More evidence that patching alone is not enough for amblyopia treatment in adults

There was an excellent post on adult amblyopia at mainosmemos.com about this study: Dichoptic training enables the adult amblyopic brain to learn

The summary of the study is as follows:

....Adults with amblyopia, a common visual cortex disorder caused primarily by binocular disruption during an early critical period, do not respond to conventional therapy involving occlusion of one eye. But it is now clear that the adult human visual cortex has a significant degree of plasticity, .... One possibility is an inhibitory signal from the contralateral eye that suppresses cortical inputs from the amblyopic eye. .... Here we provide direct evidence that alleviating suppression of the amblyopic eye through dichoptic stimulus presentation induces greater levels of plasticity than forced use of the amblyopic eye alone. This indicates that suppression is a key gating mechanism that prevents the amblyopic brain from learning to see.....

The way we have been treating amblyopia at our Vancouver clinic has always been a two-eyed or binocular vision centric approach.  We have seen first hand that this approach is far better than patching alone - it results in better, faster and more permanent results with better depth perception and all the other benefits that come with developing good functioning binocular vision.

Dr. Maino's comments on the study are spot on:

The research continues to show that adults with amblyopia have a treatable condition AND that amblyopia is not just related to decreased visual acuity in one eye. Amblyopia is a two-eyed-brain problem! When are my colleagues going to realize that you should not treat amblyopia by patching alone?

We wrote a similar post recently, see "Patching alone is not enough for amblyopia treatment".

What is the best sunglasses lens in the world? Check the ESPF: eye-sun protection factor

What is ESPF?

ESPF is eye-sun protection factor - a way to measure the degree of UV protection provided by an eyeglass lens that was developed by the French optical company Essilor.

The higher the number, the higher the UV protection of a lens.  Most lenses that tout themselves as 100% UV protection, only block UV rays that hit the lens from the front - they block 100% the UV rays that hit the lens from the front only.  Those are ESPF 5 or 10 lenses.  Advanced UV technology lenses go up to ESPF 25 for a clear lens and ESPF 50 for a tinted sun lens.

With traditional UV lenses (the ones that only block rays form the front of the lens) you still get lots of  UV exposure from rays that reflect off the back of the lens and into your eyes, as shown in this diagram:

Some lenses, like Crizal Forte UV shown in the diagram, block UV rays that reflect of the back of the lens.  This gives you more than twice the UV protection of tranditional lenses.  Crizal Forte UV is an ESPF 25 lens.  It is the highest level of UV protection that you can get in a clear lens.

What is the best sunglasses lens?

To get the maximum protection, ESPF 50, you need to go with the Crizal Sun UV lens, which is the only (as far as we know) dark tinted lens that blocks UV rays from the front as well as reflected UV rays.  See the chart tat the end of this post for a list of the available ESPF 25 and ESPF 50 lenes.

Why worry about UV exposure?

UV exposure to the eyes increases the risk of diseases like cataracts and macular degeneration, which can cause permanent vision loss.  It also leads to skin cancer around the eyes, which is the most common kind of skin cancer.

Other UV related dangers include Pingueculae (small yellowish bumps on the white of the eye) and pterygium (opaque growth over the surface of the cornea). The more UV exposure you have during your life, the more likely you are to develop one of these damaging conditions.

Here is what vision is like with macular degeneration:

Here is what vision is like with cataracts:

ESPF 25 and ESPF 50 Lenses

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Strabismus surgery rates in decline because of non-surgical treatment approaches

We came across this article that reports on a study that was published in a recent issue of the British Journal of Ophthalmology that looked at strabismus surgery rates in children up to the age of 15 from 1963 to 2010 (519,089 children in total).  The study found the rate of strabismus surgery in the United Kingdom had dropped from 189 per 100,000 in 1968 to 64 per 100,000 in 2010, a threefold decrease.

According to the article, the major reason was non-surgical treatment approaches:

A switch from surgical to non-surgical treatment approaches, rather than a genuine fall in the prevalence of strabismus was likely to explain a large part of the decline in procedure rates, said the author, who suggested regional variations may reflect differences in strabismus prevalence.

We have not had a chance to read the study, but we have written extensively on this blog about non-surgical alternatives to strabismus surgery:

Non-surgical treatment alternatives to strabismus surgery - the risk of a single childhood exposure to anesthesia 
Jan 23, 2013
The saftey of using anesthesia in surgery on children is questioned by new scientific evidence. Non surgrical alternatives to strabismus (eye muscle) surgery.

Vision therapy or surgery for strabismus (esotropia, exotropia)
Jan 17, 2013
We here at Vision Source Vancouver think that it makes good sense to use effective non-surgical vision therapy to treat strabismus (sometimes called cross eyes, eye turn, esotropia, exotropia). The reason is that strabismus or ...

Alternatives to strabismus surgery - vision therapy is 87% effective
Oct 28, 2012
Vision therapy is a highly effective non-surgical treatment for strabismus that has been validated in numerous studies.

Another risk of strabismus surgery? 
Mar 07, 2012
Strabismus - a condition where the eye abnormally turns in or out due to one or more of the eye muscles malfunctioning - is often treated with surgery in which the properly functioning muscle is cut and re-attached so that it ...

How vision therapy worked where strabismus surgery failed
Nov 14, 2012
How vision therapy worked where strabismus surgery failed - the story of Dr. Susan Barry and her book, Fixing my Gaze.

After three unsuccessful strabismus surgeries, patient says enough
Nov 19, 2012
Repeat strabismus surgeries are common and are a reason parents seek non-surgical alternatives like vision therapy. ... Vision Therapy is an effective alternative to strabismus surgery. Here is a recent comment by a reader ...

Women at Higher-Risk than Men for Sight-Threatening Eye Diseases and Conditions

CHICAGO (March26, 2013) – Among the many differences between men and women’s health, women are more susceptible to vision impairment. Of the 4.1 million Americans age 40 and older who are visually impaired or blind, 2.6 million are women. And,according to a recent study by Prevent Blindness America, more women than men have age-related macular degeneration, cataracts, glaucoma and diabetic retinopathy, the four leading eye diseases in the country.

According to the National Eye Institute, the causes are primarily due to longevity as well as hormonal factors.  Prevent Blindness America has designated April as Women’s Eye Health and Safety Month in an effort to educate women about the steps they can take today to help preserve vision in the future.

“The first thing every woman should do, especially those ages 40 and older, is get a dilated eye exam," said Hugh R. Parry, president and CEO of Prevent Blindness America.  "Through early detection and treatment, vision loss can be lessened.”

Prevent Blindness America also recommends a healthy diet, quitting smoking, taking supplements (as approved by a medical professional), consistently wearing UV-blocking sunglasses with a brimmed hat outdoors and learning of any family history of eye disease.

If anyone is experiencing any of the following symptoms, an appointment with an eyecare professional should be made immediately:

• Unusual trouble adjusting to dark rooms;
• Difficulty focusing on near or distant objects;
• Squinting or blinking due to unusual sensitivity to light or glare;
• Change in color of iris;
• Red-rimmed, encrusted or swollen lids;
• Recurrent pain in or around eyes;
• Double vision;
• Dark spot at the center of viewing;
• Lines and edges appear distorted or wavy;
• Excess tearing or "watery eyes";
• Dry eyes with itching or burning; and
• Seeing spots, ghost-like images.

Patching alone is not good enough for amblyopia treatment

This point, that was made in a study published in the September 2010 issue of the journal Optometry & Vision Science should be required reading for every amblyopia patient (or their parents):

amblyopia is an intrinsically binocular problem and not the monocular problem on which current patching treatment is predicated. Thought of in this way, the binocular problem involving suppression should be tackled at the very outset if one is to achieve a good binocular outcome as opposed to hoping binocular vision will be regained simply as a consequence of acuity recovery in the amblyopic eye, which is the current approach and which is often not found to be the case.

Developmental (behavioural) optometrists (which is what we are) treat amblyopia using the better approach. If you are looking for a developmental or behavioural optometrist, visit the website of the College of Optometrists in Vision Development.

For more information on amblyopia, including alternatives to patching, visit www.amblyopia.ca.

Developmental optometrists find problems that other doctors don't look for

One special service that we offer patients at our Vancouver optometry clinic is developmental optometry.  Developmental optometrists find problems that other eye doctors are not trained to look for and treat.

For example, see this 1996 study from the field of rehabilitation medicine published in the journal NeuroRehabilitation by Raymond et al., where the authors advise that patients with potential visual information processing deficits should be referred to a behavioral or neuro-optometrist" and noted that "referrals made to an ophthalmologist may be insufficient, as they are primarily concerned with the health of the eye only."

Another word of advice comes from a recent family advice column from the Washington Post, where the writer said:

how well your son can see, it usually takes a developmental or behavioral optometrist to tell you how well his eyes are working when he reads or when he looks back and forth from the blackboard to the printed page. Some children get headaches because they can’t focus well or their vision is blurry, but they don’t complain because they think that heads are supposed to hurt or that the world is a blur for everyone.

If your son has these or other vision problems, don’t despair. Vision therapy is to the eyes what physical therapy is to the body, and it’s effective 90 percent of the time. He’ll just have to wear special glasses for a little while every day, do some eye exercises every day and maybe play a couple of video games. To learn more, go towww.covd.org, the Web site for the College of Optometrists in Vision Development.

Unfortunately, that incorrect approach has denied many patients treatment and diagnoses that would have improved their lives.

The US Army uses vision therapy to treat traumatic brain injuries

The United States Army uses vision therapy to treat traumatic brain injuries and has developmental optometrists on staff to provide the therapy.  It's no surprise since vision therapy is the most effective way to treat the vision problems that are the result of traumatic brain injury.  Vision therapy can be though of as neuro-ocular rehabilitation or rehab for the eyes and the brain.

At our Vancouver optometry clinic, we have the largest vision therapy practice in the city and we treat many patients who have vision problems as a result of traumatic brain injuries.  Most of the injuries resulted from car accidents or concussions sustained in sporting activities.  If you are reading this because you have vision problems arising form a brain injury, you can find a developmental optometrist near you at the website of the College of Optometrists in Vision Development.

For a list of scientific studies on vision therapy treatment of vision problems caused by brain injury, click here.   Here is a video on how the US army uses vision therapy to treat brain injuries (I bet you've never seen a doctor of optometry in camouflage before!):

http://www.pentagonchannel.mil/

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Vision problems caused by brain injury in a car accident are treated with vision therapy even a decade after the accident.

Visual processing and learning disorders

A recent study published in the journal Current Opinion in Ophthalmology called "Visual processing and learning disorders" came as a surprise to developmental optometrists who have been diagnosing and treating visual information processing disorders for decades.  The main treatment modality is vision therapy, which is neuro-ocular rehabilitation or rehabilitation for the eyes and brain working together.   

The study confirmed what has always been obvious to optometrists - that if the brain cannot properly process visual information, a child will have trouble reading and learning - even if he has 20/20 visual acuity.  The surprise was that the study was  published by ophthalmologists, who for too long have denied that vision had anything to do with learning.  For example, see this 1996 study from the field of rehabilitation medicine published in the journal NeuroRehabilitation by Raymond et al., where the authors advise that patients with potential visual information processing deficits should be referred to a behavioral or neuro-optometrist" and noted that "referrals made to an ophthalmologist may be insufficient, as they are primarily concerned with the health of the eye only."

Another word of advice comes from a recent family advice column from the Washington Post, where the writer said:

how well your son can see, it usually takes a developmental or behavioral optometrist to tell you how well his eyes are working when he reads or when he looks back and forth from the blackboard to the printed page. Some children get headaches because they can’t focus well or their vision is blurry, but they don’t complain because they think that heads are supposed to hurt or that the world is a blur for everyone.

If your son has these or other vision problems, don’t despair. Vision therapy is to the eyes what physical therapy is to the body, and it’s effective 90 percent of the time. He’ll just have to wear special glasses for a little while every day, do some eye exercises every day and maybe play a couple of video games. To learn more, go towww.covd.org, the Web site for the College of Optometrists in Vision Development.

Unfortunately, that incorrect approach has denied many patients treatment and diagnoses that would have improved their lives. Thankfully, ophthalmologists have now come around to common sense. The study encourages ophthalmologists to take visual information processing seriously:

Visual processing is the main brain function allowing normal perception of what is being viewed. Ophthalmologists as well as patients must realize that with normal 20/20 eyesight interpretation of what is seen may be dysfunctional because of faulty brain processing of that which is seen by normal eyes. Abnormal Visual Processing as well as auditory processing disorders eventually lead directly to learning disorders in children and young adults.

The study also emphasizes and important point.  Just because a child can see clearly or has 20/20 vision, does not mean that her entire visual system (including the brain) is functioning properly.  For eye doctors to say that nothing is wrong with a child just because she does not need glasses, gives the child and her parents a false and dangerous sense of security.  Moreover, it is irresponsible for a professional to say that there is nothing wrong with a patient when all tests have not been performed.    For that reason, we advocate that only a comprehensive eye examination with a full developmental vision investigation should be performed on a child and "quick-and-dirty" school screenings are not much help and may even be harmful for what they miss. 

 For more information on visual information processing, visit our visual information processing page where you can download our Fast Fact Sheet.

At Vision Source Vancouver, our eye and vision clinic we successfully treat dozens of patients every year for visual information processing disorders.  

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What is Convergence Insufficiency?

Convergence insufficiency is one of the most common vision disorders that interferes with a patient's ability to see, read, learn and work at close distances. In fact, because the symptoms are similar, many children are misdiagnosed with ADHD when they actually have convergence insufficiency.  

Convergence insufficiency was recently the focus of a scientific study in the United States funded by the National Institutes of Health and the National Eye Institute. The study found that in-office Vision Therapy was the best available treatment for convergence insufficiency, replacing conventional therapies such as "pencil push-ups", with 75% of patients showing significant improvement following vision therapy.


Convergence insufficiency is a vision problem where the two eyes don't work together in unison the way they should. With convergence insufficiency the eyes have a strong tendency to drift outward when reading or doing close work. The result can cause double vision and, at minimum, make reading and learning very difficult.

Syptoms of Convergence Insufficiency

The most common signs that your child is suffering from convergence insufficiency are the following:

• eyestrain (especially with or after reading)
• headaches
• blurred vision
• double vision
• inability to concentrate
• short attention span
• frequent loss of place
• squinting, rubbing, closing or covering an eye
• sleepiness during the activity
• trouble remembering what was read
• words appear to move, jump, swim or float
• problems with motion sickness and/or vertigo

It is estimated that least one out of every 20 school-age children is impacted by convergence insufficiency. Some studies even put the number as high as 15%. However, there are other visual abnormalities to be considered. It is estimated that over 60% of problem learners have undiagnosed vision problems contributing to their difficulties.

The latest research shows vision therapy is effective

The good news is the majority of these vision problems can be treated with a program of optometric vision therapy.

Even though the study by the NEI found that in-office vision therapy was the best treatment for convergence insufficiency, some doctors who are not up-to-date on the latest scientific research still tell their patients that "pencil push-ups" are the only treatment available that if if "pencil push-ups" don't work the patient is out of luck. This is not correct. The NEI study found that in-office vision therapy was significantly more effective than "pencil push-ups" and the only treatment that was more effective than a placebo. A number of follow up studies have been done; you may read about these on the binocular vision page.

There have also been follow-up studies by Scheiman et al. showing that the results obtained from vision therapy are were long-lasting and that the treatment kinetics are favorable – meaning that that rate at which patients get better with vision therapy makes office-based vision therapy an effective and practical treatment.

In 2005 Scheiman et al. published a clinical trial in Optometry and Vision Science on the vision therapy treatment of convergence insufficiency in young adults ages 19-30. Once again, the results proved the efficacy of vision therapy treatment over other modalities that were in use at the time. The study authors concluded:

"This first multicenter, randomized clinical trial of the treatment of symptomatic CI in young adults demonstrated that of the three treatment modalities, only vision therapy/orthoptics was effective in achieving normal clinical values for both the near point of convergence and positive fusional vergence. Patients in the pencil pushups group achieved normal values only for positive fusional vergence at near and patients in the placebo vision therapy/orthoptics group did not achieve normal findings for either the near point of convergence or positive fusional vergence at near.Therefore, the effectiveness of vision therapy/orthoptics in improving the near point of convergence and positive fusional convergence values at near in adults cannot be explained on the basis of a placebo effect. Based on the results of this preliminary study, it would appear thatpencil pushups, the most popular treatment for CI, is not effective for achieving clinically significant improvements in symptoms or signs associated with CI in young adults." 

A study published in 2010 by Alvarez et al. in Optometry and Vision Science adds to the depth of the scientific evidence by showing that vision therapy produced demonstrated changes in eye movements together with significantly increased functional activity within the frontal areas of the brain, the cerebellum, and brain stem. These regions of the brain are likely to ―participate in a collicular-cortical dorsal visual networks and may reflect increased processing of visual material specific to near space. This study demonstrates the motor and neurological mechanism by which vision therapy operates. The brainscan images published in the Alvarez study are worthy of review.

Related articles:

The gold standard treatment for convergence insufficiency

What does convergence insufficiency look like?

Vision therapy for convergence insufficiency improves academic behaviors

Is your child smart in everything but school? The ultimate infographic

Problem readers may have convergence insufficiency

Adults with convergence insufficiency

New research on the connection between convergence insufficiency and ADHD

Convergence Insufficiency Treatment Success Rate

Pencil push-ups are so last decade

Binocular vision dysfunctions ate my homework

Your iphone can be a pain in the eye

60% of students labeled "learning disabled" failed two or more binocular vision tests

For more information visit: www.convergenceinsufficiency.org

To read success stories about Vision Therapy and convergence
insufficiency visit: www.visiontherapystories.org/convergence_insufficiency.html

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ADHD dianoses skyrocket - are children being inappropriately diagnosed? Vision problems can cause the same symptoms.

It is shocking that 11% of children have received a diagnosis of attention deficit hyperactivity disorder (ADHD).  This sharp rise in ADHD diagnoses over the last decade is cause many to worry about inappropriate diagnosis and the unnecessary overmedication of children.

Even more troubling, we can expect over-treatment to increase in the near future because, according to the New York Times:

the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. A.D.H.D. is described by most experts as resulting from abnormal chemical levels in the brain that impair a person’s impulse control and attention skills.

There are many reasons for the increase.  Experts believe that some doctors are quick to jump to the conclusion that a child has ADHD when they present with any indication of inattention.  Another factor may be advertising by the pharmaceutical industry that presents medication as something that can drastically improve a child's life.  Some people blame the parents for pressuring doctors into doing something to improve a child's academic performance.

ADHD medications such as Adderall, Ritalin, Concerta and Vyvanse can be dangerous.  Some children who are put on the drugs will end up with abuse and dependency problems.  Moreover, some studies suggest that 30% of the pills go to friends who take them without any medical advice.

One reason for the rise in ADHD diagnoses may be that doctors are simply not thorough enough in ruling out other treatable disorders that cause similar symptoms.  Numerous studies have shown that people with eye movement disorders such as convergence insufficiency have the same symptoms as ADHD and that vision therapy treatment of the eye disorder results in a reduction or elimination of symptoms.  Studies have proven that vision therapy is the best treatment for convergence insufficiency.

Here are some articles on the connection between convergence insufficiency and ADHD:

Related Articles:


Convergence insufficiency symptoms - doctors need to pay attention to performance related symptoms such as reading performance, attention and ADHD-like symptoms

New research on the connection between convergence insufficiency and ADHD

Is your child smart in everything but school?

Vision therapy for attention skills greatly improves reading performance

How to choose a children's optometrist - tips from a pediatric optometrist