An Occupational Therapist Treats Convergence Insufficiency

An OT treats CI

The process the author uses to treat convergence insufficiency has proven in his clinic to be very efficient, effective and repeatable. Symptoms are generally resolved in 8-10 visits for neuro-typical children and adolescences. This treatment process does not include assessment of primitive reflexes though many of the activities (not by design) may help to integrate these retained reflexes. Treatment sessions are twice a week for one hour. Home programs consist of a brock string performed 3-4 minutes in the morning and afternoon. The patient returns for their annual eye exam one year later and remain symptom free.

The Referral

Most of the referrals are made by Dr. Mark Obenchain OD, a binocular vision/peds specialist. He is a graduate of Indiana University where he completed a residency in binocular vision and pediatrics. He accepts all insurances and Medicaid.  Our patients cover a board spectrum of demographics with approximately 2/3rds being neuro-typical and the remaining 1/3rd having an additional diagnosis such as ADHD, Autism, or other developmental delay. A complete pediatric eye exam with cycloplegic dilation is performed on every child under the age 18 regardless of complaints.

The doctor diagnoses CI when:

The OT Evaluation

The occupational therapy evaluation begins with medical history, medication history and a discussion of academic performance and hobbies.

The following testing is performed:

  • extra ocular movements
  • tracking
  • stereopsis
  • near point of accommodation
  • near point of convergence
  • Developmental Eye Movement Test
  • Beery VMI, Visual Perception and Motor Tests
  • Observations are made during proactive and rotator 3 activities on Sanet Vision Integrator for eye-hand coordination, posture and balance. This performed while patient stands on balance board.

The author does not assess visual perception at this time as the patient has been diagnosed with a near vision problem which could taint the results of this test. An OT evaluation is also an untimed code making the 30-45 minute test not efficient to perform at this time. If visual perceptual problems exist after meeting all CI related goals, then visual perception is assessed and treated.

The Goals

The therapy goals are specific and measurable as well as being tied to function.

  1. LTG–Pt to demonstrate age appropriate visual skills
    1. STG–Pt to demonstrate near point convergence< 6 cm on 5 trials
    2. STG–Pt to fuse 15 BO loose prism to demonstrate improved fusion skills for improved reading and close  tolerance.
    3. STG–Pt to complete 20/30 Rock card with 2.00 flipper in 60-90 seconds to demonstrate age appropriate accommodation skills to improve read and close work tolerance.
    4. Complete Developmental Eye Movement test with age appropriate ratio to demonstrate improve ocular motor accuracy for reading tasks.
    5. STG–Pt to demonstrate age appropriate visual motor integration as tested by Beery VMI
  2. LTG–Pt to be (I) in use brock string to support in clinic treatment.

The Treatment Protocol

The below protocol has been effective and repeatable with most neuro-typical children ages 6 and up. The author has modified activities for children that have difficulties with these tasks which lengthens the amount of treatment sessions but are still effective in meeting the above goals.

  1. On the Sanet Vision Integrator
    1.  Proactive, performed monocular using R/B glasses, while standing on balance board, therapist holds head still while patient alternates touching dots with right then left hands regardless of placement of dots.
    2. Rotator 3, monocular, while on balance board. May touch with any hand, verbal cues to recall alphabet as needed.
  2. Convergence activities
    1. Tranaglyph slides with goal of reaching 30 BO and 12 BI.
    2. Loose prism Jump Vergences with “circle X square” tranaglyph for binocular feedback.
  3. Accommodation
    1. Accommodative Rock task, monocular
  4. Saccades 2 task on Sanet Vision Integrator, while on balance board, monocular with R/B glasses, head held still as needed. Goal is achieve 100% accuracy .5 interval with words.
  5. After improving with these tasks, pt may be progressed to aperture arm, often challenged with 1.00 flipper to maintain focus
  6. Visual motor integration tasks, tracing shapes, copying geoboard forms on paper and/or chalkboard/SVI and other visual motor tasks.
  7. HTS Autoslide performed at end of session

CPT code 97530- therapeutic activities, a timed code, is used for all sessions.

The Outcome

Patient are discharged upon reaching all goals as stated above on two consecutive visits. When this has occurred there have been no re-referrals for CI. There is also a resolution to many other symptoms including

  • resolution of headaches
  • improve reading fluency
  • a resolution to letter reversals in most cases
  • improve handwriting
  • improvement is self-esteem

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About the Author

 

 

 

Autism and Vision

Autism and Sight

There has been several recently published articles on autism with some dysfunctions being found at a higher rate than in the neuro-typical population. One study, published in January 2017, found consistently that children with autism reacted slower to changes in light (pupillary light reflex). The pupillary light reflex was slower when lighting changed and, in darkness, the pupil measured smaller than controls.(1)

A second study, published in 2018, found a higher rate of accommodative problems (17.4% for ASD, vs 4.9% control) for children diagnosed with autism. While there was no substantial difference in the rate of refractive error, this higher rate of accommodative problems makes a complete eye exam with assessment of near vision acuity more important.(2)

A review of evidence found several contradictory studies concerning the prevalence of eye movement defects associated with autism, though most agree that saccades inaccuracy as well as difficulties in tracking are common in ASD. These movement problems, coupled with other fine and gross motor deficits found in autism suggests a cerebellar problem.(3)

Autism and Vision

Difficulties with the integration of visual information is found in several studies. All of these studies point to a lack of integration between the parvocellular and magnocellular tract and reduced communication between these tracts.(3)

Studies found differences in VEPs (visually evoked potentials) studies in the activity of the magnocellular tract compared to neuro typical children. The difference was, most notably, a slower recovery period for the magnocellular tract and therefore, decreased integration of the information. Functionally, this may help explain the visual spatial problems frequently seen in ASD diagnosed children. (4, 5)

Lateral gazing’ behavior was also found in some children with ASD as they attempted to use peripheral vision to reduced central visual pathway input. (3) This behavior is also suggestive of magnocellular tract deficits.

Integration Deficits

A common thread through many of these studies is a decreased integration of visual information and motor pathways and the cerebellum. (6) This lack of integration could help explain the ocular motor and saccade problems, as well as increased incidence of gait problems and toe walking (7,8) and visual motor integration problems found in children with ASD. A study also showed that people with ASD do not make good use of visual information to correct posture (9). Addressing this lack of integration could be helpful making functional progress with children on the spectrum.

Summary

A complete binocular vision exam with cycloplegic dilation is very important for every child with autism (and neuro typical children too) given the potential for a higher rate of accommodative and ocular motor problems and fine motor, reading and handwriting problems.

Given the evidence of integration problems, activities for children with ASD should be “top down” type activities that require the integration of movement and vision.

Much of this research is very recent and found some changes from previous research. Many of the studies suggested these differences in results were related to redefining autism with the release of DSM-5 eliminating Aspergers and pervasive developmental disorder and grouping these into the current terminology of autism spectrum disorder. The inclusion of these subjects in studies have helped improve the understanding of vision and autism. Many of the studies also sited small samples as potential limitations.

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(1)Anketell, P. M., Saunders, K. J., Gallagher, S. M., Bailey, C., & Little, J. A. (2018, March). Accommodative Function in Individuals with Autism Spectrum Disorder. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/29424829

(2)DiCriscio, A. S., & Troiani, V. (2017, July 25). Pupil adaptation corresponds to quantitative measures of autism traits in children. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/28743966

(3)Bakroon, A., & Lakshminarayanan, V. (2016, July). Visual function in autism spectrum disorders: a critical review. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/27161596

(4)Jackson, B. L., Blackwood, E. M., Blum, J., Carruthers, S. P., Nemorin, S., Pryor, B. A., . . . Crewther, D. P. (2013, June 18). Magno- and Parvocellular Contrast Responses in Varying Degrees of Autistic Trait. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/23824955

(5)Sutherland, A., & Crewther, D. P. (2010, July). Magnocellular visual evoked potential delay with high autism spectrum quotient yields a neural mechanism for altered perception. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/20513659

(6)Miller, M., Chukoskie, L., Zinni, M., Townsend, J., & Trauner, D. (2014, August 01). Dyspraxia, motor function and visual-motor integration in autism. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/24742861

(7)Accardo, P. J., & Barrow, W. (2015, April). Toe walking in autism: further observations. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/24563477

(8)Kindregan, D., Gallagher, L., & Gormley, J. (n.d.). Gait deviations in children with autism spectrum disorders: a review. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/25922766

(9)Morris, S. L., Foster, C. J., Parsons, R., Falkmer, M., Falkmer, T., & Rosalie, S. M. (2015, October 29). Differences in the use of vision and proprioception for postural control in autism spectrum disorder. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/26314635

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 for Pediatrics Course Companion

Vision Rehabilitation for Pediatrics Course Companion

 

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!!

I have recently updated the references for my presentation.

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 has a lot of development to do. The early eye exam (6 months to one year) should find anything that may impede this development.

Common Birth to 3 vision problems

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.

 

(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

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