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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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

Protocols and Degrees of Freedom

Protocols

Protocols are nice packages of processes that allow for a task to be completed or a problem to be addressed in a predictable organized fashion.  They allow for for the process to be easily communicated, taught and used by a new person.

Protocols and the special needs needs child

Behavioral  optometry  recognizes the effect and importance of vision on the rest of the body. The effect of the visual intervention on the rest of the body increases the number variables that will effect the outcome of a protocol. Just as we as therapists must recognize the role of vision in the interventions we apply, the behavioral optometrist must also recognize the interaction of their intervention on the rest of the body.

An example:

A child with cerebral palsy develops a toe walking gait as a pathological solution to ambulating with increased trunk and lower extremity tone.  The application of base down prism, a common solution for toe walking, would, in this instance, destabilize this patient’s  gait and balance, most likely making him unable to walk. The visual input would be attempting to make his body do something it is unable to do. Is the base down prism helpful when when used during physical therapy sessions after a child has had other interventions for muscle tone? Maybe. This is the point at which an interdisciplinary team with a collective understanding of the entire person becomes most useful.

The larger point of the example is that the entire system is affected by the visual intervention but without an understanding of the entire system, the success of the protocol decreases.

Degrees of freedom

The variables within any biological human system are are complex and innumerable. The biological factors that influence the behaviors and abilities of children with special needs are even more difficult to list. Vestibular, proprioceptive,  muscular tone, sensory interpretation, etc, all are acting upon every human at all times. As a child presents to a provider, the provider must understand these systems and take into account the affect a change to any one of the systems will have upon the others. This is the challenge of anyone working with special needs children.

But a child’s degrees of freedom reach beyond his biology. All children exist in a context that includes parents, siblings, socio-economic factors, and teachers that also have an effect upon their behavior and abilities. A failure to acknowledge and understand these factors will also make the outcomes of interventions difficult to predict. As therapists working with children, it is all of these things that make us continuously look for understanding of the entire context for each child allowing us to treat this child in the most efficient way.

Toolbox vs Protocols

A large part of a therapists education involves learning to assess the degrees of freedom of the systems that that fall under their disciplines scope. Occupational therapists learn about the developmental sequence, range of motion, coordination and strength assessment. We learn standardized assessment for sensory processing and function ability and many other things. Physical therapists look at posture and gait, muscle tone, and balance. Speech therapist learn about swallowing, articulation and language processing.

But speech therapists also recognize the importance of posture for breathing to produce sounds. OTs know that a child without sufficient hand strength cannot use a walker to help him walk. A physical therapist knows a too cold room will affect the behavior of their sensory sensitive patient.  We are taught to have a holistic view of our patient to be successful.

Most therapists will talk about their “toolbox” rather than a protocol. Even interventions presented as a protocol, will quickly be modified and changed to accommodate a child’s needs and make the intervention more successful.

The Message

As the scope of behavioral optometry evolves, know that an understanding of the interaction of all systems, including the patient’s individual context, will render protocols less and less useful. The provider intervening must be able to apply tools from their toolbox freely and confidently to adjust for constantly changing demands of a specific patient and the individual needs of their special patient.

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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 as 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 skill 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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Every Optometrist should have a favorite Occupational Therapist

ODs and OTs…how i joined the team

It was my luck to find a job at a forward thinking optometry practice that wanted an occupational therapist on-site to provide low vision services (training on devices, home modification, etc). But the occupational therapy scope quickly moved to reading problems, visual motor integration, handwriting and “visual processing” problems.  I had to quickly learn about eye movements, convergence and focusing problems that our ODs were finding. I learned about the Convergence Insufficiency Treatment trial and the prevalence of eye movement problems affecting the functional outcomes of pediatric OT patients. I attended NORA training levels one and two. I even got learn about performance vision training as part of the High Performance Vision Associates.

The results were amazing. When the practice changed ownership, I continued my practice as part of an outpatient pediatric therapy clinic working with other PTs OTs and and SLPs.

Helping more Children

The OD that I worked with continues sending me patients, only now, every child is seen regardless of insurance ( a problem in the OD clinic). I frequently spend 6-8 hours a day of direct patient contact on vision patients. Now with a complete therapy clinic, the scope had expanded to managing the strength and postural problems, as well as the sensory problems often associated with children that have eye movement problems.  We are adding vision rehab to traditional pediatric occupational therapy

And the optometrist that refers to me? He is also very busy, as his reputation for performing complete eye exams on special needs children and finding problems other ODs did not, made him the “go to guy” in our community.

Why partner with an OT?

Every optometrist should have an OT that they can refer patients. As OTs, our education includes standardized testing for fine and gross motor defects, learning the developmental sequence from birth to old age and kinesiology and movement. We treat sensory problems and use reliable and valid tools to identify these problems. We are already treating the children with eye movement problems and doing the best we can. We know a part of the puzzle is missing.

Training needed

The OD may have to spend some time with the occupational therapist teaching about convergence and the near vision system and the most efficient way to treat these things. The course I present teaches the basic skills for this and I have taught about 700 therapists so far.  You, as an OD, will quickly find a receptive therapist as we recognize that vision is standing in the way of our kiddos progress, but we do not know how to fix. In return, a rewarding symbiotic relationship can begin that benefits all involved. Mostly, it benefits the children that need these important interventions to be more accessible .

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Convergence Tasks for Therapists

The Z axis

As therapists, we recognize the importance of mid-line crossing to help with primitive reflexes.  Reaching lateral outside of the base of support challenges balance and posture.

But to exercise convergence, the therapist must turn their favorite activity into the “Z axis”. This axis is the near-far axis, (referred to as the Z axis in vision) and challenges the convergence and accommodation system.  Many of our favorite activities can be modified just by turning them, to help strengthen the near vision system.

Simple convergence strengthening activities

Clothespins are great therapy tool, strengthening pinch for writing and other tasks. Having a child reach to a distance to retrieve the clothespin then hanging the clothespin on a near string can can help with convergence and divergence. The proprioceptive input of the hand hanging the clothespin on the string will cue the eyes to converge to a point.

In my clinic, I also use a cup with a straw that patients then put toothpicks in. This task can be graded by moving the cup closer to the child’s face.  This is task also made more difficult by not allowing the kiddo to touch the straw, removing the proprioceptive input,  forcing the eyes to guide the hand more accurately.

Amazing creative therapists

The brain storming part of my course is my favorite part of the day. It reminds me of the creativity and ingenuity of therapists.  We have experience applying a concept to help our patients, in an economic, convenient way. For many therapists, it is this creative part of the therapist experience that keeps us excited about what we do.  It is my pleasure to share some of the ideas that other therapists have shared with me.

Cheerios on a Straw

In the task, the patient puts cheerios on a small coffee stirrer. The hand working at the end of the straw does a great job cuing the eyes to converge. Just make sure the straw stays in at mid-line.

Ball in a Tube

In this task, a 4 ft florescent bulb protector ($4 at Home Depot) is cut in half with a ping pong ball put inside. I then placed stickers on top of the tube. The patient has to align the ping pong ball under the the sticker. In standing? Even better. Balancing on a balance board? Even better!!!

As a bonus, the scrap end of the tube become a great “light saber” for popping bubbles to work on tracking and eye hand coordination.

Thanks to therapists that I have met

The weeks I spend traveling are exhausting but the energy of the people I met help me stay motivated. Thank you to all the therapists and teachers and others, that I have met.

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