* * No financial interests to declare. Graham Peachey B.Optom, - - PowerPoint PPT Presentation

* *No financial interests to declare.

Graham Peachey B.Optom, FCOVD, FACBO. Australia.

To champion the availability and delivery of evidence based, gold standard, functional vision care.

March/April 2010

ASSESSMENT TRAINING

3

Individuals performance compared to normative database. Developmental expectations for KPI’s at each age. (Ref. 1) Samples : Samples : Express Eye. FonoFix.

Fixation Instability (Mon.) Saccadic Organization.

p17 P36

Binocular Instability (B) CountFix. Anti-Saccade Performance in Dyslexia

4

• 1. Functional Vision Defect :

Defect :

A fault or imperfection in the ‘hardware’ of the visual A fault or imperfection in the hardware of the visual system.

2 F i l Vi i D f D fi i

• 2. Functional Vision Defi

ficit: t:

Less than required or expected ‘software’ due to neuro- developmental delay &/or schemata breakdown. p y /

• 3. Visual Dysfunction:

Dysfunction:

Has ‘behaviour’ indicative of aspects of Functional Vision not working properly.

Optomotor Factors : Optomotor Factors : Deficits Deficits (Developmen (Developmental al Voluntary Voluntary Control)

• ntrol)

Ocular-Motor Factors : Ocular-Motor Factors : Defects Defects (Structure (Structure & Physiology) Physiology) (Deve (Developme

• pmental

al Voluntary Voluntary Control) Control) (Stru (Struct cture & Physiology) Physiology) Fixation Stability Strabismus; Palsy; Nystagmus; Binocular Stability (B fi i ) Heterophorias; Fixation disparity; CI M h i (Between fixations) CI; Myasthenia; etc. Saccadic Organisation (Measures response time, accuracy and self correction) and self correction)

Visual Visual Ins Inspecti tion

• n “Op

“Opera ration tional Orga al Organisa sation tion a and Endur

Endurance nce”

Performance Performance Tests Tests : : Dysf Dysfunction ction

#21 Point; NSUCO Ocular Motility Test, DEM; Groffman Tracking; Accomm, :Ret – MEM; # cyl; +/- Flipper; Keystone FVP – VEE ; VO Star ; Cheiroscopic Tracing ; Visagraph etc

6

Keystone FVP VEE ; VO Star ; Cheiroscopic Tracing ; Visagraph etc.

ENVIRON ENVIRONMENT BIOLOGY / PHYSICS Genetics Social BODY BODY Structure , eg. Optical Integrity

S

Optical Integrity, System

ystem

Physiology, Ocular Motor, Pathways & Defect Defect Pathology. Diet Trauma/Disease PERCEPTION - OPTOMOTOR COACH COACH ZPD MIND MIND Theory of Mind

Develop Developmental ental ( Neuro ( Neuro Developmental Developmental ) Acquisition Acquisition of

• f

Schemata Schemata / Break / Breakdown n

COGNITION Deficit Deficit COGNITION Deficit Deficit BEHAVIOUR HAVIOUR Operational organisation Perfo

Performa manc nce e

7

& endurance, DYSFUNCTION DYSFUNCTION

Functional Vision – A cascading interaction of three areas; Area 1; Body factors, systemic and ocular health, clarity of sight, integrity of neurology, structures , general & ocular motor physiology, etc. structures , general & ocular motor physiology, etc. Area 2; Visual Inspection ; A. Assessing the developmental status of; Fixation Stability Binocular Stability Fixation Stability, Binocular Stability, Saccadic Organisation, Subitizing and Count. B. Operational organisation and Endurance. Schemata breakdowns with Tracking, Focus & Teaming. Area 3; Visuo-cognitive Operations; Three domains – (Ref’s. 2, 3) Sensory Motor ( aka :VIP ) , Evolving Self, Problem Solving. Visual Spatial Mindful Awareness of eg. Object Permanence p g j Visual Analysis Body Construct Size , Shape Constancy Visual Motor Self Awareness Motor / Visual Hierarchy Self Monitoring Visual Auditory Self Correction Impulsive / Reflective sua ud to y Se Co ect o pu s e / e ect e (Fono Test ) Self Organisation Conservation / Logic (Ref’s. 4, 5)

8

Fischer et.al. (Ref. 6) state ........... “... it is not not the saccade control the saccade control system as as a a whole which whole which exhibi exhibits de developmen velopmental defic tal deficits in dyslexia. The eye muscles and the brainstem mechanisms for saccade generation are usually intact and do not show any systematic deficits.”............... .....” It is the frontal It is the frontal lobe lobe component, component, which regulates the synchronization

• f the ongoing reading process & saccade generation, that is not well

that is not well establishe established.” d.” p 18. p 18.

Clinical Pearl (1): Clinical Pearl (1):

“These

These Neuro – Neuro – Developmental KPI evelopmental KPI Deficits Deficits are are not not detected detected by by a a traditional traditional defect defect ‘Eye ‘Eye Exa Exam’ .” ’ .”

9



Research on Optomotor & Perceptual factors is extensive



Research on Optomotor & Perceptual factors is extensive.

• Prof. Fischer and team have made significant contributions eg:

1.

• 1. Discovered

scovered Express Saccades, 1983 (Ref.7); 1984 (Ref.8)

• 2. Established develop

velopmen ental tal KPI I milesto lestones es . 3.

• 3. Showed develo

velopment ental d l deficit icits co-exist with Dyslexia, ADHD, Dyscalculia and General Learning Dysfunctions. 4.

• 4. Demonstrated that developmental KPI deficits are typically treatabl

treatable (87% prognosis). 5.

• 5. Successful treatment of KPI deficits transfe

transfers to related educational areas. 6.

• 6. Turn-Key system

Turn-Key system for clinical neuro developmental assessment: 2002. (Ref. 9)

10

E E

 Express Eye. Uses three mini-lasers and infrared Sensors that make about 1000 readings per second. Stability of projected lights determined by body/head control. p j g y y/ Two measurement protocols : * Pro-Saccades, * Anti-Saccades. Each have 200 presentations takes about 8 minutes Each have 200 presentations takes about 8 minutes . Data Recorded Data Recorded : ( New Informati ( New Information ) n ) b l

• 1. Fixation Stability,
• 2. Binocular Stability,
• 3. Saccadic Organisation :

Response Time, Response Accuracy, Self Correction ~ % of errors, Self Correct Response Time & Accuracy.

11

Fix Test :

Fall back procedure when Express Eye can not be done ! Can be used as a ‘screening’ Performance Test. Not able to measure Response Times (b t gi es o erall time to

• Response Times (but gives overall time to

complete);

• Number of Express Saccades;
• Pattern of self correction.

12

Count Fix:

Challenges the visual system as to its capacity to recognize the number of items that are simultaneously presented for a short period of time time. (Basic Tachistoscopic Procedure for ‘Where is It” ; depends on Fixation engagement, short term memory & attention shifts to Count above 4 ) memory & attention shifts to Count above 4 ). Comp ter contains ‘de elopmental e pected’ Computer contains ‘developmental expected’ data for subjects aged 7 to 55 years. Results are displayed relative to this data . ( Ref. 11, 12. )

13

Assessing 5 aspects of Auditory-Spatial Integration.

14

S h t M d l Schemata Model.

( Ref. 12,13,14,15,16,17,18,19. )

Fix Train Fix Train VT: VT:



Used to treat & monitor progress with :



Used to treat & monitor progress with : Unstable Fixation ( Poor Magno to Parvo switch ) Slow Fixation Release ( over hold on Parvo ) Anti Saccade deficits.



Used at Clinic and complemented with : MIT ; After Image death ray; Peg rotator; Head torch ; Yoke Prism orientation; Accommodative procedures etc.



We do not use the Fix Train for home training.



VT Rx. changes used to foster visual engagement ; Held affect (Ref.17) Vegan affect (Ref.20) A/CA relationship (Ref’s. 21, 22)

Clinical Pearl Clinical Pearl (2 (2 ): ): Diagno Diagnosis is drives drives VT VT curricu curriculum um plan. plan. Activities Activities are are -

• Specific;

pecific; Se Sequential; Ada quential; Adaptive; Repetitive: tive; Repetitive: VT ~ Can not be “busines VT ~ Can not be “business as usual”. as usual”.

15

Started after ‘anti-saccade’ performance is about equal to developmental expected or plateau. Samples of activities include;

Geoboard/peg boards (Battleships codes), Parquetry blocks. Parquetry blocks. Parquetry tack. Space Fixator for ‘soft looking’. Touch induced visual imagery. Matching – Domino’s, Dice, Cards,

• Sorting. 100 Squares.
• Flashcards. (Dots.)

Count Train : Used as a Clinic VT station & to assess progress.

16



Commenced after the individual has organised their personal space ‘construct’ and has reached developmental personal space construct and has reached developmental expected with Count Train. Sample home activities include; Sample home activities include;

Rhythm activities, Metronome, Point to bell. Listen – Visualise and Repeat. VADS. Xylophone – Intensity Frequency Side Order Gap Detection Xylophone Intensity, Frequency, Side Order, Gap Detection. Rosner Auditory.

Fono Train: Used as a Clinic VT station & to assess progress Fono Train: Used as a Clinic VT station & to assess progress.

17

Pre-examination data; DOB 11/8/00 Year 3 2009 Year 3, 2009. Middle child of 3 children. ( Family History – Neg. All high achievers.) School questionnaire : Teacher reported reading below grade level. Reason for consult – slow reading and writing, confuses word beginnings. g g, g g Symptoms reported at initial consult (20/2/9); ( Parent.) Slow school progress, tracking difficulties, eyestrain at near, mistakes words with similar beginnings. Handwriting and spelling difficulties. Reports provided: Reports provided: Psycho-ed. assessment requested; parent reported all was ok. Report withheld.

18

• 1. Healthy Eyes.

y y

• 2. Functional Vision : Initial Exam. 20/2/09.

A.

Unaided VA R 6/6, L 6/6.

B.

# 4 R +0.50, L +0.50

C

#7 R +0 50 L +0 50 (# vertical 1 00 ou still vert)

C.

#7 R +0.50, L +0.50 (# vertical, -1.00 ou, still vert).

D.

#14 Poor JND’s, +0.75, 3-5 exo.

E.

#20

• 3.00

F.

#21 +1.75

G.

Keystone FVP :

H.

Remote NPC : 14 cms., Binocular String, 8cms behind bead. Exo posture.

• 3. Tests conducted; 26/2/09.



TVPS – Above average. Skilled.



Express Eye – CND. Fail.



Fix Test – Below expected – DX Fixation Instability. Fail.



Wold Sentence Copy – 1st min 16 letters 2nd min 19 letters Fail



Wold Sentence Copy 1 min.16 letters, 2 min.19 letters. Fail.



Gardner – 2 errors. ( Slow ; not automatic. ) B/L.



Count Test – poor accuracy. Fail.



Vergence ranges – fails base out recovery. BO : x/12/2. BI /18/12 BI : x/18/12.

19

Di i

d l l l d f

Diagnosis: Neuro-developmental visual inspection deficit.



Fixation instability.



Convergence Insufficiency Syndrome. Vi l M t I t ti Diffi lti



Visual-Motor Integration Difficulties.

Recommendations Recommendations:

Spectacles for VT and close work Spectacles for VT and close work. VT Prognosis : Good gains - 15 CBVT visits ; conclude - 24 visits.

Out Out Come

• me:

Out Out Come Come:

Parents ‘self discharged’ after 15 CBVT visits. Reported now reads books by chapters , instead of by the paragraph. Optomotor and Perceptual KPI deficits successfully treated. Binocular & VMI better but still low . ‘At Risk’ for Reading to Learn related functional vision problems.

20

Blue -

21

Pre-examination data; DOB 18/5/1996 : Year 7, 2009.

Youngest of 3 2 older sisters ( Family History Neg ) Youngest of 3 – 2 older sisters. ( Family History – Neg.) No school questionnaire possible. Reason for consult – Need for new glasses ; R eye turns out & noted more often.

• 2nd. Opinion.

Vi i diffi l i ‘ d’ i 3 Vision difficulties ‘treated’ since age 3. Frequent reviews – OMD & OD. Patching . Last Exam; 10 months ago. Told ‘glasses’ only treatment required. ( Myelinated nerve fibres.) ( y )

Symptoms reported at initial consult (14/1/09); Aet 12 .6 years.

“R eye lazy” Glare sensitivity with bright lights. Holds book close. Can only read comfortably for 10mins. Squints to see far. Avoids close work, behind potential at school. Sport : High performer

22 22

Sport : High performer.

Major Test Results:

 Express Eye –

• Below limits for age. ( To come.)

p y

 Keystone FVP – Far : Vert. 0 ; Horiz. 11 Exo.; Flat Fusion 4 / 2 Balls ( Supp. OD.) Large Stereo 5 / 2; Fine Stereo 9/12 ; Randot Stereo +; Col. Vis. WNL.



Near: MFBF Supp. OD; Stereo 3/6; Horiz. 11 to 19 Exo ( Pointer); Flat Fusion 4 /2.

F Fi

 FonoFix - Below expected for age.  CountFix

– Unskilled.

 VO Star

• VMI : R eyed.

( R Handed )

23

 R Exotropia – intermittent.  Basic Exo.  Convergence Insufficiency Syndrome.  VO Star : R eye preferred.

y p

 Learning Related Vision Problems. Mild LD ?

Recommendations; Recommendations; 10 week trial of VT, then reassess to determine progress. Expect functional vision skills would be improved in up to 30 CBVT sessions but may require surgery to make binocular CBVT sessions, but may require surgery to make binocular teaming easier.

24

 Keystone VEE – Distance

1 VA L 6/5 1 R 6/9 OU 6/5 1

• 1. VA:

L 6/5-1 ; R 6/9; OU 6/5-1

• 2. Fixation Disp.
• Horiz. Ortho, Vert. Ortho. C/P Stab. Easy.
• 3. Mac. Suppress.

All correct. ( R,L. & OU.)

• 4. Convergence

A, 0-5, B, 0-24, C, 0-24. Easy but slow.

• 5. Divergence

A, 0-12, B, 0-12, C, 0-12. Easy but slow.

Fusional Conver Fusional Convergence. gence. Fusional Fusional Diver Divergence. ence.

25



Keystone VEE – Near.

1.

VA L 6-2 R 5-2 OU 6-2

2

BDPQ 3D +ve Upper case 22 secs

2.

BDPQ 3D +ve, Upper case 22 secs, Lower case 25 secs, all correct.

3.

Convergence A 0-24, B 0-24, C 0-24 Easy and skilled.

4

Divergence A 0 10 B 0 14 C 0 20 Easy but slow

4.

Divergence A 0-10, B 0-14, C 0-20 Easy but slow.

5.

Fixation Disp.

• Horiz. Ortho, Vert. Ortho, C/P Stab. Easy.

Fixation Disparity Fixation Disparity ( Near.) ( Near.)

26

27

28

C 1 A l ‘Fi i I bili ’ d fi i d Case 1 : At least some ‘Fixation Instability’ deficit cases respond to developmental VT sequence ( # 22, 23.) where Fix Train is preceded by : a) General Movement Patterns :Orientation of body head eyes a) General Movement Patterns :Orientation of body, head , eyes. ( Anti-Gravity ) Mobility & Balance. Directionality. Space/Time exploration with Rhythm. b) Special Movement Patterns : Where is It ; How do I manipulate It b) Special Movement Patterns : Where is It ; How do I manipulate It. ( Centering ) Clinical Clinical Pearl Pearl ( 3 ) Clinical Clinical Pearl Pearl ( 3 ). The ‘Evolving Self’ is The ‘Evolving Self’ is facilitated by facilitated by making Mindful Awaren making Mindful Awarenes ess a a component of component of VT. VT. (Vyg ygotsk

• tsky Theor

Theory & & Socratic Socratic questionin uestioning.) ( y ( yg y y q g )

29

Case 2 : a Significant binocular instability case – responded to sensory and motor

• a. Significant binocular instability case

responded to sensory and motor learning strategies beyond monocular VT.

• b. ‘Reading to Learn’ VT typically needs to go beyond normalisation of

O & P l d fi i Optomotor & Perceptual deficits. VT now requires : d) Advanced Visual Inspection VT. e) Vision , Language Patterns. f) Visualisation Patterns f) Visualisation Patterns.

Clinical Clinical Pearl: ( Pearl: ( 4.) 4.) New precision in Diagnostic Work New precision in Diagnostic Work-Up:

• Up:

Moves the process Moves the process from from Symptom Symptom Directed Guess Directed Guessing; ng; To Mind; To Mind; Measuremen Measurement t & & Mana Management. ement. g

30

• 1. I expect an Up-serge in Public Interest looking for ‘ A Sensory Fix

for Problems in School .’

• 2. New Information for Clinical Optometry.
• 2. Educational, Mental Health, Social Justice & National Economic

Issues.

• 3. Paradigm Shift Required !
• 4. A Speciality Service beyond Primary Care .

31

Optometry has solidly researched clinical procedures for:

• 1. Objective neur

neuro dev

• developmental defic

mental deficits ts diagnosis in basic Optomotor & j p g p Perceptual areas. ( Mind .)

2.

• 2. Mea

Measure urement of ent of KPI’s KPI’s : Fixation stability, binocular stability between fixations Pro & Anti saccade control accuracy and self correction can be fixations, Pro & Anti saccade control accuracy and self correction can be made.

3.

• 3. Mea

Measure urement of ent of Response Response Time Time : Temporal ‘measurements’ of response time can be analysed for an understanding of the level of motor control: Reflex , Conscious Voluntary , Semi Automatic Voluntary.

4

Treatment Treatment Efficacy fficacy : Typically ‘deficits’ improve with VT ie. Builds neural

• 4. Treatment

Treatment Efficacy Efficacy : Typically deficits improve with VT ie. Builds neural networks = Changes Minds.

32

• 1. The integration of Neuro-Developmental optomotor & perceptual KPI

assessment is an initial challenge – but worth the effort.

• 2. The Neuro- developmental , first generation, objective assessment

technology is a unique system that ‘value adds’ in specialty VT clinics.

• 3. Holistic Optometric VT ‘value adds’ to the Turn-Key training units.
• 3. Holistic Optometric VT value adds to the Turn Key training units.
• 4. The high incidence of ‘treatable functional vision deficits’ requires more

Specialty VT clinics to emerge with co-management strategies connecting Primary care and VT providers Primary care and VT providers.

• 5. Vision care politics :

Research is available, applicable, defendable and promotable ; Connects ‘Mind ; Measurement ; and Management’ Neuro Science to VT Connects Mind ; Measurement ; and Management Neuro Science to VT.

Clinical Clinical Pearl: Pearl: ( 5). ( 5). ‘Mana ‘Management’ is em ement’ is empowered b

• wered by KPI ‘Measurement.’

KPI ‘Measurement.’ g p g p y

Thank Thank You You ! !

33