Ocular Motility Testing in Children

The purpose of this chapter is to provide the main indications, background, and procedures when assessing eye movement function in the pediatric patient. The assessment of extraocular motility function includes version and ductions using the H pattern test in order to determine the presence of underaction or overactions of the extraocular muscles (EOM). EOM testing detects abnormalities in the structural and neurological integrity caused by an acquired or congenital disease of the central nervous system. Deficits in eye movement function can also contribute to poor academic performance which requires a developmental approach to the assessment of saccadic and pursuit eye movements to determine if a referral for optometric vision therapy is indicated. For the older child who is reading to learn, an assessment of reading eye movements using objective tests, such as the Visagraph and/or the ReadAlyzer, will guide the direction of the management plan.

Delayed Diplopia After Sports-Related Concussion: A Multidisciplinary Approach to Evaluation and Management

ObjectiveTo highlight a multidisciplinary approach to the diagnosis and management of unilateral abducens palsy after a sports-related concussion.BackgroundMild traumatic brain injury (TBI) often leads to disruptions in visual functioning, affecting convergence, saccades, smooth pursuit, and accommodation. More severe TBI injuries may result in structural injuries to the ocular muscles, nerves, or the brain itself.Design/MethodsNA.ResultsCase: We present the case of a 33-year-old male with unilateral abducens nerve palsy after a sports-related concussion with loss of consciousness and multiple hemorrhagic contusions. The patient's visual symptoms manifested several days after the injury. With a multi-disciplinary evaluation involving specialists representing neurosurgery, endovascular neurology and neuro-ophthamology, unenhanced magnetic resonance imaging revealed multiple foci of intraparenchymal microhemorrhages and siderosis consistent with diffuse axonal injury (DAI), and an incidental parasagittal cavernoma. The delayed development of a sixth nerve palsy raised our suspicion for secondary axotomy, as has been described following TBI. While the probability of recovery is high, close follow up is imperative to address evolution of the patient's symptoms. In this case, the patient developed imbalance and headaches in association with his visual symptoms. For the imbalance we use physical therapy with therapists trained in vestibular therapy and for the visual symptoms we use vision therapy with trained optometrists.ConclusionsDelayed post-traumatic abducens palsy is concerning for DAI and secondary axotomy. Multidisciplinary assessment imparts the ability to evaluate for all possible causes and provide additional specialized care for recovery.

Making Modifications in Vision Therapy for a Child with Cerebral Visual Impairment and Developmental Delay

Background: Children with cerebral visual impairment (CVI) and/or developmental delay (DD) have a higher incidence of oculomotor dysfunction and visual perceptual challenges, in addition to challenges with motor control and body awareness. Such disorders could negatively impact one’s quality of life. Case Summary: This case demonstrates the efficacy of modified vision therapy (VT) activities in a 5-year-old child with CVI and DD. She completes roughly 50 sessions of VT and shows significant improvements in visual tracking and visual perceptual (VP) skills. Conclusions: This case emphasizes that children with CVI and/ or DD can benefit from VT. The progress of therapy may be affected by other motor and cognitive challenges; therefore, visual modifications to standard VT procedures can improve therapy success in these patients.

A Combined Approach of Syntonic Phototherapy along with Vision Therapy in Treatment of Rod-Cone Dystrophy: A Ray of Hope - Case Series Report

Background: Rod-Cone Dystrophies (RCDs) are characterized by the dominant clinical features of rods manifestation predominantly over the cones such as night blindness and peripheral vision worsening that leads to restricted activities of daily living. There are no medical or surgical treatments available for this disease. A combined approach of syntonic phototherapy along with the vision therapy may be a viable treatment option for the improvement in visual efficiency skills and visual function of RCD patients. Case Reports: Case 1: A female, aged 47 years old, diagnosed with severe RCD and complained of poor sight and difficulty in seeing at night in both eyes along with progressive diminution of vision for the past ten years. Case 2: A boy, 11 years of age, diagnosed with severe RCD and presented with major complaints of progressive vision loss, photophobia and falling short in school performance. Both patients were recommended for a combined treatment approach of syntonic phototherapy combined with vision therapy to be completed in our centre. Conclusion: These two patients showed significant improvement in visual acuity, oculomotor motility and visual field. Further research is recommended to enrich our understanding on the use of syntonic phototherapy along with vision therapy in managing patients with RCD which otherwise lacks in specific medical or surgical treatment.

Gamification Design on Invisible Display for Amblyopia Treatment in Indian Children: Preliminary Design Intervention Study (Preprint)

BACKGROUND India has the highest number of patients with amblyopia worldwide. For this study, we have developed a novel gaming tablet for amblyopia treatment, called Occlu-tab, which can present visual stimuli to only one eye while both eyes are open. OBJECTIVE To investigate if Occlu-tab, a gaming tablet with invisible display, is effective in improving visual acuity in children with amblyopia. METHODS We recruited 12 children with amblyopia in India to undergo Occlu-tab training. With Occlu-tab, we used eight games to provide patients with well-known techniques for vision therapy: fixation, eye-hand coordination, and pursuit eye movement. Participants were instructed to play with the Occlu-tab in a silent therapy room for 60 min per day, 3 days per week, for 6 weeks while wearing perfectly corrected glasses. The best-corrected visual acuity was determined every 2 weeks until the end of the treatment. RESULTS All 12 participants showed improved visual acuity after 4-6 weeks of treatment. The treatment games were well received by Indian children, and several requests for additional types of games were made. Parameter estimators for fixed effect showed high significance (P<.001), which suggests an evident improvement effect of the Occlu-tabs. CONCLUSIONS Occlu-tab was effective in improving visual acuity in children with amblyopia. However, game design should be improved based on the analysis of cultural and religious practices. Several patients refused to participate in the trial since they were unable to report to the hospital regularly due to financial reasons. This observation demonstrates the need for home treatment for low-income patients. In addition, home health care will be very important under a pandemic or lockdown caused by coronavirus disease 2019. In the future, this technology will be required in more accessible devices, such as televisions, smartphones, and tablets.

Character Development Creativity in Unit Blocks for Visual Spatial Intellegence Improvement of Children with Special Needs

Autism is a neurodevelopmental disorder that is present from birth or early childhood. People with autism usually have impaired social interaction, difficulties in verbal and non- verbal communication, and repetitive behaviour. One of the forms of autism treatment is therapy. Vision therapy through toys that require concentration and creativity is able to treat autism as it won’t limit the imagination of children with the disorder. Toys usually have their own patterns and programs that tend to limit children’s creativity, imagination and visual and spatial intelligence. This can lead to children’s stress and lack of confidence. A character design on unit block toys is a form of vision therapy. It develops children’s visual and spatial creativity and intelligence. It also helps children to be independent and helps with their perception. Unit blocks consist of pieces of wooden blocks with different shapes and sizes that can form even bigger shapes, based on children’s imagination and ability to design a space or a building. Children’s visual and spatial intelligence help them visualize and notice shapes, colours, spaces, and designs of the unit blocks accurately, modify their surroundings based upon their perceptions, and recreate the aspects of their visual experiences. Playing Lego blocks will help develop the visual spatial intelligence of children with autism as it stimulates their ability to express ideas and to design a character the way they like.

Virtual Reality-based Vision Therapy Versus OBVAT in the Treatment of Convergence Insufficiency, Accommodative Dysfunction: A Randomized Controlled Trial

Background: Virtual reality is being increasingly applied in vision therapy. However, the differences in effectiveness, optimal treatment cycle, and prognosis between virtual reality-based vision therapy and traditional therapies remain unknown. The purpose of this study was to compare the effectiveness of virtual reality-based vision therapy and office-based vergence/accommodative therapy in young adults with convergence insufficiency or accommodative dysfunction.Methods: The patients were randomly assigned to either the virtual reality-based vision therapy group or the office-based vergence/accommodative therapy group. The vision therapy lasted 12 weeks (1 h/week) in both groups. Binocular visual functions (vergence and accommodation) were measured and a subjective questionnaire-based assessment was performed at baseline and after 6 and 12 weeks of therapy.Results: In total, 33 patients with convergence insufficiency and 30 with accommodative dysfunction completed the study. After 12 weeks of treatment for convergence insufficiency, the Convergence Insufficiency Symptom Survey score (F2,31 = 13.704, P < 0.001), near point of convergence (F2,31 = 21.774, P < 0.001), positive fusional vergence (F2,31 = 71.766, P< 0.001), and near horizontal phoria (F2,31 = 16.482, P < 0.001) improved significantly in both groups. Moreover, the monocular accommodative amplitude (F2,25 = 22.154, P < 0.001) and monocular accommodative facility (F2,25 = 86.164, P < 0.001) improved significantly in both groups after 12 weeks of treatment. A statistically significant difference was observed in monocular accommodative facility (F1,25 = 8.140, P = 0.009) between the two groups, but not in other vergence and accommodative functions (0.098 < P < 0.687).Conclusion: Virtual reality-based vision therapy significantly improved binocular vision functions and symptoms in patients with convergence insufficiency and accommodative dysfunction, thereby suggesting its effectiveness as a new optional or additional treatment for young adults with these conditions.Trial registration: This study was registered at the Chinese Clinical Trials Registry on 16/04/2019 (identifier: ChiCTR1900022556).

Which Comes First in Sports Vision Training: The Software or the Hardware Update? Utility of Electrophysiological Measures in Monitoring Specialized Visual Training in Youth Athletes

In the present study we combined popular methods of sports vision training (SVT) with traditional oculomotor protocols of Optometric Vision Therapy (OVT) and electrophysiological indexes of EEG and VEP activity to monitor training progress and changes in performance of youth ice hockey players without the history of concussion. We hypothesized that administration of OVT protocols before SVT training may result in larger performance improvements compared to the reverse order due to the initial strengthening of visual hardware capable of handling greater demands during training of visuomotor integration and information processing skills (visual software). In a cross-over design 53 youth ice hockey players (ages 13–18) were randomly assigned to one of the two training groups. Group one (hardware-software group) completed 5 weeks of oculomotor training first followed by 5 weeks of software training. For group 2 (software-hardware) the order of procedures were reversed. After 10 weeks of training both groups significantly improved their performance on all but one measure of the Nike/Senaptec Sensory station measures. Additionally, the software-hardware training order resulted in significantly lower frontal theta-to-gamma amplitude ratios on the Nike/Senaptec test of Near-Far Quickness as well as in faster P100 latencies. Both training orders also resulted in significant decreases in post-treatment P100 amplitude to transient VEP stimuli as well as decreased theta-gamma ratios for perception span, Go/No-Go and Hand Reaction time. The observed changes in the electrophysiological indexes in the present study are thought to reflect greater efficiency in visual information processing and cognitive resource allocation following 10 weeks of visual training. There is also some evidence of the greater effectiveness of the software-hardware training order possibly due to the improved preparedness of the oculomotor system in the youth athletes for administration of targeted protocols of the Optometric Vision Therapy.