The Hart Chart

Accommodation

Accommodation is one of the mechanisms that allow us to see up close. Accommodation is the focusing of the lenses in each eye. This action, combined with the convergence, allows for us to see clearly up close. 

Accommodation is the result of the contraction of the ciliary bodies in the eye which allow for the lens to get thicker thereby focusing the image better in the fovea. This action also includes the constriction of the pupil which more precisely focuses the light on fovea making the image sharper. Here is video of this in action

 

“Its blurry up close”

When accommodation does not work, one may see blurry up close, get headaches or rub the eyes due to eye strain. The ciliary muscles attempting to make the image clear, causes this discomfort discomfort. Accommodation can be exercised to strengthen it to improve near vision. This is generally performed in conjunction with convergence exercises to improve near vision  when one treats convergence insufficiency.

The Hart Chart

A simple way to improve convergence is using a Hart chart. With this activity, a grid of letters is placed at distance and one is held by the patient, near. The patient then reads a line close (or letter) then a line at distance. This is done with one eye occluded so the accommodative action is exercised as the eye focuses near then far. In my clinic, this performed while standing on balance board to further challenge the patient. This simple activity is quite effective at strengthening accommodation. A Hart chart can be purchased from Bernell, found on the internet and is included on the Vision Rehabilitation for Pediatrics Course Companion flash drive. Heres a video.

The Hart chart is one way accommodation can be strengthened. In optometric vision therapy, lenses can be used to strengthen accommodation using an activity called Accommodative Rock.

Support your local Optometrist

A complete binocular vision assessment should be conducted before performing these tasks to make sure that are appropriate. Only an ophthalmologist or optometrist can accurately diagnose an accommodative problem.

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Vision Rehabilitation Course Companion

Resource Flash Drive

 

I have created a flash drive of resources to further the experience of my live course and webinar.  It is a collection of  web links and PDFs designed to make implementation of the presented course information easier. Click on the picture to get a better look at what is included.

 

The cost of this add-on is $20 USD and you can click here to order .  I will then send you a 128mg flash drive with the all stuff!!

Click for HTML references from the course.

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Screen Time for Children

Tablets and iPhones and Kindles..oh my!

This generation of children will not know a world without immediately accessible information. They will not live in a world where information is unable to be accessed. Every question answerable with the right choice of words entered in a search engine. Computers now augment the classroom with lessons and tests being presented digitally where once they were presented by a teacher.

The side effects of technology

As therapists, we recognize that a child sitting in front of a screen for hours is not healthy. But does science support that extended exposure to the devices is harmful?

  • Survey of 900+ children in an advantaged school found children with found girls using devices 219 min/day and boys 207 min/day. These children showed increased incidence of neck/should discomfort and increased visual symptoms. (1)
  • Another study of 502 children showed that the more screens a child had available in their bedroom the more likely the child to be obese and have poor sleep habits and a sedentary life style. (2)

These studies help show that what a child is not doing (movement, etc) while on tablet devices is having a negative impact on their health.

Computers in the Academic Environment

School systems boast of their computer to student ratio equating the use of computers and tablets to a quality education. But extended use of computers cause the same problems they do for adults, and perhaps more as children tend to not to be as self-aware of these problems, show more adaptability and work in environments without optimal lighting (3)

A study of 320 children showed increased incidence of vision problems in children who played video games on computer for over 30 minutes per day. As screen time increased, so too did the visual complaints. Complaints like headaches, dizziness and diplopia and decreased stereopsis (binocular depth perception) we all common among these children. (4)

Extended use of computers and screens lead to problems because of what the child is not doing while on the device and the devices are linked to increased vision and musculoskeletal problems. So what do we do?

Throw Them All Out?

Tablets and computers are part of our culture now with everyone interacting with devices throughout the day. There must be a balance in the use of these devices.

A properly balanced play diet that would include screen time but also include social, active and creative play. An examination of the of the skills learned during screen time would make screen time more valuable while balancing this with active play IRL (“in real life”)

LearningWorksForKids.com offers a great search engine to help identify apps that can be useful for teaching skills to children and help screen time be useful.

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(1) Straker, L., Harris, C., Joosten, J., & Howie, E. K. (n.d.). Mobile technology dominates school children’s IT use in an advantaged school community and is associated with musculoskeletal and visual symptoms. Retrieved December 19, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/29103354

(2) Chaput, J. P., Leduc, G., Boyer, C., Bélanger, P., LeBlanc, A. G., Borghese, M. M., & Tremblay, M. S. (2014, July 11). Electronic screens in children’s bedrooms and adiposity, physical activity and sleep: do the number and type of electronic devices matter? Retrieved December 19, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/25166130

(3) Kozeis, N. (2009). Impact of computer use on children’s vision. Retrieved December 19, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776336/

(4) Rechichi, C., De, G., & Aragona, P. (2017, November 01). Video Game Vision Syndrome: A New Clinical Picture in Children? Retrieved December 19, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/28850642

 

 

Common Birth to 3 Vision Conditions

Vision Birth to Three

The visual system at birth is very immature. After all, our new born has been a a dark environment since conception! Acuity develops over time as does the accuracy of eye movements.

Age (months) Skill
1 to 4 acuity is 20/200 to 20/400, follow slow moving object intermittently, basic eye movements present
5 to 8 developing color vision, not as good as adult yet
9 to 12 improving acuity, responds to faces
12 to 24 acuity improved to 20/50, developing eye-hand coordination, depth perception
24 to 36 acuity is 20/20, begins exploring environment
36 to 48 using vision for fine motor coordination.  At 48 months, refined eye movements with decreased head movement.

Assessment of eye movements before the age of three should focus on full range of motion understanding that the accuracy of these movements are still developing and will demonstrate poor accuracy and excess head movement.

“When should their head be still??”

This separation of head and eye movements should begin at about 4 years old with no head movement observed during assessment at age 10 and tapering in between. This going to be tied to development of the proprioceptive and vestibular system  as well as development of the overall brain. These system are closely linked and delay in any of them will cause a delay in ocular motor skill development as well.

When should a baby get their first eye exam?

The first eye exam should be at 6-12 months old. Infantsee, a public health program developed by the American Optometry Association, provides this first eye exam at no charge. It is vital to detect any problem that could limit development of the visual system. The next eye exam at 3 years, then annually from ages 6-18. Just as the child is growing a changing during these years, their vision could be changing as well. With the visual demands placed on our children during these years, an annual exam makes sure they are ready to meet those demands.

Common Birth to 3 vision problems

The below table is just a few the pathologies that could limit development of the visual system.

Common Birth to 3 Eye problems Pathology Acuity Prognosis Functional Problems Modification
Coloboma failure of the halves of the eye to join completely inutreo, may affect pupil, retina or lid varies depending of retinal damage stable condition glare problems if pupil is affected and retina is functional, reduced bincular depth percpetion sunglasses, motor practice
Optic Nerve Hypoplasia decreased evelopment of the optic nerve, usually assocaied with midbrain/endocrine problems varies from minimal affect to near blindness, possbile field cut, possble nystagmus stable condition Delayed motor development due to reduced visual input.   Refer to TVI at 3 yrs old. vestibular and motor facilitation tasks.
Retinopathy of Pre-Maturity scarring related to excessive blood vessel growth during prolonged O2 exposure in premature infants varies by amount of scarring stable condition depends on level of scarring, may be no delays related to vision based on acuity
Corticol Visual Impairment lack of vision due to visual pathway damage/failure to develop Usually not 100% blind stable condition near blindness, refer to TVI, use contrasting colors, movment and work peripheral to central to investigate amount of vision. Referal to TVI is important for school readiness.
Accommodative Esotropia medial eye turn due to extreme farsightedness 20/20 with glasses in place, eye turn also corrects with glasses improves, but child will remain in glasses throughout life none with early correction, amblypoia without correction glasses should be comfortable and worn at all times.
Infantile Esotropia medial eye turn not related to generally reduced due to amblyopia, may improve with correction varies, tx by surgery vs VT vs Botox reduced motor development per doctors order concerning patching, facillitate motor improvement
Amblyopia reduced acuity due decreased visual pathway development  due to prolonged suppression or lack of stimulation to visual pathway varies, 20/200 or worse to 20/50 depending on patching complaince and glasses wear compliance. may improve with compliance of tx and glasses wear, binocular vision therapy reduced motor dev., head turns, decrease binocular depth perception. Brain with compensate in time motor dev facilitation, exercise amblyopic eye if currently patching, binocular vision activities
Strabismus eye mis-alignment at rest, corrected with surgery vs VT vs Botox varies, generally reduced due to amblyopia varies greatly. Long term, brain adapts to suppression of the turned eye reduced motor dev, self-esteem, self conscious of turned eye, reduced binocular depth perception eye exercises per doctors order, facilitate motor development

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Fine motor skills and vision

Does binocular vision affect fine motor ability?

Occupational therapy has been treating fine motor problems since the beginning of the profession. From tying shoes to buttoning to handwriting, when children or adults have difficulty with this, occupational therapy is referred.

Binocular vision?

A small study (1) looked at the fine motor skills of children with reading difficulties and found those with fine motor problems also had binocular vision problems, specifically accommodative problems.  While a small study (19 children), this suggests that vision is playing a role in fine motor coordination.

Another study (2) found that children that were poor readers showed a higher occurrence of binocular vision difficulties and suggested a need for the assessment of these skills in problem readers.

Research also indicates the importance binocular vision and motion perception to development of the motor skills(3) as young a 2 years old.

OT and binocular vision

As therapists, we are seeing children with difficulties that could have a binocular vision component. While a through binocular eye exam should be completed to rule out treatable defects, therapists integrating tracking, saccade and convergence activities could help improve outcomes for their patients. Our background in developmental sequence, kinesiology and assessment of functional ability make therapists the perfect profession to address these deficits. As therapists, we address the motor part of visual motor problems, but basic tracking, eye-hand coordination tasks could help with outcomes by improving the visual aspects of this skill.

The Therapist/OD team

Therapists, both PT and OT, should get the training to feel comfortable integrating these simple tasks into the interventions they already perform. Next, reach out to optometrists in their area. This relationship will be beneficial for both the therapist and optometrist, but mostly, this will help the patient.

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(1)Niechwiej-Szwedo, E., Alramis, F., & Christian, L. W. (2017, October 27). Association between fine motor skills and binocular visual function in children with reading difficulties. Retrieved November 13, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/29096178

(2)Palomo-Alvarez, C., & Puell, M. C. (2010, June). Binocular function in school children with reading difficulties. Retrieved November 13, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/19960202

(3)Thompson, B., McKinlay, C. J., Chakraborty, A., Anstice, N. S., Jacobs, R. J., Paudel, N., . . . CHYLD, T. E. (2017, September 29). Global motion perception is associated with motor function in 2-year-old children. Retrieved November 13, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/28864240

 

 

Letter Reversals

Letter Reversals

Letter reversals are frequently an area of concern for parents as their child begins to learn writing and reading. Reversals are often viewed as a sign of dyslexia and are surrounded by myth. Here are the facts on letter reversals

  • Letter reversals are common and appropriate until a child reaches 7 or 8 years old (second grade).
  • After the age of 7-8, the children who continue to have reversals are the children that are having difficulty with reading(1)
  • Learning letters is the first time a child learns that an item becomes a different thing based on the way it is facing. A cup from seen from one side or the other is still a cup but a “b” seen the other way (“d”) is not the same thing.
  • Visual spatial and left/right body awareness correlated with children having letter reversal problems suggesting that addressing left/right awareness would improve letter reversals (2)
  • Working memory deficits, also found in dyslexia, were found in children with letter reversals, so addressing working memory may improve letter reversals. (3)
  • Children with ADHD tend to have more reversals, possibly related to difficulty in an inability to to suppress the more natural left-right flow of making most letters.

Treatment Ideas

Having the child the pull letters from a bag and identify the letters without looking at them has been a great activity (suggested by Dr. Charles Boulet) and correlated well with children having difficulty with this task that have reversal problems.

Dr. Kenneth Lane OD, FCOVD’s book , Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook, has an excellent discussion of letter reversals as well as treatment techniques. Presenting p-q-d-b chart and having the child touch “p” and “b”  with right and q and d with the left has proven to be very challenging. This activity include a component of eye0hand cooridnation and saccade accuracy that will further improve binocular vision and saccade accuracy.

The Optomteric Extension Program offers Recognition of Reversals Workbook, also by Dr, Lane (a great bookstore!!). This workbook has more activities for reversals and its only $20.

Calm the panic!!

In a few cases, letter reversals after the age of 7-8 can indicate dyslexia, but there are many other reasons a child may have reversals.

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References

  1. Terepocki, M., Kruk, R. S., & Willows, D. M. (n.d.). The incidence and nature of letter orientation errors in reading disability. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15493319
  2. McMonnies, C. W. (1992, October). Visuo-spatial discrimination and mirror image letter reversals in reading. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/1430744
  3. Brooks, A. D., Berninger, V. W., & Abbott, R. D. (n.d.). Letter naming and letter writing reversals in children with dyslexia: momentary inefficiency in the phonological and orthographic loops of working memory. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/21978009
  4. Levy, F., & Young, D. (n.d.). Letter Reversals, Default Mode, and Childhood ADHD. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26794673

Equipment for Vision Rehabilitation

“What tools do I need to perform basic vision rehab interventions in my clinic?”

The first thing one needs is information. Understanding and Managing Vision Deficits-A Guide for Occupational Therapists would be a wise investment. Dr. Scheiman’s book explains assessing and treating basic binocular vision defects making the subject approachable for therapists. He also teaches a course by the same name that would be a good start.

Vyne Education also offers a course Vision Rehabilitation for Pediatrics-Seeing the Whole the Picture, taught by this author also introduces basic assessment and treating of eye movement disorders.

The Convergence Insufficiency Treatment Trial Manual’s Chapter 8 explains the in-clinic activities used in the CITT and would also be a worth while read.

You will need an optometrist

This may be the hardest thing to find. While the complete binocular vision assessment is the standard of care, frequently this assessment is neglected. Find the optometrist in your community that consistently performs these assessments and you will most likely find a partner. COVD and NORA doctors may be most receptive to working with a physical or occupational therapist that is training in binocular vision disorders.

The optometrist diagnosis is as important as the diagnosis a therapist would get before starting rehab on a shoulder. While we can perform basic testing on a shoulder, some results would indicate further assessment by the orthopedist. Same rules would apply concerning eye movements except that even poor tracking could be caused by a lack of visual acuity requiring glasses (or more accurate glasses).  Always insist that a child have a current eye exam before working on eye movement or even skills like visual motor integration or visual perception. Performance of these tasks requires best corrected visual acuity.

What about Equipment?

The Worth 4 dot   would be a wise first investment. With models starting at about $20, it it also very cost effective and gives great first clues to a eye movement problem.

Marsden Balls offer an easy to use moving target that requires good fixation to read letters. The handy therapist could probably make one on their own.

The Hart Chart is simple way to strengthen accommodation. Do it on a balance board and add in the challenge of balance.

The brock string is a must and its cousin the barrel card can be used to strengthen convergence.  Have the patient make their own brock string becomes a great fine motor activity too.

The Developmental Eye Movement Test is quick to give assessment that gives good data to reading ability and accuracy.

 

Prism and Lenses

The rules governing the use of prism and lenses vary greatly from state to state with the interpretation of the rules varying. Because of this, the author has chosen not to openly recommend these tools. They would generally require being under the supervision of an optometrist or ophthalmologist for there use and purchase.  They also require training to understand the appropriate therapeutic use of these tools.

Be a therapist!

The near-far axis is generally referred to as the Z-axis. When we turn our midline crossing tasks into the Z axis, we are now working the near far visual system.  Check out a previous post here. Be creative and have fun.

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Learn more about this subject in a live course and webinar presented by Robert.  Its now available as a webinar too!! Hosted by PESI Education

About the Author