OptoWest VT Handout
Visi o n T h e r a p yfor Non-StrabismicBinocular Vision DisordersA Evidence-Based Approach4-5 April 2013David A. Damari, O.D., FCOVD, FAAO
Vision Therapy WorkbookDavid A. Damari, O.D., FCOVD, FAAOTable of ContentsIntroduction!Guiding PrinciplesEye Movements479Testing Eye Movements9NSUCO Pursuit & Saccade Testing9The Developmental Eye Movement Test10Eye Movement Recording Systems12Eye Movement Therapy12Wall Saccades12Hart Chart Saccades12Pegboard Rotator13Hart Chart Rows & Columns13Monocular Prism Jumps14Michigan (Ann Arbor) Tracking15Accommodation17Phoropter Testing17Nearpoint Retinoscopy Techniques18Nott retinoscopy18MEM retinoscopy18Near/Far Hart Charts20Monocular Accommodative Rock (MAR)20Monocular Lens Sorting21Split Pupil Rock (Biocular Minus Lens Rock*)21Red Red Rock (Franzblau Rock)22
IntroductionBinocular Accommodative Rock (BAR)Anti-Suppression & FusionOptoWest 20132325Fusion Testing25Anti-Suppression Therapy25MIT Box with Alternate Flash25Hand Mirror and Whiteboard Target26Stereoscope Cards with Russell Rings27Stereoscope Cards with Two Pointers28Fusion Therapy28Quoits Vectogram28Clown Vectogram30Spirangle Vectogram30Brock String31Single Aperture Rule31Double Aperture Rule32Lifesaver Card33Computer Orthoptics34List of Equipment35The Essentials35Optional Equipment36Appendix373
Vision Therapy WorkbookDavid A. Damari, O.D., FCOVD, FAAOIntroductionVision therapy, although always an accepted part of the optometric scope of practice, is often thought of asan ugly step-child by many general practice optometrists. This has been especially true in the last thirty years,as our profession has achieved gains in our prescribing privileges. In fact, many in our profession seem tonow consider optometry to be the medical branch of eye care, while ophthalmology is the surgical branch.What makes us unique, however, is that optometrists have always been the type of health-care providerswho have counseled as much as we have prescribed, who have worked with the patient instead of attemptingto impose our will on the patient. It is this characteristic of optometry that has earned us the trust of ourpatients, and that trust has earned us the privilege of expanded abilities to care for our patients withpharmaceuticals and new procedures. It is also these traditional strengths that can make vision therapy aneffective part of your patient care offerings.Why do patients go to the optometrist? They come to us to give them clear, comfortable, usefulvision. They come to optometrists so that they can do their jobs or school work efficiently and withoutundue fatigue. This has been shown to drive more than 75% of eye care. As our economy becomes moredependent on creative and intellectual productivity, the traditional services unique to optometry become moreimportant. These services have always been backed by some of the best science available. The literaturewritten on uniquely optometric interventions, such as a psychometrically-sound refractive care, low visioncare, and vision therapy for binocular and visual information processing disorders, is some of the richest inhealth care. It has been dismissed out of hand by medicine because it has not been conducted by medicine,but that does not diminish its validity. This validity has been demonstrated recently in most dramatic fashionby the findings of the Pediatric Eye Disease Investigative Group’s Amblyopia Treatment Studies (ATS).These multidisciplinary studies have again and again validated what optometrists have studied and known forover 60 years: short, active therapy based on evidence in human neurology trumps invasive, imposedregimens based on medical tradition every time. The tradition said that amblyopia could not be treated afterage 7; science has shown that plasticity lasts much longer, and optometrists have been successfully treatingamblyopia at any age for decades. The tradition said that full-time patching is the only effective treatment;science has shown that, to be effective, the treatment of amblyopia must be the treatment of a binocularcondition of disordered spatial processing, something that could never occur simply by making someoneartificially monocular every waking hour. In addition, another NIH-funded, multi-disciplinary and multicenter study, the Convergence Insufficiency Treatment Trial, (CITT) has demonstrated unequivocally thatoffice-based vision therapy programs are more effective than any other type of therapy. Pencil push-ups andprism glasses were no more effective than placebo in reducing symptoms from CI.Vision therapy is not simple. It cannot be taught in a lecture hall. It cannot be taught during a surgical ormedical residency. And while technicians or occupational therapists can guide patients through vision therapyprograms, the most effective programs can only be designed by doctors who have an understanding of all theunderlying principles of the visual system and human behavior. These obstacles have made it reassuring formany optometrists to believe the myths about vision therapy. Organized ophthalmology continues to enforcethese myths to the general public: that VT is based on anecdote and desperation and greed. Yet, with thisworkshop, we will attempt to demonstrate that vision therapy is one of the most valuable, science-basedservices doctors of optometry can provide.This manual for vision therapy attempts to capture the scientific basis and distill it into arational, systematic program for helping most of your patients with disorders of eye movements,accommodation, and binocular vision. It is hoped that this will help you to help hundreds of your patients
IntroductionOptoWest 2013to lead happier, more productive lives. It does not represent a complete program of vision therapy, however.If, after you have begun offering vision therapy based on your experience in this course, you find you haveneed for more information, congratulations! That means you are doing it well.As you find you need to know more, there are many resources you can use. The two major organizationsinvolved in vision therapy are the Optometric Extension Program Foundation (OEP) and the College ofOptometrists in Vision Development (COVD). OEP offers publications, seminars, discussion groups, andother educational opportunities throughout the United States and the world. You can access their resourcesthrough their web site, www.oepf.org. COVD is the certifying body for the specialty of vision therapy. Theirfellowship program is the model for board certification in optometry as other professions understand thatconcept: assurance that a professional has gone through the education and testing to offer expert treatment ina specialty. COVD also offers education at its annual meeting. Their web site is www.covd.org.Good luck and continued success in your pursuit of excellent patient care!David A. Damari, O.D., FCOVD, FAAO (david.damari@comcast.net)5
Vision Therapy WorkbookDavid A. Damari, O.D., FCOVD, FAAO
IntroductionOptoWest 2013Guiding PrinciplesThere are some critical principles of vision therapy that will help determine the success ofthe individuals who enter your therapy program. They are: A motivated patient is a successful patient. What is true for refractive surgery isequally true for vision therapy, perhaps even more so because VT is such an activeprocess. If you have to talk a very reluctant patient (or parent) into a program of VT,it will probably not be successful. If a patient is trying to talk you into putting himinto a program of VT, his success will probably exceed your expectations. Do not teach a test. Too often what passes for vision therapy is actually justmaking the patient repeat a test over and over until the practice effect makes thetest look better (think pencil push-ups). This method of therapy has very poortransfer to real world skills and poor amelioration of symptoms over the long-term. It is the patient’s therapy, not yours. The effectiveness of any vision therapyprogram is determined by the changes made in the patient, which makes VT likeany other behavior modification program. You must present the patient withchallenges to be overcome and then observe the patient developing strategies tomeet those challenges. Teaching strategies won’t help modify behavior over thelong term. Learning does not take place in a minute and a half. The patient must havetime to develop a strategy. Be patient with her, and make sure that she is patientwith herself. Be encouraging without assisting or smothering. You must start with step one. You cannot start a patient with the Brock string orlifesaver cards. Starting at the end of therapy forces the patient to developadaptations that will be detrimental to long-term success.The root of these five principles is that vision therapy is, at its core, a program of behaviormodification, like weight loss or quitting smoking. The undesirable behavior is embeddedin adaptations that are not healthful, but that do have some reward over the short term.These behaviors do not go away without effort. There is no quick fix.A word about reporting is necessary. Communication is the key to a successful visiontherapy practice, and a good report is the best external marketing tool you have at yourdisposal. A report should have these elements: history including birth, previous eye exams, and academic findings divided into categories such as eye movements, focusing, binocularcoordination, and (if applicable) visual information processing, with data reported instandard scores or percentiles, so that educators and other professionals canimmediately grasp the performance of the patient conclusions that are given as medical diagnoses with lay-person explanations recommendations for treatment and, more importantly, for specific classroom orworkplace accommodations.7
Vision Therapy WorkbookDavid A. Damari, O.D., FAAO, FCOVDEye MovementsEye movement testing has benefitted from advances both in science and technology.Maples and his coworkers have greatly refined the gross testing of eye movements byobservation with the NSUCO standardization. Eye movement recording has beenimproved by the use of goggles with LEDs and sensitive photocells that monitor eyemovements while the patient reads printed material. This allows for objective testing that iswell-standardized and results that are easily communicated to patients, parents, and otherprofessionals.Testing Eye MovementsN S U C O P u r s u i t & S a c c a d e Te s t i n gThese testing standards grew out of the work done at Southern California College ofOptometry in the early 1990’s. Maples and coworkers found that the SCCO method forscoring eye movement performance put emphasis on the least reliable aspect of eyemovement grading: the “ability” measure. Therefore, Maples created the NSUCO scoringsystem for gross pursuit and saccade observation. It is based on four elements: ability,accuracy, head movement, and body movement. Ability is defined as how long the childstays with the task. Accuracy is defined by saccadic intrusions and refixations forpursuits, and by over- or undershoots for saccades. Head and body movements areindications of the child’s ability to control motor overflow. The test is graded as follows:PURSUITSabilityaccuracyheadbodylevel 1no attempt 10 refixationslargelargelevel 2half rotation4 to 10moderatemoderatelevel 31 rotation3 or 4constant, slightconstant, slightlevel 42 rotations1 or 2intermittentintermittentlevel 5both odylevel 1no attemptlarge misseslargelargelevel 22 cyclesmoderatemoderatemoderatelevel 33 cyclesconstant, slightconstant, slightconstant, slightlevel 44 cyclesintermittentintermittentintermittentlevel 55 cyclesnonenonenone9
Eye MovementsOptoWest 2013When measuring pursuits and saccades using the NSUCO system, please keep inmind that the most valid (predicts academic performance) and reliable (two differentexaminers most commonly come up with the same score) category are head and bodymovements.The standards (one standard deviation below average) for this grading system are asfollows:pursuitsability Mability Facc Macc Fhead Mhead Fbody Mbody Fage 545232334age 645232334age 755333334age 855333344age 955343344age 1055444445age 1155444445saccadesability Mability Facc Macc Fhead Mhead Fbody Mbody Fage 555332234age 655332334age 755333334age 855333344age 955333344age 1055333444age 1155333445T h e D e v e l o p m e n t a l E y e M o v e m e n t Te s tThe Developmental Eye Movement test (DEM) has become one of the most well-acceptedmethods for testing reading eye movements. This is probably because of its elegantdesign, low cost, and acceptable reliability and validity. Certainly, the test’s face validitymakes it a very appealing tool for parent education.This test has improved on the old Illinois College of Optometry optometry studentproject, the King-Devick test, by creating a control for problems with automaticity ofnaming numbers. It consists of three test plates. The first plate (Test A) has 40 numbers10
Vision Therapy WorkbookDavid A. Damari, O.D., FAAO, FCOVDarranged in two columns, the second plate (Test B) has 40 numbers also arranged in twocolumns. These two plates are designed to assess the child’s rapid automatic numbernaming (RAN) performance, without undue emphasis on eye movements. If the childmakes a total of more than five errors on these two plates, then the premise that eyemovements do not play a role in those two plates has been shown to be invalid, and youshould not do Test C.The third plate (Test C) consists of the same 80 numbers, in the same order, as Tests Aand B. However, the numbers are now arranged in 16 rows of 5 numbers each. The idea isto allow observation of reading-type saccades without the element of decoding (readingwords).The instructions given for this test are key for its validity and reliability, so they are givenhere:DEM (Requires DEM test plates, recording form, and a stopwatch)1. Place Test A in front of patient.2. “This is a number-reading race. I would like you to read the numbers on this page asquickly as you possibly can. Start up here (point to the top of the first column) andread down as fast as you can. When you get to the bottom, don’t stop. Go right tothe top of the second column and keep reading down. Any questions? Begin.”3. Start the stopwatch as the child reads the first number.4. Stop the stopwatch when the child reads the last number, then record the time.5. Place Test B in front of the patient.6. “You did a great job. Now do the same thing on this page. Remember to read thenumbers as quickly as you can, and do not stop when you get to the bottom of thisfirst column. Ready? Begin.”7. Start the stopwatch as the child reads the first number.8. Stop the stopwatch when the child reads the last number, then record the time.9. Place Test C in front of the patient.10. “This page is a little different. You are going to read the numbers as fast as you canagain, but this time you will read across the lines, like you are reading words in abook. Read every number in every line, but if you think you made a mistake, do notgo back and re-read any numbers because I will have to count every number you reread as a mistake. You cannot use your fingers or thumbs to keep your place — useonly your eyes. Any questions? Begin.”11. Start the stopwatch as the child reads the first number.12. Keep track of every error. Strike through any omitted numbers or lines of numbers,write in any added numbers, and also track any substituted or transposed numbers.13. Stop the stopwatch when the child reads the last number, then record the time.11
Eye MovementsOptoWest 201314. Score the patient using the norms given at the back of the test plates or using theExcel spreadsheet written by Damari (if you sign up for e-mail, you will receive acopy). There is also a new scoring program available from Bernell (see appendix).The child’s performance on the DEM can show if there is a possible expressivelanguage delay, based on the “vertical” score derived from the combined times of Tests Aand B. It can also tell you if the patient’s saccadic eye movements are deficient based onthe ratio score or the error score. If either of those two scores is reduced relative to thepatient’s age group, then you may conclude that the patient has a saccadic dysfunction.Eye Movement Recording SystemsThere are two major eye recording systems available: the Visagraph (not manufactured anymore, but occasionally available from previous users) and the ReadAlyzer. Both offer verysimilar set-ups and eye movement analyses.The ReadAlyzer comes with complete instructions and excellent technological support.The normative values should, however, be used with caution. The reading rates (words perminute) used are not those commonly accepted by the reading education community. Thefixation and regression norms appear to be more valid.Eye Movement TherapyIt is critical during eye movement therapy that the child have good feedback about whathis body and head are doing while performing the task. Therefore, with rare exceptions, alleye movement therapy should be done standing up.Saccades are counterintuitive in that larger saccades are easier. Therefore, in therapy,start with techniques that require larger eye movements and then move to techniques thatrequire smaller, more discriminating saccades.Wa l l S a c c a d e smaterials:wall saccade handout, eye patchkey points: This technique is largely for homework, so ensure that they understand thetechnique by teaching it in your office.goals:The patient does not need to be able to do these quickly. It is moreimportant that she can do it accurately and in a rhythm, especially to thebeat of a metronome (see Hart Chart saccades, below).Hart Chart SaccadesThis technique is similar to wall saccades, but since the eye movements are smaller andthe targets are closer to one another, it is more difficult.materials:12Hart Chart, Letter Chart Instructions handout, eye patch
Vision Therapy WorkbookDavid A. Damari, O.D., FAAO, FCOVDkey points: Again, this is largely given for homework, but it is very important that thepatient understands how to do this correctly, so teach it in the office.goals:Again, the patient does not need to be able to do these quickly. Accuracyand rhythm are much more important.loading/unloading: Use of a metronome is an excellent way to load this technique. Athome, I ask patients to do it to music if they do not have a metronome.Pegboard RotatorThis is the first technique that requires an equipment purchase. It works on pursuits, andby extension on fixation ability. So while this technique is extremely helpful, it is notabsolutely necessary to the success of a vision therapy program if you want to hold off onits purchase.materials:pegboard rotator (Bernell or OEP), eye patchkey points: This is an in-office only technique. The key to this technique is in thefollowing the hole around with the golf tee and, by extension, the fovea. Itshould be performed standing up, one eye at a time, for about 5 minutes pereye.goals:Placement of the tee into the hole being followed without touching the top ofthe rotator.procedure:1. Have patient stand over the pegboard with a patch on one eye.2. Turn on the pegboard.3. Have the patient take a tee and hold it over one of the rotating holes in thepegboard.4. Tell the patient that after he follows it for two rotations, he can try to insert the teeinto the hole.5. If the patient does not make a clean placement of the tee into the hole, he has tofollow around again for at least one more rotation.loading/unloading: Slower is easier on this, so to make it easier slow down the rotationand have the patient follow the holes closest to the center. Asking questionsor other verbal loading techniques are excellent for this exercise.Hart Chart Rows & ColumnsThis takes advantage of the more complex eye movements necessary to find theintersections o
Accuracy is defined by saccadic intrusions and refixations for pursuits, and by over- or undershoots for saccades. Head and body movements are indications of the child’s ability to control motor overflow. The test is graded as follows: PURSUITS ability accuracy head body level 1 no attempt 10 refixations large large
Faculty use anecdotal notes to remember observations . Handout 2 – Sample Adequate Nursing Care Plan, pages 14-15 Handout 3 – Faculty Evaluation of Sample Nursing Care Plan, page 16 Handout 4 – Poor Concept Map, page 17 Handout 5 – Faculty Evaluation of Poor Concept Map, page 18 Handout 6 – Concept Care Map, page 19 Handout 7 – Faculty Evaluation of Good Concept Map, page 20 For .
Day 2 1. PB&J Algorithm handout 2. Algorithmic Bias handout 3. Reflection handout 4. Cats and Dogs Dataset cards 5. Playing Cards 6. Instructor Laptop and Projector 7. Student Laptops 8. Robots 9. USB Webcams Day 3 1. Ethical Matrix handouts 2. Final Project Brainstorm handout 3. Final Project Research handout 4. Reflection handout 5.
SUMMARIZING, PARAPHRASING, AND QUOTING WORKSHOP CONTENTS Lesson Plan Handout 1: "The Shanghai Secret" Handout 2: Model Citations Handout 3: A Response to "The Shanghai Secret" Handout 4: When to Use/Effective Features of Each Type of Citation Handout 5: Citations for Improvement Handout 6: "Gilmore Girls: A Girl-Power Gimmick" Reference Sheet: A Response to "The Shanghai Secret"
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Lesson 7: Identifying Skills 50 handout: Skills Identification 51 Lesson 8: things I Am Good At 53 handout: things I Am Good At 54 handout: List of 246 Skills as Verbs 55 Lesson 9: Skills Auction 56 Lesson 10: Identifying Job Values 58 handout: Job Values Inventory 60 handout: work Values Clarification 61 Lesson 11: Prioritizing Job Values 62
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