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9/22/2015
Advanced
Amblyopia
Treatment
September 2015
Jen Simonson, OD,
FCOVD
Boulder, Colorado
USA
Learning Objectives:
Learn about vision training for amblyopia to:
1. Decrease suppression
2. Improve fixation
3. Improve accuracy of accommodation
4. Develop depth perception
5. Improve acuity
All lecture slides and
links are available on
www.bouldervt.com
Potential
Benefits of a
Binocular
Approach:
Amblyopia
Is our best treatment
patching an eye?
New research is
validating that a
binocular model
of treatment is
superior to
occlusion
therapy.
Is our best treatment patching
an eye?
1. Improved treatment
compliance
2. More functional
improvement than
patching – especially in
the development of
stereopsis
3. Less regression
4. No harm to better seeing
eye (reverse amblyopia)
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Common
Causes of
Amblyopia:
The prevalence
of amblyopia is
approximately
3.5% of the
population.
1. Misalignment
of the eyes
(strabismus)
Mild
Is our best treatment
patching an eye?
Strabismus 13:93, 2005 S.E. Loudon, H.J. Simons,
The History of the Treatment of Amblyopia
◦ Assumed these conditions
interfered with the architecture of
the developing brain.
◦ Patients with amblyopia were
assumed to be anatomically
monocular and lacked the
capacity for functional
binocularity
20/40
(6/12) or better
Moderate
20/40-20/80
(6/12-6/24)
Severe
20/80-20/200
(6/24 – 6/60)
Is our best treatment
patching an eye?
2. A refractive
error
(anisometropia)
3. Form
deprivation
(ptosis/cataract)
SUPPRESSION: THE CAUSE OF
AMBLYOPIA
Robert F. Hess, PhD
Director of Vision Research, Department of Ophthalmology
McGill University, Canada
—
“Recent findings have provided strong evidence
that amblyopes actually have an intact binocular
infrastructure including binocular processes, even
in the adult amblyope. However, what appears to
have been lost is only a sign of suppression
under binocular viewing conditions. Current
evidence indicates that suppression plays a
primary role in both the binocular and
monocular deficits.”
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WHY is suppression Developed??
AMBLYOPIA TREATMENT STUDY -18 BACKGROUND
HTTP://PEDIG.JAEB.ORG/STUDIES.ASPX?RECID=235
Amblyopia affects more than acuity!
Double
Vision
Blurry
Vision
Visual
Confusion
Doble
Doble
La visión doble es muy dificil
cuando la impresión es
pequeña y poco espaciados.
Supresión arregla.
Confusión
Visual
Supresión hace que sea más
fácil de procesar la imagen
más clara.
Confusión visual es cuando
La visión doble es muy dificil
dos cosas diferentes
cuando la impresión es
aparencen en el mismo
pequeña y poco espaciados.
lugar.
Supresión arregla.
—
—
—
—
—
—
—
—
—
Contrast sensitivity
Binocular vision dysfunction
Poor stereopsis
Accommodation dysfunction
Fixation dysfunction
Vergence dysfunction
Poor visual information processing
Poor reading fluency
Reduced visual-motor integration
AMBLYOPIA TREATMENT STUDY
(ATS-18)
—
Binocular iPod treatment for
amblyopia
DICHOPTIC treatment
— Compare binocular game
play for 1 hour/day to
Occlusion for 2 hours/day.
— Ages 5-13 and 13-17.
—
MONOCULAR
http://mvr.mcgill.ca/Ro
bert/clinicaltrial/clinical
trial.html
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Monocular
Occlusion Types
Traditional treatment
v Use one eye at a time
v Goal: Equalize ocular skills
v
Ø
Ø
Ø
Ø
v Complete: “pirate”
patch, “Band-Aid”
patch, cover, hand
Fixation
Pursuit
Saccades
Focusing Abilities
Occlusion Types
v Translucent: light, but
no detail
Occlusion Types
v Blur: Bangerter
foils, tape, contact lens, nail
polish and atropine
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Occlusion Types
v Partial: bi-nasal
bi-temporal
or
(M) Activities
—
Fixationability of
the eye to
accurately
aim to one
point in
space.
Occlusion Types
v Liquid
Crystal
Glasses: Amblyz,
Eyetronix
(M) Activities
—
Saccades- the ability to swiftly and
smoothly jump accurately from one point
to the next.
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(M) Activities
—
Pursuits: the ability to smoothly and
accurately follow a moving object.
(M) Activities
—
Anti-suppression
(M) Activities
—
Accommodation - ability to focus clearly
and accurately.
(M) Activities
—
Detail recognition: Resolution
◦ After-image
◦ Line scrubbing
◦ Macula Integrity Tester
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(M) Activities
—
Detail recognition: Recognition
(M) Activities
—
Detail recognition:Vernier Acuity
http://www.nature.com/pr/journal/v60/n4/fig_tab/pr2006267f1.html
(M) Activities
—
Detail recognition: Crowding
(M) Activities
—
Prism Training
Monocular Prism Jumps –
• Awareness of eye
movements
• Localize direction and
amount of movement
• Smaller amounts of prism
are more difficult
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MONOCULAR
FIXATION IN A
BINOCULAR FIELD
Monocular Fixation in a Binocular
Field (MFBF)
v
One eye sees detail and the other eye
sees the background in the same space.
MONOCULAR FIXATION IN A
BINOCULAR FIELD
—
—
Anti-suppression
Detail recognition
1. Hide and Seek
(pom poms on black
felt)
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(MFBF) Activities
vHide
and Seek
Monocular Fixation in a Binocular
Field (MFBF)
Monocular Fixation in a Binocular
Field (MFBF)
v
Goal: accurate
perception of
details with one
eye and the
perception of
the background
with the other
eye.
2. iPad Activities:
1. Background – set to Black
2. Image – set to Red
3. Can change SIZE and
SPEED
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Both eyes see the iPad, but only the left eye can
follow the red bear:
(MFBF) Activities
3. Button Boards: Sanet Vision Integrator (SVI)Eye Hand, Rotations, Saccades with Red patch or
Red/Blue Glasses
With a white background, the eye covered
by the blue lens sees the target.
Use the blue lens on the amblyopic
eye
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(MFBF) Activities
Saccadic Fixator with red/green
glasses:
vSaccadic Fixator
The red light is
with R/G glasses
blocked by the
green filter.
— Use the red lens
on the amblyopic
eye.
—
(MFBF) Activities
v Acuvision with Red
and Green Glasses
(MFBF) Activities
4. Red- Ink Coloring
books/letter tracking
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Red letter charts
Red letter charts
(MFBF) Activities
(MFBF) Activities
5. Red/White/Black Cards:
Sherman Cards- separated
to use one color only
v Carl’s
vRotating Pegboard
with red numbers
Cardsseparated to
use one
color only
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(MFBF) Activities
(MFBF) Activities
—
Colored overlays
BIOCULAR (BIOC)
BIOCULAR
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Biocular (Bioc)
vThe
ability to see information from both
eyes, although the images are in different
spaces.
Biocular (Bioc)
vGoal: to
improve the ability of both eyes
to alternately shift focus in an un-fused
situation, which will facilitate antisuppression and prepare the patients for
simultaneous perception.
(Bioc) Activities
(Bioc) Activities
1. Vertical Prism dissociation with ball on
string
2. Squinchel
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(Bioc) Activities
3. Red/Red Rock
(Bioc) Activities
(Bioc) Activities
4. Red/Green
filters placed
side-by-side
(Bioc) Activities
vRed
v Anaglyphic
projection
Green filters placed
side-by-side on reading
material, crossword
puzzle, hidden pictures
etc.
vPolarized
or Red/Green
bar readers with the
appropriate glasses
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(Bioc) Activities
Split Vectograms
5. Spilt Vectograms
v Polaroid-
Mirror
Activity
ANTI-SUPPRESSION
ACTIVITIES
ANTI-SUPPRESSION
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ANTI-Suppression
Activities
ANTI-Suppression
Activities
—
ANTI-Suppression
Activities
Sherman Cardsentire deck
ANTI-Suppression
Activities
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ANTI-Suppression
Activities
ANTI-Suppression
Activities
ANTI-Suppression
Activities
BINOCULAR
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Binocular (B)
v The
ability of the brain to fuse information from both
eyes into one image.
v Degrees of Binocular:
• First Degree Fusion/ Simultaneous perception
• Second Degree/ Flat Fusion
• Third Degree/ Stereopsis
Binocular
Single, Clear
Binocular Vision
First Degree Activities
First Degree:
Simultaneous
Perception
—
—
Simultaneous awareness of dissimilar targets
In the SAME place (vs. biocular, which is NOT
fused into the same space)
vGoal: To see images from each eye in the
same space.
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First Degree Activities
Luster-The perception of information from
both eyes simultaneously; with Red/Green
glasses this is a shimmery color.
— Activities: White toys, Flashlight activities
—
Press Lites
First Degree Activities
1. Flashlight Activities: Press Lites
First Degree Activities
2. Cheiroscopic tracing
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9/22/2015
Cheiroscopic tracing - OPTO
First Degree Activities
3. Hole in Hand
First Degree Activities
—
Cook’s Rings
First Degree Activities
4. Red Light/Red Ring:
Red print circle on a paper
placed over a red filter with
a penlight behind both.
Patient wears Red/Green
glasses.
Can also use a red laser pointer and a red circle drawn on a white board.
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First Degree Activities
—
Mirror Superimposition: Bird in
Cage
First Degree Activities
—
Bird in Cage
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First Degree Activities
—
Second Degree/ Flat Fusion
Mixed Vectograms
vGoal: Use
both the eyes to combine
common borders and to align two images
received from each eye into a single
perception.
Second Degree Activities
1. Mirror superimposition
—
Mirror Superimposition
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2. Stereoscope cards
3. Fusion Cards
Morganstern’s Visicare cards- Pre-fusion
through Basic fusion
4. Computer activities:VTS3/4
Flat fusion 1 & 2
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Third Degree Fusion/ Stereopsis
—
The ability to perceive float and localize a
target using binocular depth perception
Stereopsis
—
THIRD DEGREE FUSION/
STEREOPSIS
Stereopsis
Integration of similar objects with some
disparity that causes stereopsis
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SILO= small-in and large-out
—
Accurate perception is of closer targets
becoming smaller and further targets
becoming larger
Third Degree Activities
v
In-instrument Techniques:
§
§
§
§
In-instrument
Stereoscope with Convergence/
Divergence Cards
Aperture Rule
Amblyoscope, Synoptophore
W-Cheiroscope
Third Degree
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Stereoscope for iPad
Third Degree Activities
vAnaglyphic
§
§
§
§
Vectograms
or Polarized Lens Techniques
Alphabet fusion book
Keystone Cards
Vectograms
Tranaglyphs
Projected vectograms
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Fixed Anaglyphs
Variable Anaglyphs
Third Degree Activities- Free
Space Fusion Techniques
—
—
—
—
—
—
—
—
—
3-Dot/Barrel card
Thumbs BI/BO
Lifesaver card
Mountain card
Star cards
Eccentric circles
String and Dowel
Yardstick and Pins
Brock String
Brock String
Prism flippers
— Prism Bar
— Magic Eye books
—
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Modified Brock String:
Convergence & Divergence
Third Degree ActivitiesComputer Fusion Techniques
Third Degree ActivitiesComputer Fusion Techniques
VTS3/4- Near and projected stereopsis
— Vision Builder- Random Dot Stereopsis,
Vergence, Jump Vergence
— HTS- Random Dot Stereopsis
—
—
Vision Tap
— OPTO
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Improving Patient Compliance
Improving
patient
compliance
Treatment Calendar
Provide a written
prescription
2. Present reading
material on the
diagnoses
3. Provide an office
policy sheet
regarding vision
training
1.
Improving Patient Compliance
4.
5.
6.
7.
Give written
instructions and
goals
Be available for
questions
Track progress with
logs and reports
Schedule follow-up
evaluations
Graph the patient’s
progress in
developing normal:
•
•
•
•
•
Acuity
Focusing skills
Tracking skills
Depth Perception
Vergence skills
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Sample Patching Prescription
Your doctor has prescribed patching for the treatment of amblyopia. Please follow
these instructions as directed. Remember to wear glasses or contact lenses
when patching, so a clear image is on your amblyopic eye.
Type(s) of Patch recommended:
□Adhesive bandage (Opticlude, Coverlet)
□Blur foil (Bangerter), clear contact paper or transparent “magic” tape
□Patch (Pirate-style or patchworks)
□Spectacle clip
□Frosted lens
□Opaque contact lens
□Over-plus optical lens (spectacle or contact lens)
□Atropine penalization
Your amblyopic eye is
the:
Patch this eye:
Hours per day:
Lazy Eye Tetris
—
https://www.youtube.com/watch?t=36&v=
Vp7hfacpBp0
Days per week:
Examples of activities to complete while patched:
References
—
Fortenbacker, OD, FCOVD “Advanced Amblyopia Treatment for Better Results” –
2015 COVD Annual Meeting.
—
S.E. Loudon, H.J. Simonsz , “The History of the Treatment of Amblyopia.” Strabismus,
13:93, 2005.
—
Amblyopia Treatment Study (ATS18) Study of Binocular Computer Activities for
Treatment of Amblyopia – http://pedig.jaeb.org/Studies.aspx?RecID=235
—
Bateman, R., Danner, R., Dowis, R., et al. (1985). Manual of Esotropia Therapy.
Colorado Vision Consultants: Colorado.
—
Press, L. Press lites – procedures for visual field awareness. Optom Vis Perf
2013;1(2):62-7. http://www.oepf.org/sites/default/files/OVP1-2_article_Press_web.pdf
—
COVD. (2009, July). COVD fact sheets. Retrieved from www.covd.org
—
Headline, T. C., Wahlmeler, I., & Bedes, V. (2005). The Vision Therapist's Toolkit. San Jose:
California.
—
Press, L. J. (1997). Applied Concepts in Vision Therapy. Mosby: 978-0815167297.
—
Birch, Eileen E. “Amblyopia and Binocular Vision”. Prog Retin Eye Res. 2013 March; 33:
67-84. Doi:10.1016/j.preteyeres.2012.11.001
—
Simonson, J. Optometric Management, Volume: 48, Issue: December 2013, page(s): 26 –
33.
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