VISION THERAPY FOR CHILDREN

Sadly, many children with visual development disorders are mislabeled, misdiagnosed or mistreated. As a result, child and his family suffer needlessly. KRISHNA VISION THERAPY is about putting an end to needless suffering. They have helped many of children and families go on to lead happier, healthier and more productive lives.

Highly trained, experienced vision therapists

Though they work with the wide variety of vision problems, their specialty is working with visuo-cognitive difficulties, often described as visuo-spatial, visual perceptual or visual processing disorders. They tailor their approach to the child’s particular needs, to remedy his or her condition in the most positive and nurturing way. The staff is well-trained and highly experienced with autism, PDD, ADD, dyslexia and other so-called learning disabilities. They see children who have not yet learned how to use their eyes and vision correctly and have not integrated their visual skills with the rest of their senses and movements. These difficulties are often not observed until second or third grade.

Conditions

• Amblyopia or Lazy Eye
• Vergence Problems
• Focusing Problems
• Squint or Crossed Eyes
• Nystagmus

AMBLYOPIA OR LAZY EYE IN CHILDREN

Amblyopia is commonly known as lazy eye. Amblyopia means poor vision in an eye that could not develop normal sight during childhood. This can happen in both the eyes as well.

If the brain has not received clear images from the weak eye, it starts neglecting this eye. The eye is then said to be amblyopic or lazy as vision does not develop to its potential.

Common causes of Amblyopia

• refractive errors such as short sightedness, long sightedness or astigmatism
• large difference in spectacle powers between the two eyes
• strabismus or squint
• Obstruction or deprivation of vision by droopy eyelid,cataract, any corneal opacity or other eye diseases.

Management

Successful treatment depends on how severe the Amblyopia is and the onset of deprivation of vision.

• Spectacles: The child should be encouraged to wear his or her spectacles as much as possible throughout his waking hours if he or she is being treated for Amblyopia
• Modified Patching: Patching the good eye for few hours to force the lazy eye to work may be advised in few children. Patching requires a tremendous amount of cooperation and understanding by the parents, teachers and peers.
• Pharmacological Treatment: Sometimes we prescribe some medications to help the amblyopic eye see.
• Vision Therapy: Individualized computerized programmes, sometimes with help of prisms are aimed to remove the suppression in the brain towards the lazy eye and enable the brain to acknowledge impulses sent to it from that eye.

Advantages of vision therapy in the treatment of Amblyopia

• works on both eyes, so develops binocular vision and 3D or stereo vision
• helps in adult Amblyopia reversal
• shorter treatment time span or quicker rehabilitation
• Longer retention or no regression so it’s a onetime treatment modality.
• Better compliance and acceptance

VERGENCE PROBLEMS IN CHILDREN

Vergence dysfunction involves disjunctive eye movements in which the visual axes either move toward each other (convergence) or away from each other (divergence), resulting in the inability of the eyes to accurately fixate and stabilize a retinal image.In simpler words, vergence dysfunction is the inability of the two eyes to accurately point in the same position at any particular time at any particular distance.

Causes of Vergence Dysfunction

It may occur due to

• Disturbances in binocular eye movements
• Alteration in visual environment
• Head trauma
• Certain systemic disorders like Graves’s disease, Parkinson disease, Alzheimer disease etc.
• Genetic predisposition

Types of Vergence Dysfunction:

• Convergence Insufficiency
• Divergence Excess
• Basic Exophoria
• Convergence Excess
• Divergence Insufficiency
• Basic Esophoria
• Fusional Vergence Dysfunction
• Vertical Heterophorias
• Out of these, convergence insufficiency (CI) is the most common binocular vision disorder in which eyes do not work together for near work.

Symptoms of patients with Vergence anomalies:

Most of the persons with vergence anomalies remain asymptomatic until the time visual environment is altered specifically in the situation of increased near work. Usually following symptoms are found in a person with vergence anomalies:

• Eyestrain
• Headaches
• Blurred vision
• Double vision (Diplopia)
• Heavy eyelids
• Ocular discomfort
• Eye fatigue
• Sleepiness
• Lack of concentration
• Avoidance of eye contact
• One shoulder higher
• Short attention span
• Movement of print while reading
• Frequent loss of place while reading
• Squinting of eye
• Excessive rubbing of eyes
• Cover or close one eye while reading
• Motion sickness and/or vertigo

Early detection and prevention of Vergence Dysfunction

Early detection of vergence dysfunction is required to prevent the conversion of this anomaly to squint. The most important age to detect any vergence dysfunction is before 2 years as this is the developmental age of normal binocularity. In children, it is all the more important to diagnose the condition as early as possible to provide best academic success opportunities.

Diagnosis of Vergence dysfunction

Careful examination of the patient holds key for proper diagnosis of vergence dysfunction. It may include the following:

• Complete patient history
• Thorough eye examination including:
• Visual Acuity
• Refraction
• Ocular Motility and Alignment
• Near Point of Convergence
• Near Fusional Vergence Amplitudes
• Relative Accommodation Measurements
• Accommodative Amplitude and Facility
• Stereopsis
• Ocular Health Assessment
• Systemic Health Screening

Management of Vergence Dysfunction

After thorough interpretation and analysis of the examination results, a strategy to manage the condition is drafted that may include:

• Correction of any refractive error like far-sightedness, near-sightedness, astigmatism etc.
• Prism lenses
• Training Spectacle lenses for all close work to improve focusing stamina

Vision Therapy for Vergence Dysfunction:

The main aim of vision therapy in Vergence dysfunction patients is to eliminate the signs and symptoms and improve the quality of life of the patient. VT works in following three phases:

• First phase normalize accommodative and vergence amplitudes by using large targets and encouraging patient to maximize his efforts to increase vergence amplitudes.
• Second phase increase the speed of response to accommodative and vergence stimuli by using targets and different stimuli.
• Third phase is called jump or step vergence stimuli in which patient is required to make large-jump accommodative and vergence movements instead of incrementally increasing stimuli. This phase automate both accommodative and vergence reflexes.

Advantages of vision Therapy:

• Improves reflex-fast fusional vergence
• Expands slow vergence responses
• Restores accommodative flexibility
• Enhances the flexibility between accommodation and vergence
• Re-establishes automated, effortless accommodative and vergence responses under any stimulus condition.

FOCUSING PROBLEMS IN CHILDREN

Accommodation (focusing) Dysfunction is a non‐aging, non‐refractive, neuromuscular abnormality of the visual system.In simpler terms, an individual who cannot hold prolonged near focus is considered to have accommodation dysfunction.Accommodation is the adjustment of an eye to see objects at different distances by changing the shape of the lens through the action of the ciliary muscles. Any dysfunction or interference with the ability of eye to accommodate is termed as accommodative dysfunction and can be of following types:

• Accommodative excess/spasm is excessive accommodative response than required for accurate near binocular vision
• Accommodative infacility/inertia is slowness to change accommodation from one level to another
• Accommodative insufficiency is the reduced level of focus stamina (accommodation) for accurate near binocular vision. Almost 80% of Convergence excess children also demonstrate Accommodative insufficiency.
• Ill-sustained accommodation is a condition in which the AA is normal, but fatigue occurs with repeated accommodative stimulation.
• Accommodative paresis/palsy is the absence of an ability to produce an accommodative response as a consequence of some disease or trauma.

Accommodative paresis, excess, and ill-sustained accommodation are relatively rare, and accommodative insufficiency and infacility are the two most common types of accommodative dysfunctions.

Characteristics of Accommodation Dysfunction

• Acquired fatigue problem which produces eye strain and strain
• Inadequate accommodative accuracy, facility and flexibility
• Reduced amplitude of accommodation
• Inability to easily sustain accommodation
• Is caused by prolonged near work

Cause of Accommodation Dysfunction

Accommodation dysfunction can develop because of any of the following reasons:

• Poor general health of the person due to chronic fatigue syndrome
• Certain medications like Ritalin, antihistamines etc.
• High degree far-sightedness
• Eye turn especially Esotropia
• Extreme Near Point Stress
• Prolonged near tasks
• Stressful near focused task

Symptoms of Accommodative Dysfunctions:

Symptoms appear when eye is under excessive near stress for prolonged period and includes the following:

• Visual Stress symptoms:
• Red eyes
• Sore eyes
• Headache
• Blurry vision
• Reduced near point acuity
• Excessive rubbing of the eyes
• Eye strain
• Reading problems
• Periodic blurring of distance vision after prolonged near visual activities
• Periodic double near vision
• Difficulty to sustain near vision
• Glare with computer screen or even page
• Excessive fatigue
• Sensitivity to light
• Poor concentration
• Abnormal postures to make work closer to the eye e.g. tilting of head
• It can be asymptomatic with patient or his relative complaining of avoidance of reading or other close work

Early detection and prevention of Accommodative dysfunction

Although early detection does not assure long-term sustainability of accommodative dysfunction but it is definitely ideal to get it diagnosed before the condition worsens. In fact, in the case of children, it is all the more important to diagnose it as early as possible to allow the child to grow properly and avoid any kind of effect on his future school performance. For this, the first eye examination of the child should be just after he completes 6 months age, followed by the second examination at 3 years of age if everything is fine. But in the case of any abnormality in the vision, early follow-ups should be planned and followed.

Diagnosis of Accommodation dysfunction

The evaluation of accommodative dysfunction may include, but is not limited to the following areas:

• Complete patient history
• Thorough eye examination including:
• Visual Acuity
• Refraction
• Ocular Motility and Alignment
• Near Point of Convergence
• Near Fusional Vergence Amplitudes
• Relative Accommodation Measurements
• Accommodative Amplitude and Facility
• Stereopsis
• Ocular Health Assessment
• Systemic Health Screening

Treatment strategies for Accommodative dysfunction:

• Correction of any refractive error like far-sightedness, near-sightedness, astigmatism etc.
• Addition of plus lenses to stimulate accommodation
• Training Spectacle lenses for all close work to improve focusing stamina
• Vision therapy to restore normal accommodative dysfunction includes following techniques or procedures:
• Accommodative rock technique is done by alternating lens powers, or by alternating fixation distance. Rocking with lenses bolster the sufferer’s ability to sustain focus while reading for extended periods of time.
• Monocular activities with the help of eye patches
• Binocular activities with a loose plus or minus lens held in front of one eye, and a loose prism lens in front of the other eye to dissociate.
• Volunteer accommodation controlling techniques

SQUINT OR CROSSED EYE IN CHILDREN

A squint or crossed eye is a condition where both eyes do not move together. One eye deviates either inward, outward, upward or downward while the other eye remains straight.

Common causes of squint

• Lazy eye
• Nerve or muscle paralysis
• Refractive errors
• Corneal scar, cataract or retinal problems

Management of Squint

• Treatment of squint requires a combination of glasses, exercises and surgery
• Exercises in the form of vision therapy which are computerized and individualized help to regain control over eye movements and fusional abilities.
• Squint correction is important as if left uncorrected it leads to deep Amblyopia and psychological problems in children.

Advantages of Vision therapy in squint patients

• Corrects Phorias
• Develops binocular vision
• Post surgery helps maintain the alignment of eyes
• Helps correct paralytic squints
• Helps settle double vision or diplopia
• Develops depth perception
• Non surgical option

NYSTAGMUS IN CHILDREN

Nystagmus is usually an infantile condition that occurs in very early age and causes abnormal and involuntary movement of the eyes resulting in swinging motion rather than staying fixed on an object or person. The eyes move together oscillating or swinging like a pendulum. It may also cause the eyes to jerk sideways or up and down.

Different kinds of Nystagmus

• Manifest nystagmus that is present all the time
• Congenital nystagmus is present from birth
• Manifest-latent nystagmus is always present but worsens when one eye is covered
• Acquired nystagmus is caused by an accident or some diseases like multiple sclerosis, brain tumor etc.
• Latent nystagmus occurs when one eye is covered

Basic types of Nystagmus

• Optokinetic (eye related) can occur due to optic nerve abnormalities, congenital cataracts and retinal dystrophies.
• Vestibular (inner ear related) or jerk nystagmus in which eyes slowly drift in one direction and then jerk back in other direction.

Symptoms of Nystagmus

• It is an involuntary condition, meaning people with the condition cannot control their eyes.
• It worsens with tiredness and stress
• Affects both vision and appearance
• Unclear image formation due to continuous sweeping of eyes
• Eyes in constant motion
• Abnormal head posture

Vision Therapy for Nystagmus

Vision Therapy program for Nystagmus involve the use of visual, auditory, tactile, & proprioceptive feedback in conjunction with visual attention, visual imagery, and relaxation techniques to train and improve visual skills & abilities resulting in followings:

• Improved vision
• Improved Eye-Muscle Coordination
• Better eye contact
• Accurate Visual Tracking
• Eye Control
• Sustained focus
• Visual Perception
• Eye-hand Coordination
• Good Visualization