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Vision Therapy: An Overview of Complaints and Symptoms

To kick-off our Vision Therapy discussion, let’s review the most common patient complaints that lead you down the path of investigating visual system dysfunction. The best place to find visual system issues is during the routine eye examination. Your patient is liking coming in to your office with a complaint (or several). Dr. S has compiled an overview of the most common complaints from patients that raise a red flag:

Temporal headaches? It could be convergence
issues! via

Headaches

Ask your patient to show you where their head hurts. The isolation of certain areas can be dramatic, and especially helpful to your diagnosis! If Dr. S asks a child where their head hurts and they point directly to one area, the child almost just diagnosed themselves. If they point to their temples she is thinking binocular issues, and if the child points to their forehead she is thinking accommodative issues. Conversely, if the child says “all over” or is vague about their headache, talking to a parent about the symptoms can sometimes clear up confusion. A child may have a hard time describing their symptoms, but a parent can often fill in the gaps. A parent may observe a child rubbing a particular area, or remember a time that their child gave them more details about their headache symptoms at home.

Blurry Vision – especially that comes and goes

It's important to ask not just what distance is blurry, but if it is blurry all the time, or only in certain environments or after certain activities. A classic entering complaint for accommodative dysfunction is actually blurry vision reading the board at school. It may seem counter-intuitive at first, but if the child's eyes are have trouble keeping focused up close (accommodation), then they also will have trouble relaxing the focusing system back out to see in the distance. The focusing system gets "locked up" if you will. This patient usually has relatively good vision at their eye exam, and will have a prescription right at zero in most cases. If you investigate further, a lot of times even the child has noticed their vision is only blurry in the distance at school after they have been doing paper work or reading or taking a test. Again, this one complaint almost diagnoses things without doing one extra test.

Tired Eyes

Difficulty Reading

Ask about school performance, reading speed, and how the child reads. Do they often lose their place when reading? Do they sometimes start reading the same line they just finished? Are they having to use a finger to track their place? All of these issues are commonly found in children with ocular motor dysfunction.

Difficulty copying from the board

This is a great example of a combined visual skill task. The patient has to use their eye muscle movement to track the line, and then their focusing system to change from their paper to the board. Challenges here could be an issue with accommodation, ocular motor skills, or both!

Try reading this artistic rendering of doouble vision,
and imagine how long it might take you to finish
a paragraph. via

Seeing words move and bump into each other when reading

Dr. S recommends this phrasing as a better way to describe double vision to children. If you have ever asked someone if they have double vision, you will quickly learn that even adults aren't sure what that means, much less a child. Describing it as moving or jumbling words and letters can be a more relatable description to the patient.

Reversals of letters or numbers

General disinterest in reading or poor performance

Often times discussing these symptoms requires speaking with the parent, because it is difficult for a child to fully discuss and describe their own symptoms (especially if they are quite young). Teachers often give parents good insight on what they witness the child doing in the classroom, and I often ask parents specifically about anything teachers might have said. Unfortunately, many visual development issues can go undetected until a child begins struggling in the classroom, and a teacher can be a good resource as to how the child is functioning on a daily basis.

We have focused on children to this point, because their visual system is still struggling to perform the tasks required in the classroom. For a child with a visual system issue, whether it is difficult focusing at near, keeping the eyes working together, or movement and tracking skills of the eye muscles themselves, the classroom is like an obstacle course challenging the child at every step. The simple act of copying from a board, reading a book, or writing letters and numbers can be excessively challenging for a child with visual system issues, and that is why visual problems are often misdiagnosed as behavioral or attention issues. Children in the classroom are not the only patients that suffer from visual efficiency problems, however. I often see adults with binocular issues too, but on average adults tend to be less symptomatic because their eyes have been dealing with these issues for years. Adult visual systems have typically made adjustments and compensations to deal with their visual system’s inadequacies. These can be seen in head tilts, suppression of one eye, and even career selections! A patient with major visual dysfunction probably isn’t going to pursue a career that requires long hours reading or in front of a computer screen. Catching visual development issues early is key to giving the eyes their best chance at working efficiently later in life, but even adults can benefit from therapy if they are symptomatic.

In Adults:

Dr. S reports that the same symptoms that affect children are often adult complaints as well. Patients with binocular or accommodative visual issues may sometimes slip through the cracks as children with only mild symptoms, but long hours in front of a computer can make their visual system’s inefficiency rear its ugly head in serious strain and end of day fatigue at the job. In addition to longstanding development issues, there are major traumatic events like brain injuries, concussions, and a host of systemic medical conditions that can cause new onset visual system inefficiencies that require immediate intervention. Patients suffering from stroke, Lyme disease, and meningitis can often have issues with accommodation and binocular vision, and Dr. S has seen good success with treating these patients with prescriptive lenses and in office vision therapy.

Common Symptoms Post-Trauma

Concussion patients can suffer from a host of visual deficiencies. While irregular pupillary reaction is often an initial symptom, the visual processing and focusing ability of a patient can take months to recover. The most common visual disorder after concussion is a difficulty focusing to read (or accommodation issues). Sometimes prescription reading glasses can temporarily help relieve eye strain as the visual system recovers. There are also a multitude of studies that show concussion sufferers may have immediate decrease in their ability to track and make reading eye movements (pursuits and saccadic eye movements). The King Devick test is even being offered as a way to help diagnose concussions due to its ability to quickly find ocular motor issues.

Traumatic brain injury can often cause visual processing issues like new onset reversals, neglect (where the patient ignores parts of their vision even though they can functionally see), and midline shift. These visual inefficiencies can cause severe difficulties as the patient attempts to navigate their world, and visual therapy can help patients to learn to compensate for these changes in their visual system.

Asking a patient to fill out the numbers on a clock can be telling after a traumatic brain injury. If they suffer from spatial neglect, the patient knows that the clock needs all 12 numbers, but they just cannot get their brain to process that other half of the clock, so all the numbers get crammed into just one side. Vision therapy can help the patient learn to compensate for their neglected area of vision. via

Interested in learning, how Dr. S uncovers her patients’ visual system inefficiencies? The next post will outline her diagnostic routine and the tests she feels yield the best results.

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An Introduction to Vision Therapy

clear vision but eye strain issues 11:36 AM

For best visual clarity, depth perception, and ocular comfort, your eyes need to be able to work together--with ease! But every single day I see patients whose eyes struggle to do so, causing uncomfortable strain, fatigue, and even double vision or severe headaches and migraines. For these patients, their day is a constant battle getting their eyes to function – either struggling to fuse together, to keep near objects clear and in focus, to move eyes smoothly and easily for reading vision performance, or even to adequately process peripheral vision information for important activities like driving or walking around. These are skills many of us take for granted; our eyes just naturally perform them. But for a multitude of people worldwide, these "normal" visual skills are a daily struggle, and no single pair of glasses or LASIK surgery is going to solve the problem. Luckily, optometrists are dedicated to helping your eyes not just see clearly, but to maximizing every area of your visual performance.

Vision Therapy can address a plethora of visual function issues, from
binocularity to accommodation to visual processing. Via

Are you working in high demand visual environments like all-day computer use, where so many of us now spend our work days? Visual performance can take a major dip under these scenarios, causing eye strain, headaches, and even blurry vision at the end of the day. And in children, visual system development issues can devastate their school performance, causing them to reverse numbers and letters, and struggle with reading speed and comprehension. These problems often go undiagnosed. Children with visual efficiency issues would typically pass a pediatric office screening exam; affected adults might have perfect driving and distance vision, and many times never had any vision problems until they started their current job. But vision is not just about being able to read the 20/20 line. By not having their visual system evaluated fully, potentially hundreds of thousands of school children could be struggling unnecessarily in their classwork, or even being misdiagnosed as having attention deficit issues! Luckily there are a growing number of optometrists dedicated to helping these patients retrain their visual system to work more efficiently. Eyedolatry is honored to bring you a series of posts dedicated as a primer to vision therapy – what signs and symptoms to look for in your routine eye exams, what equipment you need to get started, and how to practically incorporate vision therapy into your office.

Meet our Vision Therapy panelist, Dr. S

She is a residency trained pediatric and vision therapy specialist, currently practicing in Illinois. Her insights and experiences in starting a vision therapy practice will be featured throughout the coming posts. Please email or post comments here if you have specific questions for her in her area of expertise.

Up this week: The symptoms to look for when investigating visual system inefficiencies that could benefit from therapy.

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Fashion in Focus: Tortoise Never Fails

eyedolatry glasses fashion 10:44 AM

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My Pupil is Dilated!

blurry vision dilated pupil 9:24 PM

Have you ever looked in the mirror and noticed, "wow one of my pupils looks huge?" Well if you have just been to the eye doctor and had your eyes dilated, that is perfectly normal. But a dilated pupil out of the blue can also be a huge medical issue, and a quick google search of the symptom is enough to scare yourself senseless. Before you high tail it to the nearest ER, let's look at some of the possible normal causes that could have resulted in a temporary dilation effect:

Dilation Drops

Red cap? It will sting when
it goes in, and there is a good
chance your eye will be dilated.

I know this is obvious, but sometimes you may get prescribed drops with a dilation effect for more than just a routine dilation at your doctor's office. If you were prescribed atropine, homatropine, scopolamine, cylcopentolate, or tropicamide, then you are taking a dilating eye drop. Atropine may be prescribed during amblyopia treatment as a type of "patch" for the good eye. Homatropine (which is no longer available) and now cylcopentolate are often prescribed during severe uveitis to prevent iris inflammation from closing off the pupil. It can also be used for a pain reliever effect during treatment for corneal abrasions or accommodative spasms. If you see a red cap on your eye drop, it is probably going to have a dilation effect.

Motion Sickness Patches

Going on vacation? Scopolamine patches are incredibly effective at knocking out motion sickness, but a dilated pupil on the same side you were wearing the patch is a common side effect. The dilation usually goes away within a few hours after removing the patch.

Dilated pupils? Visine is the usual suspect.
Please America, just stop buying this stuff
already and get the moisturizing drops you
need instead. via

Visine or Red Eye Drops

This is the most common dilation offender in my experience. Visine, Clear Eyes, and other "red eye" drops lessen the appearance of redness (temporarily) by constricting the diameter of the blood vessels on the white of the eye. As a side effect, you can also induce a dilation. If you stop taking the drop, the dilation effect should slowly wear off. Some homeopathic eye drops or home remedies can also have these side effects. If you see anything in the ingredients about belladonna extract, a dilation side effect is likely.

Oral Decongestants

If you are taking oral sinus medications, there is also a low risk of a dilation side effect. Oral decongestants that contain phenylephrine are a well-known possible offender. Phenylephrine is commonly used in your eye doctor's office to dilate your eye, so a dilation from oral phenylephrine is not all that uncommon.

Plants

This is probably the least likely culprit, but certain plants (belladonna was mentioned already) can cause a temporary dilation by coming into contact with their leaves and then touching around the eye.

What to do if your pupil is dilated?

This person had a larger dilation effect in his right eye after a routine dilation at the eye doctor. Sometimes one eye will have a larger response, and it can be quite dramatic. via

Take a deep breath, and then ask yourself a few simple questions.

1) Can you see clearly in the distance? If your pupil is truly dilated, then it is perfectly expected for you not to be able to see well up close. Dilation means that the eye muscles of the iris are relaxed, and if they can't constrict to close the pupil, you likely can't use your eye muscles to focus on near objects either. But unless you are highly far sighted, your distance vision should feel relatively normal with your glasses or contact lenses on. If your vision is totally dark, severely blurry at all ranges, or you are seeing floaters or flashing lights in your vision, then call your eye doctor immediately. Other suspicious symptoms like one sided weakness, double vision, inability to move the eye in all directions, inability to open or close the eye, or a spike in blood pressure or blood sugar levels all necessitate immediate medical attention!

2) Do you feel any pain? A dilation will cause you to feel more sensitive to bright lights, but it should not be sharply painful at all. If you feel sharp or throbbing pain, or nausea, then please call your eye doctor immediately. You may be experiencing a severe spike in your internal eye pressure which needs immediate treatment.

3) Have you been using any medications or eye drops? 9 times out of 10, you used Visine earlier that day.

4) How long has your eye been dilated?

If you have a medication or external-induced dilation, and you stop the medication, then the dilation should typically wear off in a few hours. Scopolamine, homatropine, or atropine dilation effects can last much longer however. In someone with light or blue eyes, an atropine-induced dilation could take several days to a week to completely wear off. The important part is that a medication induced dilation will always go away, eventually. A medical condition causing a dilated pupil isn't going anywhere.

5) Have you suffered any injuries or trauma?

Concussions are commonly associated with dilated pupils. If you had a recent fall or head injury, and now have a dilated pupil, please go to the hospital.

A dilated pupil can be something very serious, so it is always important to seek medical care, especially if you have any of the associated symptoms listed above. I would suggest always triaging a blown pupil with a doctor instead of trying to self-diagnose at home, but hopefully this post helps put you more at ease if you notice a dilated pupil after using a few drops of Visine.

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A Discussion of Redness Complaints with Bausch and Lomb Ultra

Bausch and Lomb Ultra 10:00 PM

With any new products, there can sometimes be a few surprises. If you read my post about Bausch and Lomb's new monthly Ultra contact lens, you know that I found it exceedingly comfortable and a very exciting new option on the market. The overwhelming response to their launch of Ultra has been positive, with most patients reporting better initial comfort and less end of day dryness compared to other monthly lens options. But as more doctors began fitting the lens around the country, a surprising finding began showing up in a minority of lens wearers: redness.

via

There are no official reports that have been published, but based on anecdotal evidence, within 2-3 days of lens wear some patients were experiencing redness around the cornea (or limbal hyperemia in its technical term). This redness typically had no associated pain, discomfort, dryness, or vision change. The eyes were just a little red. Within a day or two, the redness would be entirely gone in most patients, even if they had not discontinued lens wear.

I have spoken with representatives for Bausch and Lomb, and they suggest that redness complaints should be handled on a cases by case basis, as any patient may have issues adjusting to a new lens material. The Ultra silicone hydrogel polymer is extremely oxygen transmissable (163 dk/t in a -3.00D lens), so breathability issues seem an unlikely culprit. They suggest that if your patient experiences any pain, discomfort, or vision changes, to of course discontinue the lens immediately, and contact your office. But if they are having no other symptoms, I was told by the Bausch and Lomb representative that the patient may continue to wear the contact lenses and in many reported cases, the redness resolved in a day or two without any complications. Of course, they recommend that if the redness persists or other symptoms develop, the patient should come back in to be seen immediately. As with any new contact lens being prescribed for a patient, a 2-3 week follow-up for all new fits is often a good way to check for any problems that may arise with lens wear.

As a personal experience, I did not experience any limbal hyperemia on my first day of lens wear, but I did find that my eyes were slightly injected at the end of my second day of lens wear. I removed the lenses for bed, and woke up with clear eyes again in the morning. I thought nothing of it because I am solely a daily contact lens wearer at this time, and even if this is the best monthly contact lens in the world, it can never deliver what a daily contact lens can. As a precaution I did not wear lenses on day 3, and I experienced no discomfort or symptoms. On day 4 I wore the lenses again, and this time no redness at end of day. Of course, this is all anecdotal, but it may be true that your eyes just need time to adjust, and the redness your patient may experience could potentially resolve without any further issue.

While Bausch and Lomb has no official comment on what may be causing this redness in some patients, there are a number of possible theories being floated by ODs. The lens is a 8.5 base curve, and many doctors theorize that the lens may be tightening up as certain patients wear the lens through the course of the day. If this is the case, and a tight lens syndrome was developing, then discomfort and vision issues would be expected to develop, and the lens would need to be refit for patient safety. The fact that the redness in many reported cases resolves without other symptoms may make tight lens syndrome less likely, but it should always be ruled out in patients by a discussion of symptoms, and careful evaluation of the movement of the lens on the eye.

Other possible culprits reported include a possible solution interaction. There have been several case reports that show that a minority of patients may experience comfort issues when pairing Acuvue products with Opti-Free Replenish or Express solutions. Since Bausch and Lomb Ultra was designed with a similar lens shape and edge design as Acuvue Oasys (and by the same person), it may be that this lens also has interaction issues with certain lens solutions. There are no official staining grid reports since this lens is so new, but Bausch and Lomb does suggest pairing their lens with Biotrue, or their new PeroxiClear hydrogen peroxide solution. In the FDA trials performed by the company to bring this lens to market, these solutions were used with good success. As a personal aside, I was using PeroxiClear with my lenses and still experienced day 2 hyperemia, but it did resolve quite quickly the next morning after the lenses were removed overnight.

Staining grid studies are a controversial topic, but can raise some interesting discussions as to what solutions we should really be recommending to patients for the contact lens brand that they wear. We don't have information about Ultra yet, but perhaps it to requires a certain solution brand to perform at its best in a sensitive patient population. via

So what do these reports of redness with the Ultra lens mean to you? I still think that this lens could be a great option for patients that are experiencing dryness and end of day comfort issues with other monthly lens options, but aren't ready to jump into daily contact lenses due to price. The Ultra is also ideal for refitting those Acuvue lens overwearers that are trying to get a month out of a 2 week product -- the edge profile of the lens is almost identical to Oasys, making for the easiest transition to monthly lens products that I have had in my office. I have been very careful as to the K values that I have fit this lens on, and to this point have only had myself experience redness, and none of my patients. I have proactively instructed my patients to call me if redness or other symptoms develop, but have not heard from anyone. I have also been following Bausch and Lomb's advice to recommend Biotrue or hydrogen peroxide solutions with this lens, just in case it is a solution interaction issue in sensitive patients. If fit with a proactive attention to detail, I think that you will have the same success in transitioning patients to this new, very comfortable and highly breathable lens material.

Have you had issues with hyperemia after wearing Ultra for a few days, or have a theory of your own why this side effect is showing up in doctor's anecdotal discussion of the lens? I would love to hear more input as to other people's experience with this lens, whether you are a prescribing doctor, or a patient that is trying it out for the first time!

UPDATE: I was at a meeting last night, and a culprit for the redness complaints has been found! Issues were isolated to a single manufacturing plant, where they found that too much NaCl (salt) was being used in lens manufacture. That increased salinity created redness when the lens was put on hte eye. Bausch and Lomb has remedied this problem and moving forward does not expect any continued redness issues.

Disclaimer: I am not a Bausch and Lomb employee, or in any way affiliated with their company except that I have worn their lens and am fitting it for my patients with good success. The conversation provided in the post above is all anecdotal and I have performed no actual studies on the lens myself and would not consider myself qualified to do so. To this point, there are no official reports as to how many people experience redness with the lens (we know it is a minority, but we do not have a percentage) and there is no official statement from the company concerning the most likely cause for hyperemia reports in these patients other than these situations should be investigated by the doctor on an individual basis.

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