MT 1 Flashcards
(261 cards)
1
Q
How can you change acc. demand?
A
Lenses or distance
2
Q
What inspires accommodation
A
Attention
3
Q
What tests for Accomodation
A
Absolute accom, relative accommodation, posture/accuracy, facility
4
Q
Tests for absolute accommodation
A
Donder’s push up and minus lens method
5
Q
Will dander’s or minus lens method give greater AA
A
Donders
6
Q
What if you get OD and OS difference with minus lens method?
A
Adaptation may be occurring. Try from other eye.
7
Q
Tests for Relative accommodation
A
PRA and NRA
8
Q
PRA
A
Perform mono and if increased accommodation (mergence will be problem) and vice. Pt. must diverge.
9
Q
Determining a near point add
A
halfway between NRA and PRA
10
Q
NRA
A
Convergence. If it is high it is due to overminusing
11
Q
BCC
A
Determine posture. Make pt. spherical. Start with increased plus so vertical lines clear first.
12
Q
Who would you not run BCC on?
A
Ptt. with incorrect cyl. May have meridonal amblyopia.
13
Q
Plus/Minus facility procedure
A
Perform for 2 minutes. If really failing can go for 1 minute.
14
Q
Which equates with near point symptoms best?
A
Acc. facility
15
Q
What is most common symptom of accommodation disfunction?
A
Headache
16
Q
What affects fixation most strongly?
A
Attention
17
Q
SCCO 4+ system
A
Have pt. look at a target for 10 sec. If cannot hold for 5+ then there is a great problem.
18
Q
Line scanning with opthalmoscope
A
Measures where the eye normally fixates when looking ahead
19
Q
Should you train fixations?
A
No pursuits is better. Fixations are boring
20
Q
Fixation training tests
A
- Golf tees with hopping
- McDonald Chart
- Tachistocopic task (flash letters and see what remembers)
21
Q
Pursuit dysfunction tests
A
- NSUCO 2. Low bead test score 3. Suspision during motility
22
Q
Pursuit disfunction Symptoms
A
Excessive head moving when reading. Confusion during return sweep. Skipping lines when reading. Losing place when reading. Using finger when moving. Word omission or transposition when reading. Illusory text movement. Deficient ball playing. (Won’t find pt. that only has pursuit problem)
23
Q
Pursuit Training
A
Relative motion between the observer and the target of interest. Should have predictable direction and speed. It is not a pursuit movement if you have to write it down to remember it.
24
Q
How should you train pursuits
A
Monocular–>binocular
25
Motion in training pursuits
Can have target, head, or both.
26
Why is it important to pay attention during pursuit training?
You should modify to make them more challenging.
27
Loading examples in pursuit training
Have them stand on unstable surface. Cognitive load them by having them say the alphabet backwards.
28
Rolling ball
Have pt. track ball while it rolls back and forth. Can track with light or laser.
29
Stationary target head movement
have the patient move and look at a stationary target
30
How to modify pursuit tasks
Cannot complete task goal, jerky pursuits, uncontrollable head/body tracking, clenching hands, rigid neck, facial contortions.
31
Thumb pursuits
Have patient track their thumb. Provides strong feedback. Can go to a large, no detail-->smaller, no detail-->smaller, central detail.
32
Flashlight tag
Pursuit training.
33
Marsden Ball Pursuits
Can lay down, hopping (follow ball with tennis racket and when you say to they will hoop it), tapping, or bunting.
34
Penny Drop
Pursuit training. Have the patient drop penny in cup when you say when
35
Spear the Picture
Pursuit training.
36
Pegboard rotator
Outside rotates faster. Have them watch and fill in certain areas
37
What is the main ddx question you have to ask when you find pursuit problems?
Is the problem worsening (acquired) or has it never been good in the first place (developmental lag)
38
Extreme Pursuit Issues
See cogwheel steplike pursuit. Would also see basal ganglia and cerebellar disease. Should comange with other specialties.
39
Is a VT exam the same as a Primary care exam?
NO! A primary care exam should be done before a VT exam. Primary care only samples skills and sees if they are normal
40
VT Case History
Main concern, secondary concern, review refractive history, review of ocular or systemic histories (esp, meds and neurological), goals of patient, Standardized symptoms survey (CISS)
41
Most common signs of prolonged near work/concentration
blurred vision, double vision, squinting, HA, eye fatigue/strain, inexplicable rubbing or itching of eyes, sleepiness with near work
42
Other signs of prolonged near work/concentration
Instability of print, excessive tearing/blinking, nausea, difficulty copying from the chalkboard, difficulty reading, avoidance of near work (may get tangled up with ADHD), Difficulty staying on task.
43
Convergence Insufficency Symptoms Survey
15 symptoms rated on a scale from 0-4. Better if you read ? to pt. 0=never 1=infrequent 2=sometimes 3=fairly often 4=always. Score of > 16=symptomatic of CI
44
VT and Refraction
Refraction should have been done prior to VT. Measure VA's and make sure run is accurate. Accurate run is critical to accurate assessment of accommodation and vergence
45
Calculating mergence demand for the pt
pd in cm/target distance in m
46
Vergence demands can be created by..
1. target distance 2. prisms 3. target separation (to be fused)-target demand 4. the need to counterbalance a heterophoria
47
Primary stimulus for vergence
binocular retinal image disparity
48
Tonic vergence
The underlying level of vergence activity without a target. Just space out and see where mergence lays. Distance cover test approx.
49
Fusional Vergence
The mergence that occurs in response to binocular target disparity. Used to overcome phonic tendencies.
50
Accommodative vergence
Vergence that occur in response to change in accommodation
51
Proximal vergence
mergence that occurs due to mental or psychological awareness of target nearness.
52
What system innervates the EOM
Somatic nervous system
53
What does stress affect?
Accommodation that will then affect vergence. Vergence is not affected directly.
54
Can vergence be voluntary?
No! Must affect accomm. that then affects vergence.
55
What lenses do you want to use to measure vergence?
CAMP lenses-> corrective ammetropia most plus.
56
Esophoria
The eyes tend to aim closer than the target
57
Exophoria
The eyes tend to aim further than the target
58
Heterotropia
An abnormal condition of vergence posture in which binocular vision is absent or abnormal and only one eye is aimed at the target of regard.
59
cover test set up
Discrete target to fixate. Hold target at primary gaze. Bracket prism results. Have control lenses but before refraction.
60
Expected vergence posture far
0-2 exo
61
Expected vergence posture near
0-7 exo
62
Gradient AC/A
Normally at near. Change lenses and keep distance the same
63
Gradient AC/A lens response
May have a closer response with minus lenses. Plus and minus with differ.
64
Gradient vs. calculated AC/A
Highest AC/A with calculated-->middle is negative AC/A-->lowest is positive AC/A. Commonly do Plus lens as want to rxn plus lens.
65
Normal AC/A from calculated
3-5
66
High AC/A
Low accommodation adaptation, higher prism adaptation
67
Low AC/A
High accommodation adaptation, lower prism adaptation
68
Forced mergence fixation disparity cuve
Saladin card, sheedy disparometer, computerized chart system (far). indicates ability for fast prism adaptation
69
Prism adaptation
Indicated by speed with which the mergence system re-creates the habitual vergence posture (phoria) when it is challenged with prisms
70
Which patients are not good candidates for prism therapy
Patients that are fast prism adaptators.
71
Which patients are more likely to have near point stress?
Patient with poor prism adaptation.
72
Before what surgery should the prism adaptation test be performed?
Before surgical management of strabismus
73
Sheard's and Percival's criterion
Assume that symptomology is not related to vergence dysfunction if the criterion is met. Also provides additional method to calculate a prism prescription to alleviate symptoms. (forced mergence curves are better though)
74
Sheard's Criterion
The blur point in the compensating vergence 'reserve' (the range opposite the phonic posture i.e. BO for exo) is at least twice the demand.
75
For sherd's criterion if the 40 cm phobia is 9 exo what must the patient have to not have symptoms
the PRV must be at lest 18
76
What deviations does sherd's work best with?
Exo
77
Percival's criterion
The demand line (not the phobia value) should be in the middle third of the total mergence range (from BO blur to BI blur). This method requires plotting the zone of clear single binocular vision.
78
what deviations does percival's work best with?
eso
79
Type I ogle curve
Most common. No problem
80
Type II ogle curve
Eso. Responds to plus. Shift down
81
Type III ogle curve
EXO. Response to prism. No minus
82
Type IV ogle curve
Very rare. no prism can shift
83
What type of an ogle curve do you want?
Flat in the center
84
NPC
Use threshold target acuity. Accommodative and vergence demand are the same. Repeat 5 times to assess stamina.
85
Minimum NPC values
Break=8 cm. Recovery=11 cm
86
Capobianco method
Record NPC break using a penlight without a red lens and then through a red lens. >2 cm difference is problematic.
87
when do you always do mergence amplitude?
Near. Only far prn.
88
When to use prism bar?
Very young or intermittent strab.
89
Vergence facility
Cannot be measured without accommodation. Use flippers or hayne's distance rock.
90
Prism flipper facility
Ask patient to report any suppression or diplopia. Do not flip until time runs out. Record suppression or diplopia and NOTE which side.
91
Binocular Vision
How visual space is represented in the binocular vision process. Motor and sensory aspects of binocular vision. Corresponding retinal points.
92
Binocular sensory fusion
The neurological blending of visual information presented to each eye so that greater information is derived from the binocular image.
93
Levels of sensory fusion
none, stimulus perception, superimposition/flat fusion, steropsis.
94
Is stereopsis threshold measured normally?
No as test doesn't go down far enough
95
Random dot
Global test. Requires bifixation (unlike local)
96
Lateral disparity
Local test. Does NOT require bifixation.
97
Howard-Dolman Device
No monocular cues if set right. Can get an actual threshold here for steropsis.
98
Test for assessment of superimposition/flat fusion
worth dot test or computerized chart systems.
99
What stops sensory fusion from occurring
suppresion, anisometropia, fixation anomalies, strabismus, inadequate motor vergence
100
Is it possible to have suppression at far but not near?
yes as the flashlight gets further it becomes more difficult to fuse
101
What is the minimum data for a vergence system evaluation?
Phorias, vergence ranges, NPC, facility, steropsis.
102
NSUOCO Oculomotor test
Fixation stability (not part of test). Gross pursuit eye movements, gross saccadic eye movements. Patient is standing, hand at side. No instruction on head movement. Separation of targets 20 cm apart.
103
DEM
Looks at reading eye movements
104
Visagraph/readalyzer
Looks at oculomotor movement
105
Type I DEM
Normal
106
Type II DEM
Saccadic disfunction
107
Type III DEM
Delayed verbal automaticity
108
Type IV DEM
Combination of II and III
109
Signs/Symptoms of Saccadic disfunction
re-read or loose place when reading, move head when reading, use of finger when reading, reread or skips words, choppy or slow reading, poor reading comprehension, may have vestibular problems.
110
NSUCO fail
When below expected performance for age
111
DEM Fail
Below 16 percentile in ratio or error scores.
112
Visagraph fail
Below expected performance for age.
113
Primary goal with saccadic VT
them to perform better in their own enviorment
114
How do you know where to saccade?
Your peripheral vision
115
First priority with saccadic VT training?
Accuracy
116
Second priority with VT saccades?
increase speed with accuracy.
117
Final priority with VT saccades?
Automaticy and transfer of skill
118
With saccadic VT begin with _____ movement at far, proceed to _____ movements at near.
gross, fine.
119
Saccade demand variables
Vergence and accommodation at play with a saccade at near vs. far. Moving the distance is not a big factor. The distance the saccade place a greater role.
120
What do you expect if accommodation is not a problem with Hayes distance rock
They will be able to say the first row of letter fine but then it will be hard to get to second line as they have to saccade.
121
Saccadic training start binocular or monocular
start monocular (make the patient do twice as much work. both will be moving)
122
Saccadic training sequencing
Initially use finger guiding then remove. Eliminate head movement (beanbag), low cognition to high cognition and distraction. Predictable to less predictable patterns
123
Is the distance to saccade the same in reading?
no words are different lengths
124
Loading in saccadic training
Add speed on top of skill, metronome when predictable, plus and minus lenses, BI and BO prism, acuity requirement, distraction/repetition, gross motor activity.
125
When to use a metronome?
If task is predictable and accuracy is achieved but speed and automaticity is needed.
126
Frustation levels with VT
Work at the patients level. Not above
127
Phase Ia of Saccadic Therapy
Gross saccades (predictable)
128
Doorwary or corner saccades
Phase Ia. far or near. Have them saccade to four corners like on a door. Can add a metronome.
129
Hart chart options
Phase Ia. Hart chart strips (for more even saccades) , column jumps, 4 corner saccades. Can add a metronome and pointing feedback (laser). Can add balance demand.
130
Alphabet pencil saccades
Phase Ia. Can add metronome or pencil movement. Recommend 1 cm separation to 10-15 cm. Hold against solid color awl to facing cluttered room. Can add slight viewing distance difference between pencils.
131
Sequential fixator
Phase Ia. Print on transparencies. Baseball or stickers. Must be predictable targets.
132
Meter stick saccades
Phase Ia. Have them look at different things on stick. See the marking prior to the saccade. Focus on peripheral vision.
133
Feedback with corner/dorwary saccades
use a device with an after image. Will see a plus or after image. put target on one place and see if over or under shooting.
134
Hart chart strips
Cut two strips. Tape on wall at given distance. Control head movement. Add metronome.
135
hart chart column jumps
Position 1-6 m away. Variation of any pattern can be made but you need a purpose. hard to go from second to second last.
136
4 corner saccades with hart chart
Can use feedback with after image. Can add metronome. Go from corners with
137
Is it harder for children if their saccade pencils are close together or further apart?
Easier if they are separated by a further distance (gross develops first). Fine saccades are harder.
138
Phase IB of saccadic therapy
Gross saccades (less predictable)
139
Wayne Saccadic Fixator
Phase IB. Gross unpredictable saccade. Feedback via lights and sound. Self-paced mode scores time to complete. Instrument-paced mode scores number of hits. Add letters under lights. Want a low score (as a timed scored)
140
Instruments similar to Wayne Saccadic fixator
SVT (australia), Sanet vision integrator, Vision coach, Dynavision (only one with buttons)
141
Laser spelling
Saccadic phase Ib. Random letters scattered on a wall/door. Feedback with laser or pencil. Searching saccades. Add distractors. Can add metronome.
142
Sequential fixator for phase Ib
Phase Ib. Transparency sheet with less predictable pattern. No metronome as not predictable
143
Continuous motion
phase Ib. Random numbers or letters scattered on a page. Have them circle the letters or number continuously. Searching saccade. Can add metronome?
144
Computer Saccade Programs
Phase Ib. Computer example for gross unpredictable saccades. Allows control of stimulus presentation. Scores average response time and % correct. use it as a reward as kids like.
145
Wayne Directional Sequencer
Phase Ib. Pattern overlays for lightboard. Follow the arrow pattern. Feedback with lights and sounds. Metronome mode.
146
Saccadic Phase II
Fine saccades (predictable pattern)
147
Percon/saccadic workbooks
Phase II. Gross to fine saccades. Gross column jumps, intermittent row saccades. variety of patterns.
148
Column and page saccades
Phase II. Column: call out first and last letter on each line then go to 2nd or 3rd. Page saccades: same concept but call out the first and last word on each line
149
4 corner saccades at near
Phase II as at near.
150
Saccadic Ladders
Phase II. Go from 2:1
151
Saccadic Phase III
Reading pattern saccades
152
X and O worksheet
Phase III. Closer to reading type saccades. Good lead into michigant tracking. Can add flippers for accommodation.
153
Michigan Tracking
Phase III. Searching task with alphabet clusters. Accuracy first, then speed. Work to smaller font size. Can add flippers for accommodation.
154
Word finds
Phase III. Searching task with alphabet. Work to smaller font sizes. Instructions are critical for predictable saccade.
155
Symbol counting
Phase III. Searching task with symbol clusters. Can add flippers. Know the correct amount by first and last number
156
Dotting o's in newspaper magazine
Phase III. Searching task with alphabet clusters. Can add flippers.
157
Guided / Moving Window
Phase III. Computer based program. Controls exposure of words during reading to direct saccades. Build speed of controlled eye movement during reading.
158
Tachistoscopic task
Phase III. Increase span of recognition per fixation. Develop better mechanism to guide saccades.
159
Strobelights/ NIke strobe
Devlops prediction saccades. Slower flash rate requires saccade prediction. Must know where you are saccading.
160
Generic programing considerations
Gross to fine. Approximate to refine responses. In to out of instrument. Monocular to binocular. Peripheral to Central. Suppression controls. Challenge without overwhelming. Skills in isolation to skill integrations.
161
What lenses should the patient be wearing during VT?
The best lens for the patient. A plus add will limit phasic response, limit accommodation adaptation requirements, reduce AC/A influence. Because of adaptation may have better results with less plus.
162
Accommodation adaptation
The key to keeping symptoms down. Phasic is a quick response.
163
Cookbook approach for bioengineering VT
Stimulus sensitivity-->phasic training-->specific skills-->adaptive training
164
Stimulus Sensitivity
Bring awareness to stimulus cues. Internalize responses for voluntary control. What does it feel like to change accommodation. May not need any time for this.
165
Stimulus sensitivity example with accommodation
Blur detection: plus/minus lens sortion Awareness of accommodation: plus and/or BO walk away, mental minus, split pupil rock
166
Stimulus sensitivity example with vergence
Prism sorting (put prism monocularly and ask if image moves until they find lowest prism with movement.
167
why Phasic training important
daily visual tasks need it, link to asthenia, aid progression through other steps, find minor deficiency or OD/OS performance imbalance
168
Phasic training vergence examples
Facilities. Plus/minus flippers, prism flippers, near far rock
169
Rank the combinations from hardest to easiest. BIM/BOP, BOM/BIP, BI/BO only, +/- only
Hardest (BIM/BOP) --> BI/BO +/- only--> BOM/BIP
170
Specific Skills
Training deficient skills. General treatment approach with this model. General treatment approach within the model. Slow rate of change of any phasic activity. Hold facility activities for longer periods. Hold ramp stimulus extremes for short periods. Large jump stimulus. Should use diagnosis-specific recommendations, in to out of instruments, large to small visual features, increasing demands, multi sensory elements
171
Example of training deficient skills with accommodation
Normalize amplitude. Equalize skill increasing/decreasing accommodation. Voluntary control over acc excess/plus tolerance.
172
Ex of training deficient skills with vergence
improve and balance fusional ranges, normalize recoveries, control/accuracy of disparity, synchronize sensory benefits with motor vergence
173
Adaptive training
Adaptive training will decrease regression. Some think improved phasic skills may be enough. Problem is that symptoms are normally gone when adaptation training has began. Do a task all at once. Hold activity for adaptation (up to 2 minutes). Add free space activity and out of primary gaze
174
Adaptive training example with accommodation
Read two minutes before flipping.
175
Adaptive training examples with vergence
Large changes in stereoscope for 2 minutes. Large prism changes every 2 minutes.
176
What do you need for optimal stereoscopic vision?
Equal consistent input, equal monocular perception, perception integration, relative comparision of object distances.
177
What contributes to good 3D vision?
Optical accuracy, accommodation and mergence consistency, no fusional disruption (suppression), perception. Anything less then optimal=stereopsis less than optimal
178
3D vision and breastfeeding
Those that breastfeed have better stereoscopic vision
179
3D vision and visual input
A poor input=poor 3D. Optics: power accuracy. Visual health: tears, cornea, lens Visual skills: poor accommodation or mergence control
180
SILO
Feedback cues for 3D vision. Can use for control of mergence
181
Can steropsis be improved?
Yes.
182
How long was 3D vision penalized after patching?
Occurred after only 8 hours of patching.
183
Why do 3D vision symptoms increase?
Increase with vestibular interaction and disorder, neuromuscular disorder, accommodation or mergence disorder, medications, sedentary lifestyle.
184
Why do 3D vision symptoms decrease?
Immersion, presbyopia.
185
Progression of 3D vision training
1. awareness of float 2. localization of float image (unnatural image has a location compared to physical objects) 3. localization comparison of 2 floating images (refinement, stereoscopic movement perception) 4. similar steps at far.
186
Awareness of float examples
Marsden ball and quoits juxtaposition. See the ball going through the ring.
187
Localization of floating image
Relies on comparison to a physical object. Use one hectogram with many pieces of built in depth. Pointer for localization. Progress with more obvious float to less float (typically BO activity). Do 2-5 minus, 2-3 times a day. Modify BO demand with each trial. Get rid of pointer and then start using BI.
188
Localization comparison of floating images
Use a double vecto holder. Two matched vectos and polarized glasses. Set to 2-4 (Top BI and bottom BO). Patient studies size and location of top and bottom image through filters. Shows a dramatic SILO effect. Can also set top image for small BO and patient bracket lower image to match float. Continue with BO and then finally BI.
189
Localization comparison of floating images at home
Have them use the chart but make them ignore the numerical values
190
3D training at far
Can use stereoscope cards or juxtapose at distance. Can also use projected hectograms and match distances.
191
Steresocope cards
Train 3D at far. Brewster stereoscope. Intially BO demand cards. Can have a pointer localization task. Can change demands and depth with tromboning. Requries fund in and trusted patient. Recommend at least 10 minutes a day.
192
Therapy devices for Accommodative disorders
Lenses, target distance, target features, the patient (success determined by how pt. uses device)
193
Is it better to do one long section each day or a couple of short sections a day?
It is better to build a habit and do them more often
194
Sensitivity to blur/awareness of accommodation
Often only in office required (if no amblyopia). Awareness of blur, awareness of accommodation effort, voluntary control of accommodation. Can do lens sorting or minus lens activities.
195
Lens Sorting
Primarily use clarity cues to sort lenses by optical power. Must patch. Use a distance chart or general viewing conditions. Start with plano, +1, +2. Tell them that lens shape, mag do not help. With young patients handle and give forced choice.
196
Lens sorting progression
Increase plus with .25 increments. If mix in a minus lens start with higher values (-1 no less then -.5).
197
RXN lens sorting
Often only in office.
198
Minus lens activities
Target 1.5 m away. Monocular. Variety of minus lenses. Include all techniques with a minus lens.
199
Accommodation Awareness training
Check if clarity can be achieved with a -4 lens. Patient describes sensation associated with increasing an decreasing accommodation. Voluntaryily hold accommodation with lens insertion and with removal. Normally use as an intro to mental minus.
200
Mental Minus
Use for voluntary accommodation. After awareness of accommodation. Voluntary increase or decrease accommodation before the lens is applied or removed. Should do 5X each eye.
201
Accommodative Infacility
Reduced facility, poor sustaining of near visual comfort, lag of clarity. Can use VT or low plus for partial relief.
202
VT for accommodative in facility goals
Normalize facility values, minimize plus/minus skill difference, reduce or eliminate symptoms. usually takes 3-12 sessions
203
Phasic training ideas for accommodative infacility
Near far rock, split pupils rock, loose lens rock, plus/minus flippers, BIM/BOP facilities.
204
Near Far rocks
Accommodation infacility. Hold one chart close to you. Go to where right before you blur. Try to get as far as you can for distance. Prescribe 2-3X per day. Add metronome once it is not overwhelming. Want 60-75 bpm for this task. Can do loading technique-balance and beanbag. Can use near acetate chart to watch eyes
205
Split Pupil Rock
Use prism in lens. Arms length facilities. Change vertex distance to alter dioptric amount. Monocular. Progress by increasing power, push maximum facility improvement. RXN of OD and OS 2-3 total minutes each.
206
Split pupil rock goals
-6 lens in spectacle plane with 15-20 cpm on 30sec trial.
207
Bi-ocular Rock
Get double vision. Increase accommodation to make lower one clear. Must do voluntary accommodation to direct eyes between images. Do not use with patient that gets motion sick
208
Loose lens rack and plus/minus flippers
Accommodative in facility. Normalize facility with little decline over 2 minutes of facility challenge. Want 10 flips each 30 s for 2 min with +/- 2. Therapy: push for up to 20 cpm in one minute trial; at least 15 cpm average for 2 minute trial.
209
Loose lens rack and plus/minus flippers goal
Establish power for training and increase to +2/-5. May need to use BOM/BIP initially. Maybe only plus or only minus at a time.
210
RXN loose lens rack and plus/minus flippers
Determine max power to reduce facility to 7-9 flips in 30 s. When patient reach at least 12 cpm increase the power until a goal is reached.
211
BIM/BOP Facility
Accommodation Infacility. Start with 6 BI/BO and +/-1.50. 30 sec want 7-9 flips. Adjust one power up or down at a time to achieve this rate and then send home.
212
Specific skills and adaptive training with in facility training
Normally don't do either of these.
213
Key points of accommodative insufficiency
Inadequate accommodative amplitude. Reduced or unsustained clarity at near. Distance blur after sustained near work. Brow or headache.
214
Using CISS for AI
Repeatable and reliable.
215
Treatment for Accommodative insufficency
Plus add for immediate relief. VT for improvment
216
VT and accommodative insufficency
3-12 session. Want to normalize accommodation amplitude and amplitude based symptoms. Blur sensitivity training activities are very useful.
217
Accommodative Insufficency Phasic training
Improve amplitude with directional phasic activities such as greater minus powers with facility. Graduate to increased and more sustained amplitude activities.
218
Specific Skill improvement ideas
jenson rock, split pupil rock, minus lens tromboning, minus lens walk up
219
Jensen Rock
Maximize accommodative demand of near-far rock. Reduce letter size as possible if not progressing to other activities. Monocular. Hold chart a few cm further away than NPA. Near far rock as prior. Can use transparent near rock.
220
Modified Jensen Rock
Accom. Insuff. Monocular. Push up amplitude: hold slow count to 5. Line 1 of near far rock. Repeat each time moving to the next line down the chart.
221
Split pupil rock
Accom. Insuff. Use maximum minus (-8). Work to bring lens to spectacle plane.
222
Minus lens tromboning
Accom. insuff. Minus lens (-4 to -8). Monocular. Slowly bring the lens from arms length to spectacle plane and keep target centered in the lens. Slowly reveres the movement. Keep target clear. Point is to move lens slowly. Sustain at spectacle plane for 10 sec.
223
Minus Lens Walk Up
Accom. insuff. Similar to tromboning but use distance rather than lens. Start at 2-3 min. Once it is perfectly clear take a step forward. Repeat until cannot go closer without blur. Add minus lens in 2 D when 10 cm achieved.
224
Variables for adaption
Large change, all at once, hold. Use a large lens change, rest breaks with goal of distance clarity, extended tasks
225
Accom. insuff. adaption skills
Monocularly: at leat 2 D of loose lens changes. Change power for each long article
Binocularly: change flipper power each page turn of a novel. Loaner lenses of varying amounts. Recommend up to 15 minutes per day total. Varying reading/working distance every few minutes.
226
Other issues to consider with Accom. Insufficency
Medications and post trauma
227
Ill Sustained Accommodation
A less degree of AI. NRA and PRA reduced. Repeated NPA results in fatigue. Facilities are slow. Fatigue towards the end of the day.
228
Treatment for ill sustained accommodation
VT. Mayble low plus to provide partial relief.
229
Goals for ill sustained accommodation
Improve amplitude, normalize accommodation facility, emphasize adaptation elements. normally 2-9 sessions
230
How to treat ill sustained accommodation
Treat like you would accommodative insuficiency
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False CI Review
Low stimulus AC/A. More normal resonse AC/A. larger than expected plus. Asthenopia. Difficulty with near point.
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Treatment for CI
Low plus additional may improve accommodation response. VT.
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Treatment for CI goals
Improve accommodation accuracy/sustaining. Normalize any residual vergence skills deficiency. 6-16 sessions.
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Phasic training for false CI
Blur sensitivity before or at the same time. Use same techniques as accommodative in facility.
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Specific skill training false CI
Improve any minor amplitude deficiencies (emphasize detailed targets and need for clarity). Possibly BIM added to previous activity ideas, especially with small target detail. Crossed cylinder focus.
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BIM addition for false CI
Challenge the acquired range and accuracy of accommodation against opposing mergence demand. BINOCULAR. Near far rock with BI for near target. Remove for distant target. BIM/BOP facility after +/- alone. With each step of binocular test walk up add 10-15 BI prism.
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Crossed cylinder focus for false CI
Increase patient appreciation for degrees of clarity. Improve patient's ability to regulate accuracy and stability of accommodation. Monocular. Patient adjust focus to make vertical and horizontal lines darker. Add plus or minus sphere for a challenge. A finishing technique. G
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Adaptive training for false CI
See AI
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Accommodative Excess Review
Reduced lag/any lead with MEM, less than +0.5 on BCC. Low NRA binocular and monocular. Nearpoint strain. Distance blur after near work.
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Treatment for accommodative excess
VT. Passive plus lens treatment may be used, typically in conj. with VT
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Goal for VT Tx of AE
Address any causative mergence problem. Normalize accommodative release skills. Normalize lag. Takes 6-18 sessions.
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Phasic training for AE
Same accom. infacility
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Specific skill improvement for AE
Split pupil rock, plus lens walk away, base out walk away, Jensen rock. Combination of above.
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Split pupil rock
Improve reduction direction of facility. Encourage improvement of speed in reduction direction.
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BOP walk away
Need reduced total accommodative response at near. Plus lenses +/-1. largest BO prism they can fuse at 20 cm. Start 20 cm then take a walk back. Pt. must know what excellent clarity looks like. Only perform a max of 6x per day.
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Adaptive tx for BOP walk away
Plus additional lens wear. Sustain large lens change about every two minutes of reading. Rest breaks from near tasks, maybe with bO prism when looking at far distances.
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Pseudomyopia Tx
Full tolerable plus rx at all distance. VT.
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Pseudomyopia review of key problems
Variable distance and/or near blur, var. manifest refraction, small to moderate difference between manifest and cylcoplegic refraction, low NRA, variable esotropia at far and/or near, AE may be similar pattern at far, may be worse after near point task
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Goals for pseudomyopia
Extending near viewing, mergence difficulty as primary problem, medication, trauma, emotions. Cycloplegia.
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Tx for Pseudomyopia
Full tolerable plus rx at all distances, VT.
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Phasic training for pseudomyopia
Emphasize facility activities, maybe plus only or very small plus/minus facilities, try to equalize response time in each direction, BIM/BOP facilities.
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BOP walk away
Good for pseudo myopia.
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Adaptive component ideas for Pseudomyopia
Same as accommodative excess.
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Other issues with pseudomyopia
Medication, physical or emotional trauma, may need retainer plus addition lenses
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Accommodative Spasm Key Points
Variale distance and/or near blur, variable exophoria at far and/or near, low NRA, Minus addition X cylinder value, variable refraction, significant difference between manifest and cylcoplege, may have extreme near point strain, diplopia. Generally quick onset.
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Accom. Spasm tx
Full tolerable plus at all distances, VT, Reduction/removal of any contributing issues as possible. Cycloplegia-cyclopenolate to break spasm. Consider intermittent mild cycle if tapering
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Goals for accom. spasm
Normalize reduced facilities, elimination of variable far and near blur, voluntary control of accommodation. Typically 8-18 sessions.
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Phasic training for acc. spasm
Facilities. Plus only. Try to equalize response time in each direction. BIM/BOP facilities.
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BOP the spasm
Modify for far as possible.
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Adaptive component with spasm
Use as accommodative access.
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Other issues with accommodative spasm
Medications, physically or emotional trauma, may need retainer plus additional lenses.
