Vision Therapy Thank You! Grand Rounds

11/12/2013Lynn F. Hellerstein, O.D., FCOVD, FAAODevelopmentalOptometristSpeakerVision TherapyThank You!Grand .comwww.LynnHellerstein.comAuthorCentennial, COMeeting the Needs ofALL Your Patients VT Treatment of choice for:– Binocular, accommodative, oculomotordysfunctions– Amblyopia/strabismus– Visual processing/learning difficulties– Brain injury/special needsCourse Objectives are to: Learn about the incidence of vision problems in patientswith complex behavioral and learning issues. Provide an overview of the latest research supportingvision therapy. Learn about some of the most common visual disordersthat respond well to vision therapy through casepresentation. Recognize the signs and symptoms of vision problemsassociated with patients with learning disability, braininjury and autism spectrum disorder. Learn about the vision therapy treatment options and newtechnology. Emphasize the importance of co-management strategies inworking with patients with complex visual issues.A Public Health Need 1 in 30 children will developAmblyopia 1 in 25 children will developStrabismus From AOA InfantSEETHE CONCERNTBI affected 320,000 military in war inIraq & AfghanistanVisual perception and eyemovement abilities are strongpredictors of academic scoresTBI Signature Injury in Iraq & Afghanistan(Harvard U. Grad. School of Education)25-30% Returning SoldiersWarden D. Mild TBI during the Iraq & Afghanistan Wars. J HeadTrauma Rehabil (2006;21)1

11/12/2013Did You Know?1 of 4 kids have problemsVisualSKILLS/EFFICIENCYD.M. – 15 yr10th GradeDid You Know?of children with learningproblems have visual problemsD.M. – 15 yr10th Grade CT: D – ortho; N- 9 exoNear ranges: 18/3 BO; 20/12 BIPRA: -1.00D; NRA: 2.00 DCrossed cylinder: 1.75 A/B studentActs “dyslexic”, but tested- not!Eyes fatigue, blur with near workDoesn’t like readingPrevious VA – “20/20”D.M. – 15 yr10th Grade VIP Evaluation – all scores at or aboveage level VISAGRAPH2

11/12/2013D.M. – 15 yr10th Grade DIAGNOSIS?– RE– Binoc./acc/om dysfn– VIP– Motor– OtherD.M. – 15 yr10th Grade Treatment? Lenses VT Referral Tutor Audiologist Psychoeduc PhysicianWhat’s the Solution?D.M. – 15 yr10th Grade DX: CI, Acc. Insuff., Sacc. DysfnRX: .75 D spheres for nearVT: 16 sessionsImproved reading fluency, likesreading, no symptomsOcular MotorTechniques3

11/12/2013Accommodative-BinocularTechniquesPower of LensesC.J. - 6 yr.Kindergarten Diplopia Closing eye Pediatric Ophthalmologist- since age 4– “Minimal AET”– No amblyopia– SV RXC.J. - 6 yr.Kindergarten Mother opticianAsked for bifocal“Not needed”Referred by optical storeC.J. - 6 yr. Treatment ResultsVisual InformationProcessing4

11/12/2013Visual Motor TechniquesVisual Information ProcessingTechniquesBrain Injury Traumatic AcquiredBrain Injury– CVA, Aneurysm, tumor, anoxia,aneurysms5

11/12/2013Vision PathwayDid You Know?“20% optic fibers - midbrainone of most common devastatingimpairments of head injury”Focal– Barbara Zoltan, MA, OTRAmbientJ.F. – 30 yr.TBI Research TBI – major cause of death anddisability worldwide– Park E, Bell JD, Baker AJ. TBI: Can theconsequences be stopped?Canadian Med Assoc J 2009;178(9):1163/70J.F. – Symptoms–Headaches–Diplopia–Blurred vision–Motor function decrease–Poor balanceAttention/concentration Mild TBI from fallEvaluated 2 ½ yrs. post injuryReferred by neurologistLVE – Ophthalmology- 1 yr.J.F. – stein L, Freed S. Rehabilitative OptometricManagement of a TBI Pt. JBO, 1994;(5)6:143-1486

11/12/2013J.F. - Diagnosis TBI by HX Normal retinalfunction IOP WNL Hyperopia Intermittentexotropia Acc. insufficiency ConvergenceinsufficiencyJ.F. – Diagnosis Homonymous, incongruous, lowerright quadrantanopsia Abnormal conduction throughanterior visual pathways Visual processing deficitsJ.F. – Treatment RXJ.F. –Post VT Cover test– 1.00D – Dx– 2.00D, 2 prism diopter BIOU –Near Rehabilitative vision therapy – 1yr. later– 32 weekly sessions w/homesessionsJ.F. – Post VT Dx – ortho Near–8exoph (int. altXT 10) NPC 5/8” (10/14”) Ranges DX 16/20/6 (6/2BO) 20/6 (12/6 BI) Ranges NR 14/3 BO(Diplopia) 24/17 BI(Diplopia)J.F. Visual Fields Pre-VT Pursuits & Saccades– Well controlled, no discomfort Accommodative Status– PRA -1.00D (Diplopia )– NRA - 2.00D (Diplopia) Visual Fields increased VECP changes7

11/12/2013J.F. Visual Fields Post-VTJ.F. – Contrast SensitivityPre-Post VTJ.F. – VECPPre-Post VTJ.F. – 30 yr.Post VT Functional improvement– Visual symptomology decreased Fatigue– Drive– ADL Wears Distance & Near RXVision ResearchVECP Abnormal FindingsVECP TESTINGINTERVAL ANDSUBGROUPTBI GROUP I(receivingOptometricrehab.)TBI GROUP II(no treatment)Baseline72%81%12-18 months38%78%TBI Resources Freed S, Hellerstein LF. Visualelectrodiagnostic findings in mildtraumatic brain injury.Brain Inj 1997; 11 (1):25-36 Hellerstein LF, Freed S, Maples WC.Visual profile of patients with mildbrain injury.J. Am Optom Assoc 1995; 66 (10: 634-39)8

11/12/2013TBI ResourcesLife after brain injury isnever the same!Suter P, Harvey L. (eds). Co-author ofChapter I in Vision Rehabilitation:Multidisciplinary Care of the PatientFollowing Brain Injury.CRC Press, 2/11Why Offer VT?Co-ManagementHellerstein & BrennerVision Center, P.C.Doctors of Optometry Great solution Generates HAPPY, successfulpatients YOU can change people’s life!Lynn Fishman Hellerstein, O.D., F.C.O.V.D., F.A.A.O.Tricia Brenner, O.D.Sara Grell, O.D.Joe Borden, O.D.7180 E. Orchard Road, Suite 103Centennial, CO 80111(303) 850-9499OPTOMETRIC VISION THERAPY REFERRAL/CONSULTATION FORMTO:HELLERSTEIN & BRENNER Vision Center, P.C.Greenwood Medical Center (SW corner or Orchard & Quebec)7180 East Orchard Road, Suite 103Centennial, Colorado 80111(303) NG:Patient:Address:City/State/Zip:Telephone: Date:Email:I am referring the above patient to your office for the following reasons:eye strain/headachesperceptual evaluation (poor school perform.)computer useinfant/preschool evaluationreading/TVpost trauma/stroke evaluationdrivingstrabismus/amblyopiafluctuating acuitydouble visionaccommodative dysfunctionexophoria/esophoriaadditional informationpatient is to return to my office for eyewear needs.FROM:Co-ManagementReferring ementREFERRAL PROCEDURES1. The referring doctor indicates to the patient that a specific visual problems exists, ormay exist, which requires specialized care. The patient can be informed that the doctors andstaff at the Hellerstein & Brenner Vision Center P.C. have specific expertise in the diagnosisand treatment of this visual condition and a referral to their care is recommended.2. You may tell you patient that the doctors at the Hellerstein & Brenner Vision Center, P.C., willcommunicate via written report to you, the referring doctor, to assure a “team” approach to thevisual care of the patient. You will continue to provide all prescriptive needs (glasses and/orcontact lenses) for the patient, unless you request otherwise.3. You then tell your patient to call our office for an appointment (303-850-9499). When wehear from your patient, we always ask who referred him/her so that appropriate office policiesare followed dealing with patients referred by an optometric colleague. The referring doctor isnoted in the appointment book by the patient’s name. Please send any records and/or prior testresults.4. A full report will be forwarded following our diagnostic assessment.5. We commend, to the patient, your expertise in recognizing the condition and the need forreferral for a more in-depth evaluation and/or possible treatment.6. Specific diagnostic testing is ordered:a. to define and/or differentially diagnose the nature of the condition;b. to determine the prognosis for treatment;c. to investigate the full ramification of how the condition affects visual performanceand other systems.7. Following the diagnostic test battery, the patient, parents or interested parties are seen for aconsultation where the diagnosis, prognosis and treatment goals are thoroughly discussed andexplained.8. If the prognosis is poor, the limitation to recovery is explained to the patient. Then adaptive orcompensatory suggestions are made which provide alternative strategies to reduce visual stressand frustration and improve visual performance. Insurance coverage is discussed.9. The patient then enters into a program of treatment.10. At this point, a report of our findings is sent to you and any other concerned professionals (e.g.teacher, school nurse, principal, neurologist, etc.). The report credits you with the initialrecognition of visual dysfunction and referral for treatment.11. Upon completion of treatment, we retest those areas deficient in the initial evaluation, and afollow-up report is sent to the professionals concerned.12. The patient is then referred back to you, the primary care optometrist, with periodic progressevaluation at the Hellerstein & Brenner Vision Center, P.C., when appropriate. Continuedcommunication with the referring doctor is encouraged when necessary. How to identify VT patients– Case History – school & development– Visual efficiency – Cover test, motilities,fusion ranges– Visual processing – reversals, writing,sports– Strabismus, amblyopia– Special Needs9

11/12/2013Ask How Do You Get More Info?Does your child Resist reading or writing?Have difficulty with or avoid sports?Have test anxiety?Seem smart in everything but school?Lack aoa.orgwww. Nora.ccFind a DoctorReview Ask your optometrist 2 questions Vision is in the BRAIN Be preventive Co-Management Successful solutions– Do you do near point testing?– Do you provide vision therapy orrefer to an Optometrist who does?Lynn F. Hellerstein, O.D., FCOVD, FAAOIt’s Time!Make a difference for:YourselfYour kidsYour studentsThank nk YouDrH@LynnHellerstein.comCentennial, CO303-850-9499www.LynnHellerstein.comCentennial, CO10

Visual electrodiagnostic findings in mild traumatic brain injury. Brain Inj 1997; 11 (1):25-36 Hellerstein LF, Freed S, Maples WC. Visual profile of patients with mild brain injury. J. Am Optom Assoc 1995; 66 (10: 634-39)