16. Computer Aided VT Resources Brainware Safari
Computerized Aided
Vision Therapy
Gary Vogel, OD, FAAO
Available from Bernell
800-348-2225
http://www.brainwareforyou.com/
http://www.bernell.com/
Brainware Safari Conclusions
• Easy way to incorporate VT for BV
Helms D, Sawtelle SM. A study of the effectiveness of disorders into your practice
cognitive therapy delivered in a video game format. Optom
; ( )
Vis Dev 2007;38(1):19-26. • Monitor the output to check for compliance
Students in the study group showed an average of 4 years and 3 and tricks!
months improvement on tests of cognitive skills, compared to
4 months improvement for the control group and showed an • Remember that the key is in diagnosing
average of 1 year and 11 months improvement on tests of patients and follow-up
achievement compared to 1 month for the control group.
http://www.brainwareforyou.com/
VT Equipment WWW Sites for BV/VT
Use the tools Gemstonevision.
discussed Org
You do not need a
whole room of
VT “stuff”
85/97

17. BV Organizations BV Organizations
COVD http://www.covd.org/ PAVE/Parents Active
OEP http://www.oep.org/ for Vision Education
http://www.pave-eye.com/
htt // /
949-250-8070
Neuro-Optometric
Rehabilitation Association
AAO BV Section http://www.noravc.com/
http://www.aaopt.org/secti
ons/bvppo/aaobvp.html 301-984-1441
Patient WWW Sites Patient WWW Sites
3 D Pictures
• http://www.chil
http://www.vision3d.com/optical/ dren-special-
index.shtml#stereogram
i d ht l# t needs.org/visio
d / ii
n_therapy/what
How Does Binocular Vision Work? _is_vision_ther
apy.html
http://www.vision3d.com/stereo.html
90/97
Position Statement on VT
Practice Management
AOA, AAO, COVD many others:
Position Statement on Myths
Optometric Vision Therapy
“The American Optometric Association VT i Too Expensive!
is T E i !
affirms its long standing position that You Can’t Make Money Doing VT!
optometric vision therapy is effective in the
treatment of physiological, neuromuscular and
perceptual dysfunctions of the vision
system……..” Which is it? Can’t have it both ways!

18. Practice Management Practice Management
First All BV Disorders are a
Comprehensive Examination
Then
Th
Medical Condition
ed ca Co d t o
Visual Efficiency
CI, CE, DI, DE, Pursuit/Saccade Dysfunction
Strab/Amblyopia
Follow-up
Practice Management Practice Management
Accommodative disorders Visual Discomfort
te d
tend to be refractive
e act ve
Accommodative insufficiency, excess, infacility,
is
i a medical diagnosis
i i i
instability, etc
95/97
All Ages Can Benefit….
More Patients
Better Patient Care
Evidenced Based
Do it!

19. Questions? Contact:
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor, Pediatric/Binocular Vision Service
Illinois Eye Institute/Illinois College of Optometry
3241 S. Michigan Ave.
S Ave Chicago, Il. 60610
Chicago Il
312-949-7280 voice 312-949-7668 fax
Private Practice 773-935-2020
MainosMemos.com
dmaino@ico.edu
www.LyonsFamilyEyeCare.com
www.ico.edu