RESEARCH POSTER PRESENTATION DESIGN © 2015

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BACKGROUND

Assessment:

1. Bilateral Strabismic Amblyopia

2. Constant Alternating Esotropia

3. Suppression of Binocular Vision (dense)

4. Stereopsis Defective with Fusion

5. Saccadic Dysfunction

6. Nystagmus

7. Pseudophakia OU

8. RE: Mild Hyperopia OU, Mild Astigmatism OU

Plan:

1. Begin 32 session vision therapy program

2. Vision therapy program to emphasize fixation, saccadic accuracy and speed,

pursuits, reaction time, span of recognition, dynamic acuity, binocular pairing,

scanning, central-peripheral integration to build driving and reading skills.

3. Prescribed Bioptics to be used for driving.

4. Recommended Adaptive Driving Program

DIAGNOSES

REFERENCES

1. Maino, Dominick. (2009). Neuroplasticity: Teaching an Old Brain New Tricks. Review of Optometry, Web. 07 Feb.

2017.

2. Astle, A. T., Webb, B. S., & McGraw, P. V. (2011). Can perceptual learning be used to treat amblyopia beyond the

critical period of visual development? Ophthalmic & Physiological Optics : The Journal of the British College of

Ophthalmic Opticians (Optometrists), 31(6), 564–573. http://doi.org/10.1111/j.1475-1313.2011.00873.x

3. Astle, A. T., Webb, B. S., & McGraw, P. V. (2011). The Pattern of Learned Visual Improvements in Adult Amblyopia.

Investigative Ophthalmology & Visual Science, 52(10), 7195–7204. http://doi.org/10.1167/iovs.11-7584

4. Levi, D. M., & Li, R. W. (2009). Perceptual Learning as a potential treatment for amblyopia: a mini-review. Vision

Research, 49(21), 2535–2549. http://doi.org/10.1016/j.visres.2009.02.010

5. Li, R. W., Klein, S. A., & Levi, D. M. (2008). Prolonged Perceptual Learning of Positional Acuity in Adult Amblyopia:

Perceptual Template Retuning Dynamics. The Journal of Neuroscience : The Official Journal of the Society for

Neuroscience, 28(52), 14223–14229. http://doi.org/10.1523/JNEUROSCI.4271-08.2008

6. Wolpaw, J. R. (2012). Harnessing Neuroplasticity for Clinical Applications." Brain 135.4. pag. Web.

7. http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y

8. Marottoli, R. A., de Leon, C. F. M., Glass, T. A., Williams, C. S., Cooney, L. M., Berkman, L. F. and Tinetti, M. E.

(1997), Driving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New Haven EPESE.

Journal of the American Geriatrics Society, 45: 202–206. doi:10.1111/j.1532-5415.1997.tb04508.x

9. Kamino, Lisa. (2016). Bioptic Telescope Driving and Low Vision Rehabilitation: A Review. Optometry & Visual

Performance 4.2: 57-61. Print.

10. Gary S. Rubin, Edmond S. W. Ng, Karen Bandeen-Roche, Penelope M. Keyl, Ellen E. Freeman, Sheila K. West, the

SEE Project Team. (2007). A Prospective, Population-Based Study of the Role of Visual Impairment in Motor Vehicle

Crashes among Older Drivers: The SEE Study. Invest. Ophthalmol. Vis. Sci. 2007;48(4):1483-1491. doi:

10.1167/iovs.06-0474.

11. http://www.stdavidsrehab.com/programs-services/outpatient-rehabilitation-services/driving-program.aspx

12. https://www.ocutech.com/product/ocutech-sightscope-flip/

13. Singh, Neeraj K., Ritika James, Avdhesh Yadav, and Divya Jyoti. (2016). Vision and Driving Difficulties with Nystagmus: Finding New Pathways. Optometry & Visual Performance 4.4: 146-51. Print.

VISION THERAPY PROGRAM

Program Length: 32 weekly in-office sessions

• 55-year-old Caucasian Female

• Main concern: “Improve vision and day to day living, improve acuity. I'd like to

drive again.” Wore bifocals from her 30's. Left eye turned in more after surgeries

(DSEK in 2014)

• Ocular History

– Last Eye Exam: 10/3/2015 with Primary OD

– Currently wears Scleral contact lenses

– Fuch's Dystrophy, Nystagmus, cataracts, h/o DSEK and RK

– Signs and Symptoms: eye turn, lazy eye, halos around lights,

clumsy/bump into things, floaters, reduced night vision, bothered by

glare

• Occupation: Psychotherapist, Priest

• Lifestyle: fitness training, gym, yoga, running/jogging, walking, cooking, knitting,

birding

• Medical History:

– Daily Medications: Wellbutrin XL, Armour Thyroid, Prednisolone

– Allergies: seasonal allergies,

– Last Medical Exam: September 2015

– Systemic review: Thyroid dysfunction

– Family history: Hypertension, heart disease, cancer, learning problems

The Optometry Center for Vision Therapy; San Antonio and Austin, Texas

UIW Rosenberg School of Optometry; San Antonio, Texas

Alisa Nola, OD; Briana Larson, OD, FCOVD, FAAO, FNORA; Annie Ramirez, COVT

Gaining Independence Through Vision Therapy, Bioptics, and an Adaptive Driving Program

Pertinent Exam Findings

RESULTS

DISCUSSION

-The prescribed vision therapy program included transferring

visual skills to driving: scanning, central-peripheral integration,

figure ground, reaction speed, processing speed, discrimination,

and in-office training with bioptics.

-Bioptic telescopes and an adaptive driving program should be

considered for a patient with moderate low vision and motivation

to improve driving skills.

-There is substantial evidence that residual plasticity is present in

the adult brain, allowing for the treatment of visual dysfunctions

past the critical period.

-Neuroplasticity is often experience dependent, time-sensitive and

strongly influenced by the environment. Attention and motivation

are also critical factors for plasticity 6 .

-Perceptual learning techniques have been proven to demonstrate

enduring effects on the visual system and transfer to new visual

skills 2-5.

-Visual discomfort, glare, driving difficulties, and reduction in near

tasks have been reported to decrease quality of life in those with

nystagmus. Yoked prisms, vision therapy, and occupational therapy

training were effective in relieving visual discomfort. With further

training and potential vision, a person with nystagmus can improve

driving skills 13.

HISTORY

Initial Exam Progress Evaluation

(at 6 months)

VA's cc Habitual

DVA 20/80- OD; 20/80 OS NVA 20/200 OD; 20/80 OS

DVA: 20/70+ OD, 20/60- OSNVA: 20/70 OD, 20/60 OS

Lensometry PALs

+5.00-2.25x077 OD+3.75-1.50x179 OSAdd +2.25

Cover Test D: CRET 45pdN: CAET 40pd

D: CRET ~35pd N: CRET 45pd

Pursuits +nystagmus horizontal beat, more in left gaze

Same

Saccades Gross overshoots to the right 100% Accurate

Stereopsis (-) Random Dot Stereopsis, 70" Wirt Circles

(-) Random Dot Stereopsis, 140" Wirt Circles

NPC Break 1", Recovery 3", OS out x3, (+) diplopia

Break 2-3", (-) diplopia, able to diverge eyes together

Worth 4 Dot D: constant OD suppression I: constant OD suppressionN: at 4" intermittent 4 to OD suppression; and at 2" reported fusion (no movement with cover UCT).

D: constant OD suppression I: constant OD suppressionN: alternated suppression; intermittent fusion at 12" with 25BO

Developmental Eye Movement

Test

Speed: 25%Accuracy: >55% (graded on 13-year-old scale)

Speed: 45%Accuracy: >55% (graded on 13-year-old scale)

Patient Comments

• Can see more in the periphery in the shower now.

• She is more centered when parking her car.

• Graduated adapted driving course with bioptics.

Final Progress Evaluation Summary (30/32 weeks):

VA cc: DVA: 20/50 OD; 20/40 OS

NVA: 20/60 OD; 20/40 OS

Cover Test: Distance: 35pd CRET

Near: 25pd CRET

Saccades: Accurate

NPC: TTN x3, (-) diplopia

Worth Four Dot:

• Distance: Constant alternating suppression

• Intermediate: Constant alternating suppression

• Near: fusion at 3 feet; uncrossed diplopia closer than 3 feet

Developmental Eye Movement Test: 35% Speed, 33% accuracy

Subjective improvements: Driving with bioptic and loves it. Better at

parking her car. She now reads for pleasure without fighting to see

clearly. Can paint toe nails now (never been able to do).

Plan: Recommended an extension of program to continue developing

visual skills.

Bioptics

The SightScope Flip (Ocutech), Galilean telescope, is available in 1.7x and

2.2x powers, and is helpful for those with mild vision loss (20/100).

Bioptic Fitting and Follow Up

VA cc and 2.2x SightScope:

DVA: 20/50 OD

20/30 OS

Recent studies have confirmed that residual plasticity is present in the adult visual

brain with amblyopia 1-5. Neuroplasticity has been broadly defined as the ability of

the central nervous system to reorganize its structure, function, and connections in

response to external or internal stimuli 6. Historically, amblyopia was believed to be

untreatable past the critical period of visual development (7-9 years of age) 1.

Through stimulation of the afferent pathways of the visual system utilizing vision

therapy, or perceptual learning as referred to in some studies, visual skills can be

improved in an adult. Substantial plasticity in adults has been found with prolonged

visual perceptual learning 5. Importantly, the effects are long-lasting and can be

transferred to new visual tasks 2-5. Vision therapy was used to improve the function

and quality of life in an adult patient with long-standing amblyopia, strabismus,

nystagmus, and binocular vision disorders. This case involved using occlusion

therapy, vision therapy, bioptic telescopes, and an adaptive driving program to

improve visual function and transfer skills to driving.

Moderate low vision is classified as having best corrected vision between 20/70 to

20/160 7. Bioptic telescopes were prescribed in this case to meet the patient’s goal for

driving. Driving is often a goal for those with low vision. For many individuals,

driving is associated with a sense of independence, personal identity, and life

satisfaction 8. A bioptic telescope system, telescope mounted on the superior portion

of the spectacle lenses, has been found to be useful by those who have low vision

(see Figure 1). During the majority of the driving time, patients view through the

carrier lenses and for brief moments (approximately 2 seconds, or 5% of the time)

view through the telescope to view street signs, traffic lights, and other distant

objects 9. Generally, bioptic telescopes provide 2x and 4x magnification and a field of

view between 6 and 16 degrees 9. Although visual acuity is the only visual factor that

is required in all states for a driver's license, it has been shown to have a weak

association with motor vehicle collision rates 9,10. Bioptic driving safety includes

being adequately trained on using the telescope, as well as with other visual

functions. Good candidates for bioptic driving includes congenital, stable visual

impairments, with full peripheral visual fields 9.

After an appropriate bioptic telescope has been determined (dependent on state

bioptic telescope laws and patient characteristics), the patient must receive training to

be proficient with using the bioptic while driving. Occupational therapists, vision

rehabilitation specialists, and certified low vision therapists usually provide this

specialized training. The adaptive driving program determines driving ability by

assessing different areas in vision, cognitive processing, physical ability, and driving

assessment (see Figure 2) 11. The driving assessment generally begins in a stationary

environment (parking lot), then in the car, next in slower or suburban areas, and

finally in highways and/or faster paced environments. Once an individual has proven

to be proficient in driving with the telescope, they are evaluated by the state licensing

agency to determine if a license will be issued.

https://www.ocutech.com/product/ocutech-sightscope-flip/Figure 1: Bioptic telescope

Vision Assessment

• Spatial

• Depth

• Peripheral vision

• Visual Acuity

• Glare

• Visual attention

• Scanning

Cognitive Processing

• Reaction speed

• Memory

• Divided Attention

Physical Ability

Driving Assessment

• Start in parking lot

• Familiarize with vehicle

• Assessment in slower/suburban areas, then highways/city

Figure 2: Adaptive driving program

Specific Skills Therapy

Oculomotor

Fixation, Saccades,

Pursuits

• Hart Chart with Rotator

Board for Dynamic Acuity

• SVI Eye-Hand Proactive and

Reactive

• CPT Scan with Processing

Speed

• Track and Read: Words with

Cognitive and Timed Loading

• Distance Hart Chart with

Bioptics

Central-Peripheral

Integration

• SVI Rotator with Central

Fixation

• MacDonald Card with

Dynamic Acuity

• Track and Read: Span of

Recognition with Central

Fixation

Binocular

Vision

Anti-Suppression

Phase 1: MBF

• Red Transparency with

Red/Green Glasses

• MBF CPT Search with Timed

Component

• MBF Number Saccades with

Metronome Beat

• MBF SVI Letter Chart Motion

Phase 2: Bi-Ocular

• Red/Green Bar Reader over Hart

Chart

• Red/Blue SVI Saccades 1

• Polarized Glasses and Mirror

• Rotating Red/Green Chart

Functional Pairing

• Penlight Fusion with

Red/Green Glasses

• Bead and String Stationary

with Red/Green Glasses

• Gross Divergence Targets

Visual

Processing

Discrimination

• VIPS: Discrimination: Color

Grids

• Tumbling U Chart

• Multi-Matrix

Figure Ground

• VIPS: Figure Ground: Hidden

Pictures

• Red and Green Chart Search

and Scan

• Focus Flexibility

Processing Speed

• Perceptual Speed Timed

• SVI Tachistoscope

• CPT Search Timed