Amblyopia treatment

A large focus of what we do at our Vancouver eye clinic is the treatment of amblyopia using optometric vision therapy.

Developmental optometrists have long used active forms of therapy to rehabilitate the lazy eye that does not see well in amblyopic patients. The advantages of therapy over patching are that therapy is much more enjoyable for children than wearing an eye patch.  Moreover, therapy develops the binocularity (i.e. binocular vision or the two eyes working together as a team) of the visual system.

While optometrists have been doing this for a very long time, only recently have eye surgeons and the wider medical community come on-board with this approach. Dr. Leonard Press has found this passage in a new book on Vision Development by Dr. Daw, Professor Emeritus of Ophthalmology and Neuroscience at Yale University, where Dr. Daw acknowledges that vision therapists have been using effective active forms of therapy for a long time.

“Use of perceptual learning and video games has helped by increasing activity and attention as the therapy is done. Many of the principles have been employed by pediatric vision therapists for some time, but the publicity generated by “Stereo Sue” and others has helped to broadcast them.”

As stated in this passage, much credit goes to Dr. Susan Barry (known as "Stereo Sue") and her book Fixing My Gaze for increasing awareness of vision therapy techniques.  Dr. Barry is a neuroscientist, who was born with strabismus (an eye turn) and had lived all her life without stereo vision, meaning that she could not see in three dimensions. Her case was also the subject of an article in the New Yorker by Oliver Sacks.

She had three surgeries to "correct" the eye turn cosmetically but she still could not see properly and the eye was still turned, although less than before. She had lived this way for over 40 years until she met optometrist Dr. Theresa Ruggiero. Dr. Ruggiero treated Susan with vision therapy which corrected the eye turn and allowed her see in three dimensions for the first time in her life.

Thanks to vision therapy and the work of developmental optometrists, amblyopia is now widely regarded as a binocular problem, not a monocular problem upon which the old treatment of eye patching was based.  Here is one quotation from a study that makes the point:

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.

Hess, Robert F.; Mansouri, Behzad; Thompson, Benjamin, A Binocular Approach to Treating Amblyopia: Antisuppression Therapy. Optometry & Vision Science:September 2010 - Volume 87 - Issue 9 - pp 697-704

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Is your child at risk for a vision disorder? Take this interactive quiz to find out. Wednesday, February 8, 2012

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Life demands more than 20/20

In order for children to learn well, they need to see well. Parents may not realize there is more to good vision than 20/20 and that there are conditions that vision screenings can miss. Two optometrists conducted a visual experiment where common visual problems known to affect learning in kids are simulated in 4 adult teachers, and their experience and reaction are discussed.

 

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Which treatments are better than patching for amblyopia?

Patching is often the worst treatment for amblyopia for a number of reasons, including loss of self-esteem and exposure to bullying.  There are more effective and pleasant treatments available.  Read more...

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The ultimate amblyopia infographic

The amblyopia experts at Vision Help have created this helpful info-graphic to help spread the word on the latest science in treating amblyopia (lazy eye).  We are re-posting it here to help spread the word on the latest treatments and the important information that patching for many hours a day is an out-dated and unnecessary practice.

Advanced treatments are available at our Vancouver vision clinic at at the clinics of developmental optometrists across North America.  To find a doctor near you, visit the College of Optometrists in Vision Development.

Related articles:

More evidence that patching alone is not good enough for treating amblyopia

Apr 29, 2013

Patching alone is not good enough for amblyopia ... - See for Life
Apr 22, 2013

Active therapy is more effective for amblyopia
Nov 20, 2011

Childhood vision disorders lead to adult problems 
Jun 13, 2011

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".

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.

Take your kids to see "Thor": doctor's orders!

One of problems in diagnosing vision disorders in children is that children who have never had normal vision have no way to know that there is anything wrong with their vision.  They have always seen that way and they think that everyone else sees that way too.

Most optometrists can tell you a story of a young child, perhaps 5 or 6 years old who goes to the eye doctor because she is not picking things up in school and a visual problem is suspected.  It turns out that the child is severely myopic and has likely never even seen the faces of her parents beyond identifying them as a particularly shaped blurr.  It is a heart warming moment when the child sees her mother clearly for the first time!  Here is a video of Dr. Randahwa telling this story about what happened with a five-year old girl in our Vancouver opometry clinic:

The same is the case with patients who have strabismus or ablyopia.  While the former may present itself in the form of a noticeable eye turn, amblyopia (or lazy eye, as it is is sometimes known - a condition where one eye is not working properly and may even be legally blind) is not obvious.   Patients with these conditions suffer from binocular vision problems (when the two eyes do not work together properly) and will often have stereo vision problems that make it impossible for them to see in 3D.  The problem is that such a child will not be able to tell you that there is anything wrong with her vision, because it has been that way for her entire life.  Read my older post about the book "Fixing my Gaze" to learn about a famous case of 3D deficiency and how an optometrist used vision therapy treated the problem.

Lack or depth perception and 3D vision could be a sign of a potentially life threatening disease.  It could be caused by eye cancer shutting off communication between one eye and the brain.  Cancer such as this should be caught early before it causes noticeable vision changes - that is the key to successful treatment and the reason why annual eye exams for children are so critical.

3D movies (like Thor, pictured to the right) and video games are an opportunity for parents to test 3D vision.  If a child does not experience the sensation of objects coming out at her from the screen, she may have a binocular vision problem.  You can ask your child to reach out for an object that is popping out of the screen.  If she does not reach out or does so at inappropriate times, you should take her to the optometrist for clinical testing.  

You can also ask your child to describe what the 3D movie or game is like.  Be careful not to ask vague questions like, "is this movie different from an ordinary movie?"  The child will be wearing 3D glasses, which can alter color and so the movie will be different for those reasons alone. 

While 3D media offer parents an opportunity to catch a visual problem, parents can always, and should regularly visit their optometrist where visual disorders like strabismus and lazy eye are routinely tested and diagnosed. 

Properly functioning binocular vision is not just necessary for enjoying the latest entertainment but it is vital for learning, sports, driving and it is necessary for many careers (you can't be an eye surgeon without good binocular vision, for example).

For more information of children's vision, eye care, and children's optometry, please visit www.kidsvision.ca.

Related articles:

What is 3D Vision Syndrome?

Don't like 3D movies? You may have 3D Vision syndrome

Life threatening disease found in girls eye - lack of 3D vision was the clue

Fixing My Gaze - Can you imagine not having 3D vision?

TED - ideas worth spreading - Susan Barry on how vision therapy gave her 3D vision

TED: Ideas Worth Spreading: Dr. Susan Barry on how vision therapy cured stereoblindess

Neuroscientist, Dr. Susan Barry, gave a TED talk on how optometric vision therapy allowed her to see in three dimensions for the first time at the age of 48.  Until then, she was stereo-blind, meaning that she could not see the world in 3D like people with normal vision.  Stereo-blindness is also called stereopsis.


TED stands for Technology, Entertainment and Design and is a global set of conferences owned by the private non-profit Sapling Foundation, formed to disseminate "ideas worth spreading".

Dr. Barry's story is now fairly well known.  Her 2009 book, Fixing My Gaze was Amazon.com's number 4 most popular science book of the year.  Her story was also the subject of an article in the New Yorker by famous scientist Oliver Sacks (who was played by Robin Williams in the film Awakenings).  


In this talk, Dr. Barry discusses the notion of the "critical period", a long-held belief among neuro-scientists which is being dis-proven by Sue Barry's story as well as current research.  Until very recently, it was thought that there was a critical period in human brain development beyond which the brain was "set in stone" and could not change.  The implication of this belief was that people with disorders like stereo-blindness or amblyopia that originate in the brain could not be cured beyond the age of 5 or 6.


Scientists now accept that the brain displays considerable neuroplasticity and that even the brains of adults can be trained to see normally.  In addition to conditions such as stereo-blindness, this has important implications for other brain-eye disorders such as strabismus, amblyopia and visual information processing disorders.  


Neuroplasticity is actually a prime reason for the success of vision therapy in treating these disorders.  As developmental optometrists will often say, vision therapy is like physical therapy for the eyes and brain.


More people that ever before are discovering that they are stereo-blind.  With the explosion of 3D entertainment, some parents are noticing that their children do not experience 3D media the way that normal-seeing people experience it.  This is often a red flag that prompts the parents to take their child to the optometrist for an eye examination.  Fortunately, as Susan Barry's story demonstrates, we can successfully treat people who are stereo-blind.


Click here to learn more about 3D vision and stereo-blindness.

Is your child at risk for a vision disorder? Take this interactive quiz to find out.

Organizations devoted to eye care estimate that one in five children has a vision disorder.  This can be something relatively simple like nearsightedness or farsightedness that can be corrected with eyeglasses.  However, more complicated disorders are also a possibility such as strabismus, amblyopia, convergence insufficiency, binocular vision problems, lack of depth perception and the list goes on.  To help you assess your child's risk, take the quiz at the bottom of this post.

It is critical that parents take their child's eye health and vision seriously.  I remember one kindergarten student who came in for her first eye exam.  Her vision was bad enough that she had never seen her mother's face before!  For her, the world was a collection of blurry blobs and because she had always seen that way, she assumed that it was normal.  The only way to really know if your child has a vision problem is to take the child to see an optometrist.

Click here to download the BC Doctors of Optometry brochure on childrens' eye health.  It is also available in a number of other languages.  Click the language of your choice:

English
French
Chinese
Punjabi
Spanish
Filipino
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For more information on vision and eye care for children, click here.

Here is the quiz:

http://www.optometrists.bc.ca/code/navigate.aspx?Id=86

Can't recognize faces? You may have a brain-related vision problem.

A study in the new issue of Optometry and Vision Science helps increase our understanding of how people recognize faces and why some people have difficulty with that task.

The authors looked at adults who had one eye removed while they were babies.  The study's results show that face perception is more difficult for adults that developed with the use of only one eye. The authors propose that vision connections in the brain may be reorganized in response to the removal of one eye and suggest that the visual system requires normal binocular vision  (two eyes working together) during development in order for brain areas associated with the perception of faces to fully mature.

The study has important implications for childhood vision care and suggests that vision problems during childhood development can have lasting impacts on brain development.  Optometrists routinely check for and treat conditions that can impact normal binocular vision such as amblyopia, strabismus and convergence insufficiency. 

It is important, critical even, for parents to have their children's eyes examined every year to ensure that such a condition does not go untreated.  Most of these conditions are easier to treat while the child is very young.  Optometrists can examine a child as young as six months to ensure that their eyes and visual system are developing properly and can then monitor potential problems as the child grows and develops.  If  problems materialize they can be treated effectively if caught early. If you are a parent, click here to review my childrens' vision guidelines. For more information on optometry for children, click here.

Video Game therapy, optometric vision therapy are more effective than patching alone in treating amblyopia

Optometrists have long been at the forefront of research into the vision problems and their relationship to the brain. 

Optometric vision therapy, for example, has been shown in studies to be more effective than patching alone in the treatment of amblyopia. Patching involves covering the good eye so that the weak eye is forced to received and process stimuli. The basic principle is that active therapy for the weaker amblyopic eye will improve acuity as well as promote properly functioning binocular vision. 

Many optometric clinics use video games as part of a vision therapy program to treat amblyopia.  Now a  number of studies have now shown that this approach is effective. 

In one such study, Optometrists at the University of California at Berkely did a pilot study that has found that playing video games can help improve the vision of adults with amblyopia. The study found that participants experienced marked improvement in visual acuity and 3-D depth perception after spending just 40 hours playing off-the-shelf video games.

“This study is the first to show that video game play is useful for improving blurred vision in adults with amblyopia,” lead author Dr. Roger Li, research optometrist, was reported as saying.  “I was very surprised by this finding; I didn’t expect to see this type of improvement.”  I don't think that most optometrists would be surprised.  The results confirm the clinical experience of those of us who use vision therapy to treat amblyopia.

The study was published in the August 2011 issue of the journal PLoS Biology and is freely available online.

Amblyopia is a brain disorder in which the vision in one eye does not develop properly.  It is the most frequent cause of permanent visual impairment in childhood, affecting around 3% of children.

But amblyopia is not just a problem for children.  It is also the most common cause of one-eye visual impairment among young and middle-aged adults.  Amblyopia in children can be often be successfully treated but adults do not generally respond as well to traditional treatment. 

Many eye doctors feel that treatment is hopeless after the age of 8 or so.  However, the outlook is not so bleak in the light of recent research into perceptual learning which has challenged the orthodox idea that no vision improvements are possible in adult amblyopes.

Research has shown that that intensive training on a perceptual task -like the kind of exercises prescribed  in optometric vision therapy- such as getting two horizontal lines aligned, could lead to a 30-40 percent improvement in visual acuity.

Since the PLoS Biology study on video game therapy, others have reached a similar conclusion.  Researchers from India reported similar findings from a study that looked at video game therapy for children at the American Academy of Ophthalmology 2011 Annual Meeting.  Children who had video game therapy showed 27% better vision improved that those children that were treated with patching along.

Optometrists who treat amblyopia have been saying for a long time that patching alone is not sufficient.  I'm happy to say that the recent research is proving them right and I hope that parents and patients with amblyopia get the message.

For more information visit www.amblyopia.ca

Image courtesy of imagerymajestic / FreeDigitalPhotos.net.

Fixing My Gaze - Can you imagine not having 3D vision?

I just read an inspirational book called Fixing My Gaze about neuroscientist, Susan Barry, who was born with strabismus (an eye turn) and had lived all her life without stereo vision, meaning that she could not see in three dimensions.

She had three surgeries to "correct" the eye turn cosmetically but she still could not see properly and the eye was still turned, although less than before. She had lived this way for over 40 years until she met optometrist Dr. Theresa Ruggiero.

Dr. Ruggiero treated Susan with vision therapy and corrected the eye turn and allowed her see in three dimensions for the first time in her life. Can you imaging how her world was transformed? I've heard rumors of a "Fixing My Gaze" movie but have not been able to confirm them.

Here is what Susan Barry said in an interview with Scientific American about how the world looked different after vision therapy:

"For the first time, I could see the volumes of space between different tree branches, and I liked immersing myself in those inviting pockets of space. As I walk about, leaves, pine needles, and flowers, - even light fixtures and ceiling pipes - seem to float on a medium more substantial than air. Snow no longer appears to fall in one plane slightly in front of me. Now, the snowflakes envelope me, floating by in layers and layers of depth. It's been seven years since I gained stereovision, but ordinary views like these still fill me with a deep sense of wonder and joy."

Our vision therapy practice includes many patients with strabismus but all of them are very young (obviously it is better to fix the problem when a patient is young to save her from living years with the condition).

Susan Barry's story is remarkable in that she was in midlife when she received vision therapy. The conventional wisdom, now being disproved by new studies, was that after the age of 7 or 8 , the brain could not be trained (or "rewired") to see in new ways. The old scientific thinking was that after early childhood, the brain became fixed. In fact, Susan Barry herself and other scientists thought that it was impossible for her to ever see in 3D.

Now, we know that the brain exhibits neuroplacticity and that given the proper behavioural therapy, even adults can rewire their brains. This has given hope to many people who did not receive treatment for visual processing disorders at a young age. Now it seems possible that even older patients with amblyopia or strabismus and other binocular vision disorders can benefit from treatments like vision therapy.

You can hear interviews with Susan Barry and read more about her story at her website: http://www.fixingmygaze.com/.