Effects of vision therapy on near exodeviation in children with convergence insufficiency treated during the convergence insufficiency treatment trials

PURPOSE

To report the change in the magnitude of near exodeviation in children with symptomatic convergence insufficiency successfully treated with office-based vergence/accommodative therapy in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial.

METHODS

A total of 131 children 9-14 years of age with symptomatic convergence insufficiency classified as successfully treated with office-based vergence/accommodative therapy at the 16-week outcome visit were included. Masked examiners measured the near ocular deviation by the prism and alternate cover test at baseline, primary outcome and 1-year post-treatment. The mean change in near deviation was calculated from baseline to primary outcome, from primary outcome to 1-year post-treatment and from baseline to 1-year post-treatment.

RESULTS

Of the 131 participants successfully treated with vergence/accommodative therapy, 120 completed the 1-year post-treatment visit. A significant change in near exodeviation was observed at baseline to primary outcome (2.6Δ less exo, p < 0.001, moderate effect size d = 0.61) and at baseline to 1-year post-treatment (2.0Δ less exo; p < 0.001, small effect size d = 0.45). The change from primary outcome to 1-year post-treatment (0.6Δ more exo; p = 0.06, small effect size d = 0.11) was not significant. Forty per cent (48/120) of participants had a decrease in near exodeviation >3.5∆ (expected test/retest variability) between baseline and the primary outcome examination. Of the 120 participants, one (1.0%) was esophoric at the primary outcome and was subsequently exophoric at 1-year post-treatment. Four participants (3.3%) who were orthophoric or exophoric at the primary outcome were esophoric (all ≤3∆) at the 1-year post-treatment visit.

CONCLUSION

On average, the near exodeviation was smaller in size immediately after the discontinuation of vergence/accommodative therapy (2.6∆, moderate effect size) and 1 year post vergence/accommodative therapy (2.0∆, small effect size) in children with convergence insufficiency who were successfully treated; 40% had a clinically meaningful decrease in exophoria. The development of near esophoria was rare.

Office-based vergence and anti-suppression therapy for the treatment of small-to-moderate angle intermittent exotropia: A randomised clinical trial

PURPOSE

To evaluate the short-term (1 week after completion of treatment) effect of office-based vergence and anti-suppression therapy (OBVAT) on the Office Control Score when compared to observation alone in children with small-to-moderate angle intermittent exotropia (IXT).

METHODS

In this single-masked (examiner masked), two-arm, single-centre randomised clinical trial, 40 participants, 6 to <18 years of age with untreated IXT, were randomly assigned to OBVAT or observation alone. Participants assigned to therapy received 60 min of OBVAT with home reinforcement once per week for 16 weeks. Therapy included vergence, accommodation and anti-suppression techniques. The primary outcome measure was the comparison of the distance Office Control Score between the two groups at the primary outcome visit (i.e., 17-week follow-up visit).

RESULTS

At the primary outcome visit, the OBVAT group (n = 20) had a significantly better distance Office Control Score (adjusted mean difference: -0.9; 95% CI: -0.2 to -1.5; p = 0.008; partial eta squared: 0.19) than the observation group (n = 16). Participants from the OBVAT group were more likely than those from the observation group to have ≥1 point of improvement at the 17-week visit (OBVAT group: 75%; Observation group: 25%; p = 0.006).

CONCLUSIONS

In this randomised clinical trial of participants aged 6 to <18 years with IXT, we found that the OBVAT group had a significantly better distance Office Control Score than the observation group at the 17-week visit. This study provides the first data from a randomised clinical trial demonstrating the effectiveness of OBVAT for improving the control of IXT. Eye care practitioners should consider OBVAT as a viable, non-surgical treatment option for IXT. A full-scale randomised clinical trial investigating the long-term effectiveness of OBVAT in treating IXT is warranted.

Post Stroke Visual Impairment: Interdisciplinary Collaborative Program - Canadian Perspective

Post-stroke visual impairment (PSVI) affects more than 60% of the people who have a stroke but visual function is not routinely assessed in most stroke units. Recent high-quality research in this field has produced evidence-based assessment and management practices for PSVI. Orthoptists have integrated into the stroke care team in the United Kingdom (UK) to provide this valuable service. This paper outlines the development and implementation of the first known orthoptic PSVI service in North America. A pilot program was developed between the Ophthalmology, Neurology, and Physical Medicine and Rehabilitation Departments in Saskatoon, Saskatchewan, Canada. A new referral pathway was established to refer stroke patients with PSVI directly to an orthoptist with specialization in PSVI. Clinical findings from the first year of operation are reported. One hundred and seven visual deficits were suspected by the referring service. Visual field deficits were the most commonly reported PSVI. Diplopia was the most commonly reported oculomotor deficit in this cohort, and visual neglect/inattention was the most common visual perceptual deficit reported. Reading issues were the most commonly reported functional issues. Following assessment by an orthoptist, 45 additional visual deficits were identified and addressed. Stroke patients require assessment and treatment for PSVI. Orthoptists are perfectly suited to PSVI assessment and management. There is an opportunity to increase orthoptists' scope of practice in North America to ensure stroke patients receive specialized vision assessment and treatment.

Oculomotor screening and neuro-visual rehabilitation following pediatric brain tumor resection

Visual difficulties are common after brain tumors, despite a lack of visual complaints at diagnosis. These include difficulties with eye movements, visual coordination, vergence, accommodation, and photophobia, in addition to more obvious problems such as visual field defects.This case report presents the results of a thorough neuro-visual evaluation in a boy with sequelae after a brain tumor including intermittent double vision that was not explained by routine visual examination. Subjective complaints included poor reading perseverance, intermittent blurred and double vision, headache around the eyes when performing near activities, less efficient eye movement behavior in reading tasks, and increased sensitivity to visual motion. The patient participated in a multidisciplinary visual rehabilitation program that included reading glasses with prism compensation and tinted glasses, as well as training with the aim of improving eye teaming, near vision functions, and perseverance in eye movements.The patient responded quickly to the vision therapy program, with positive changes after just four weeks. Repeated neuro-visual evaluations over eight months showed remarkable improvements that were stable over time. This encouraging case report supports the notion that neuro-visual evaluation and rehabilitation should be included in the follow-up of patients after brain tumors.

Awareness of Usher Syndrome and the Need for Multidisciplinary Care: A Cross-Occupational Survey of Allied Health Clinicians

Background

Usher syndrome is the most common cause of deaf-blindness, affecting up to 1 in 6000 people. Multidisciplinary care is required to maximize outcomes for individuals and families. This study assessed awareness of Usher Syndrome amongst allied health clinicians who provide care related to the primarily affected senses of hearing and vision, ie, optometry, orthoptics and audiology.

Methods

A prospective cross-sectional online survey of clinicians working in Australian university-affiliated clinics (7 optometry, 1 orthoptics and 4 audiology) was completed between September 2021 and January 2022. Questions were asked about the cause, common symptoms, and awareness of health professions who manage Usher syndrome.

Results

The 27 audiologists, 40 optometrists, and 7 orthoptists who completed the survey included 53 females (71.6%), had an average age of 37 years (range 24-70), and had an average duration of clinical experience of 13 years (range 1-45 years). The majority of respondents correctly identified Usher syndrome as a genetic condition (86%), identified at least two of the affected senses (97%), and identified the progressive nature of the vision and hearing losses (>90%). Awareness of vestibular dysfunction and its characteristics was low, as was knowledge of the key treatment roles that speech pathologists, genetic counsellors and geneticists play in the management of Usher Syndrome. The majority of respondents also did not identify important aspects of care within their own discipline.

Conclusion

This study has shown that there is a need for targeted education to be delivered to hearing and vision care allied health clinicians to raise awareness of the vestibular impacts and aspects of vision loss experienced by people with Usher syndrome. This education needs to target the broad range of clinicians who have a key role in providing multidisciplinary care (including speech pathologists, geneticists, and genetic counsellors) and to identify the key aspects of good-quality multidisciplinary care.

20/20: Where are Orthoptists Going?

The year 2020 has been greatly anticipated by the entire ophthalmic community. This year's Scobee lecture will be a photographic look at our past with the orthoptists and pediatric ophthalmologists we have learned from, taught, and worked with. A sobering snapshot of our present will reveal a world with extreme medical access inequality. This creates a need for an inexpensive screening device for amblyogenic anisometropia. A technique for such a fast and inexpensive screening device will be shown using first retinoscopy; and then compare the effectiveness of the direct Heine streak ophthalmoscope, a common ophthalmic instrument, will be shown to be effective in screening for ≥1 diopter of spherical anisometropia. The challenges of the present hint at an optimistic future for orthoptists, expanding their role as physician extenders to help ease the medical access inequalities in the world. Finally, I introduce the patron saint of the blind and those with vision impairment.

Role of orthoptics and scoring system for orbital floor blowout fracture: surgical or conservative treatment

AIM

To assess the role of orthoptics in referring patients with orbital floor blowout fracture (OFBF) for conservative or surgical treatment and based on the results, to propose a scoring system for such decision making.

METHODS

A retrospective analysis of 69 patients with OFBF was performed (35 treated conservatively, 34 surgically). The role of orthoptics in referring to surgery or conservative treatment was retrospectively evaluated, the factors with the highest significance for decision making were identified, and a scoring system proposed using Logistic regression.

RESULTS

According to defined criteria, the treatment was unsuccessful in 2 (6%) surgically treated and only in one (3%) conservatively treated patient. The proposed scoring system includes the defect size and several values resulting from the orthoptic examination, the elevation of the eyebulb measured on Lancaster screen being the most significant.

CONCLUSION

The study demonstrates the benefits of orthoptic examination when making decisions on conservative or surgical treatment and for diagnosing ocular motility disorder (with or without binocular diplopia) in OFBF patients. The proposed scoring system could, following verification in a prospective study, become a valuable adjunctive tool.

Orthoptic assessment of vision in patients with complex disability: the importance of understanding the patient's communication methods

Care for children with acquired brain injury requires a multi-disciplinary team (MDT) to maximize rehabilitation. These children frequently present to the orthoptic clinic with complex difficulties impacting visual functions and eye movements. We report on one case which led to a reevaluation of our current assessment methods, clinical care pathways and the contents of clinic correspondence. We present a case report of a 14-year-old girl who suffered a cardiac arrest due to underlying Wolff-Parkinson-White syndrome; MRI revealed hypoxic brain injury with extensive white matter and basal ganglia volume loss. On presentation, it was evident there was a significant impact on visual function. Conventional optotype acuity testing was not possible. Her inability to maintain fixation made observational responses unreliable. Observations revealed no steady fixation, exotropia and roving eye movements. Although she was reported to be unable to speak, progress with communication was reported and she was able to give repeatable, reliable responses to indicate "yes" or "no." These cues were used and a response of 1.70 cycles per degree was obtained under binocular conditions. This communication method was also utilized to assess visual fields by confrontation. However, the clinic letter written by the ophthalmologist based on the orthoptic assessment simply provided the acuity score with no interpretation of the information or how it was obtained. This case highlighted the importance of understanding a child's communication methods so that assessment can be appropriately adapted. The referral letter was lacking in detail regarding the patient's abilities but equally the ophthalmology letter provided limited detail impacting on the MDT practitioner's ability to understand and apply the information. This case has highlighted the importance of good communication: professionals need to acknowledge and work with an individual's communication methods so that assessment can be completed. Professionals also need to improve communication of relevant findings to others involved in the patient's care.

Vision Screening Assessment (VISA) tool: diagnostic accuracy validation of a novel screening tool in detecting visual impairment among stroke survivors

PURPOSE

Screening for visual problems in stroke survivors is not standardised. Visual problems that remain undetected or poorly identified can create unmet needs for stroke survivors. We report the validation of a new Vision Impairment Screening Assessment (VISA) tool intended for use by the stroke team to improve identification of visual impairment in stroke survivors.

METHODS

We conducted a prospective case cohort comparative study in four centres to validate the VISA tool against a specialist reference vision assessment. VISA is available in print or as an app (Medicines and Healthcare products Regulatory Agency regulatory approved); these were used equally for two groups. Both VISA and the comprehensive reference vision assessment measured case history, visual acuity, eye alignment, eye movements, visual field and visual inattention. The primary outcome measure was the presence or absence of visual impairment.

RESULTS

Two hundred and twenty-one stroke survivors were screened. Specialist reference vision assessment was by experienced orthoptists. Full completion of screening and reference vision assessment was achieved for 201 stroke survivors. VISA print was completed for 101 stroke survivors; VISA app was completed for 100. Sensitivity and specificity of VISA print was 97.67% and 66.67%, respectively. Overall agreement was substantial; K=0.648. Sensitivity and specificity of VISA app was 88.31% and 86.96%, respectively. Overall agreement was substantial; K=0.690. Lowest agreement was found for screening of eye movement and near visual acuity.

CONCLUSIONS

This validation study indicates acceptability of VISA for screening of potential visual impairment in stroke survivors. Sensitivity and specificity were high indicating the accuracy of this screening tool. VISA is available in print or as an app allowing versatile uptake across multiple stroke settings.

Could Modifying the Bagolini Glasses Improve the Reliability of Responses?

Aims:

Bagolini striated lenses are a useful test of binocular vision, but the variations in the striations (frequency and thickness) can impact on the perceived image. Also, responses can be difficult to interpret in young children. Therefore, the aims of this project were to evaluate the impact of striation frequency and the addition of coloured filters on subjective responses.

Methods:

Three sets of striated lenses were made (small, medium and large striations), each produced in two forms (both lenses clear, or with a red and blue lens). Also, Bagolini glasses (Optiker Ryser) were used, with and without the addition of red and blue filters. Subjects were asked to report what they perceived, with subsequent questions regarding the number and length of lines.

Results:

Forty-two adult subjects were tested, with uniocular VA ranging from –0.18 to 1.10 logMAR (mean 0.08 ± 0.25). The number of lines seen when varying the line thickness did not vary between coloured and clear lenses (post-hoc analysis following ANOVA, p > 0.1 in all comparisons). Adding red/blue filters to the original Bagolini glasses did not alter the rates of subjects perceiving a cross (Chi-square, p = 0.8). However, the laser-cut lenses produced a significantly shorter light streak than the original lenses (One-way ANOVA, p < 0.001), but the colour of the filters made no difference to the length of streak perceived (Tukey’s Test, p = 0.20).

Conclusions:

The addition of coloured filters did not impact on the responses given to the original or laser-cut lenses, suggesting this modification may aid responses in children. However, further evaluation is required with finer striations and thinner lenses to improve the visibility of the lines.

Orthoptic Home Visits for Stroke Survivors: Results from a UK Professional Practice Survey

Aim:

Orthoptists are perhaps the only allied health profession without a standard home visits service in the UK, although it could arguably be of benefit to many orthoptic patients. The aim of this survey was to identify whether home visits are being offered, or have the potential to be offered, within the orthoptic profession.

Method:

A survey of the orthoptic professional body (BIOS) for the UK and Ireland was developed and data collected between January and March 2016. Descriptive analysis was used to report the quantitative findings. A thematic analysis approach was undertaken for the written responses within the free-text boxes of the survey.

Results:

461 BIOS members responded to the survey (response rate of 30.7%). Ten hospital sites (3.7%) reported offering home visits, and 444 members (96.3%) reported that they do not offer home visits, with little desire or perceived need for such a service. Only certain patients reportedly meet requirements for an orthoptic home visit, including those unable to attend the hospital due to poor health, transport issues, reduced cognition, stroke and learning difficulties. Implementation barriers were reported including staff safety, assessment quality and cost.

Conclusion:

Home visits are infrequently conducted within the orthoptic profession. However, where offered, certain patient groups were suggested to benefit from this service when they cannot attend hospital and thus, home visits could present a viable means of providing equitable visual care. Future research is required to explore orthoptic home visits compared to other forms of rehabilitation, and address concerns from the orthoptic professional body.

Ten Years On - A Survey of Orthoptic Stroke Services in the UK and Ireland

Aim:

In 2007 a national orthoptic survey identified poor provision of vision assessment for stroke survivors. The purpose of this study is to report a 10-year update of this survey to identify changes in clinical practice over recent years.

Methods:

An online practice survey of registered orthoptists (British and Irish Orthoptic Society, BIOS) was undertaken to scope vision services for stroke survivors.

Results:

At the time of this survey, there were 223 orthoptic departments and 227 stroke units in the UK and Ireland. 317 responses were received representing 178 orthoptic departments – an 80% response rate for orthoptic departments. Of the respondents, 92% reported having a stroke unit in their hospital. A stroke/vision service was provided by 98% of responding orthoptic departments for 77% of stroke units but with only half providing a vision service on the stroke unit. Only 33% of vision services were funded and funding remains the primary barrier to providing a stroke/vision service. About 85% of respondents were aware of the national clinical guidelines for stroke and the BIOS extended practice guidelines for stroke.

Conclusions:

There has been a positive increase in awareness of stroke-related visual impairment and a steady improvement in provision of eye care for stroke survivors. However, there remains a lack of provision of specialist vision services specifically on stroke units which infers a health inequality for stroke survivors who have visual impairment. Their visual impairments can remain undetected and thus undiagnosed and unmanaged due to unsatisfactory patient care.

Conjugate Eye Deviation in Unilateral Lateral Medullary Infarction

Background and Purpose

The initial diagnosis of medullary infarction can be challenging since CT and even MRI results in the very acute phase are often negative.

Methods

A retrospective, observer-blinded study of horizontal conjugate eye deviation was performed in 1) 50 consecutive patients [age 58±15 years (mean±SD), 74% male, National Institutes of Health Stroke Scale 2±1] with acute unilateral lateral medullary infarction as seen in MRI (infarction group), 2) 54 patients with transient brainstem symptoms [transient ischemic attack of brainstem (TIA) group; age 69±16 years, 59% male], and 3) 53 patients (age 59±20 years, 49% male) with diagnoses other than stroke (control group).

Results

Conjugate eye deviation was found in all patients in the infarction group [n=47 (94%) with ipsilesional deviation and n=3 (6%) with contralesional deviation] compared to 41% (n=22) in the brainstem TIA group and 15% (n=8) in the control group (p<0.0001). Within all groups mean deviation and range were similar for both sides (to the right vs. to the left side 26.6°±12.3 vs. 26.1°±12.3 in the infarction group, 10.5°±5.8 vs. 8.4°±6.3 in the brainstem TIA group and 4.5°±3.2 vs. 7.5°±3.2 in the control group). The extent of eye deviation was significantly greater in the infarction group (p<0.05).

Conclusions

All patients with MRI-demonstrated unilateral medullary infarction showed conjugate eye deviation. Therefore, conjugate eye deviation in patients with suspected acute lateral medullary infarction is a helpful sensitive sign for supporting the diagnosis, particularly if the deviation is >20°.

What Do We Expect New Graduate Orthoptists to Do?

Aims:

To validate the content of an updated orthoptic curriculum for the British & Irish Orthoptic Society (BIOS), BIOS members were surveyed about their views on what an orthoptist should be able to do soon after entering the profession.

Methods:

An online survey of all practicing members of BIOS was carried out. In 35 questions across 5 domains (professional behaviour, foundation knowledge and theory, investigation, management and research and literature skills) covering the range of orthoptic practice, orthoptists were asked about the breadth and depth of knowledge required. Results were analysed by the respondents’ working environment, experience, geographical region and teaching involvement.

Results:

325 orthoptists (27% of the membership) provided useable data, and 265 provided a full dataset. Orthoptists are frequently required to exercise considerable autonomy and responsibility for patient care from very early in their careers across many domains, often in the least-supervised environments. There was broad agreement across most core topics but wider variation in opinion in more peripheral domains. More experienced orthoptists value the wider medical aspects of orthoptic practice more highly.

Conclusions:

The survey confirmed that there is generally a good match between current undergraduate teaching and clinicians’ expectations of newly graduated orthoptists. It is clear that training must prepare graduates for a high level of professional autonomy from the earliest stages of their careers. There may be a place for targeting CPD provision for professionals at different stages in their careers.

Effect of treatment of symptomatic convergence insufficiency on reading in children: a pilot study

BACKGROUND

To evaluate the impact of treatment of symptomatic convergence insufficiency using office-based vergence/accommodative therapy on reading skills in children.

METHODS

Children (n = 44) ages nine to 17 years with symptomatic convergence insufficiency were administered the following four reading tests: Wechsler Individual Achievement Test II; Test of Word Reading Efficiency; Test of Silent Word Reading Fluency; and the Gray Oral Reading Test, at baseline and eight weeks after completion of a 16-week program of office-based vergence/accommodative therapy. To determine whether significant change occurred with therapy, change in performance was compared to zero. Treatment response was determined using a composite score of symptoms and signs at the conclusion of treatment and at the 24-week outcome visit. Participants were classified as early responders, late responders, or non-responders based upon whether criteria for successful treatment were met at the completion of 16 weeks of treatment, at the 24-week outcome visit, or not met at either visit, respectively.

RESULTS

After treatment for convergence insufficiency, statistically significant improvements were found for reading comprehension (mean = 4.2, p = 0.009) and the reading composite score (mean = 2.4, p = 0.016) as measured by the Wechsler Individual Achievement Test at the 24-week visit. These improvements were related to the clinical treatment outcome measures (p = 0.011) with the largest improvements occurring in those who were early responders to treatment. Reading speed (words per minute) increased significantly on the Gray Oral Reading Test (p < 0.0001). No significant improvements were observed for single word reading or reading fluency as measured by the Test of Word Reading Efficiency, the Test of Silent Word Reading Fluency or the Gray Oral Reading Test.

CONCLUSION

Improvements in reading comprehension and reading composite were found after office-based vergence/accommodative therapy, with the greatest improvements in those who responded early to treatment.

Visual Impairment Screening Assessment (VISA) tool: pilot validation

OBJECTIVE

To report and evaluate a new Vision Impairment Screening Assessment (VISA) tool intended for use by the stroke team to improve identification of visual impairment in stroke survivors.

DESIGN

Prospective case cohort comparative study.

SETTING

Stroke units at two secondary care hospitals and one tertiary centre.

PARTICIPANTS

116 stroke survivors were screened, 62 by naïve and 54 by non-naïve screeners.

MAIN OUTCOME MEASURES

Both the VISA screening tool and the comprehensive specialist vision assessment measured case history, visual acuity, eye alignment, eye movements, visual field and visual inattention.

RESULTS

Full completion of VISA tool and specialist vision assessment was achieved for 89 stroke survivors. Missing data for one or more sections typically related to patient's inability to complete the assessment. Sensitivity and specificity of the VISA screening tool were 90.24% and 85.29%, respectively; the positive and negative predictive values were 93.67% and 78.36%, respectively. Overall agreement was significant; k=0.736. Lowest agreement was found for screening of eye movement and visual inattention deficits.

CONCLUSIONS

This early validation of the VISA screening tool shows promise in improving detection accuracy for clinicians involved in stroke care who are not specialists in vision problems and lack formal eye training, with potential to lead to more prompt referral with fewer false positives and negatives. Pilot validation indicates acceptability of the VISA tool for screening of visual impairment in stroke survivors. Sensitivity and specificity were high indicating the potential accuracy of the VISA tool for screening purposes. Results of this study have guided the revision of the VISA screening tool ahead of full clinical validation.

Using Technology, Bioinformatics and Health Informatics Approaches to Improve Learning Experiences in Optometry Education, Research and Practice

Rapid advances in ocular diagnostic approaches and emerging links of pathological changes in the eye with systemic disorders have widened the scope of optometry as the front line of eye health care. Expanding professional requirements stipulate that optometry students get a meticulous training in relevant information and communication technologies (ICT) and various bioinformatics and health informatics software to meet current and future challenges. Greater incorporation of ICT approaches in optometry education can facilitate increased student engagement in shared learning experiences and improve collaborative learning. This, in turn, will enable students to participate in and prepare for the complex real-world situations. A judicious use of ICTs by teachers in learning endeavors can help students develop innovative patterns of thinking to be a successful optometry professional. ICT-facilitated learning enables students and professionals to carry out their own research and take initiatives and thus shifts the equilibrium towards self-education. It is important that optometry and allied vision science schools adapt to the changing professional requirements with pedagogical evolution and react appropriately to provide the best educational experience for the students and teachers. This review aims to highlight the scope of ICT applications in optometry education and professional development drawing from similar experiences in other disciplines. Further, while enhanced use of ICT in optometry has the potential to create opportunities for transformative learning experiences, many schools use it merely to reinforce conventional teaching practices. Tremendous developments in ICT should allow educators to consider using ICT tools to enhance communication as well as providing a novel, richer, and more meaningful medium for the comprehensive knowledge construction in optometry and allied health disciplines.

Pediatric Ophthalmology Practice Efficiency: Utilization of Orthoptists as Partners in the Pediatric Eye Care Team

BACKGROUND AND PURPOSE

The profession of orthoptics has been present for over 100 years and was created as a partnership with pediatric ophthalmology in an effort to provide better strabismus care to children. Orthoptists are known to improve practice efficiency, but to date, no quantitative data has been presented in the literature to support this claim. Proper utilization of an orthoptist is critical to improving practice efficiency and revenue.

METHODS

Over a 6-month period, the financial impact to a pediatric ophthalmology practice by the addition of a second certified orthoptist (C.O.) was analyzed. Both indirect and direct income and expenses were considered.

RESULTS

Despite their increased salary compared to an ophthalmic assistant, the utilization of an orthoptist provides considerable return on investment. The addition of a certified orthoptist increased practice revenue by over $70,000.

CONCLUSION

The addition of a certified orthoptist in a physician's practice significantly increases practice revenue generated. When considering models of healthcare within ophthalmology, the use of an orthoptist as a physician extender has been shown to improve practice efficiency in a cost-effective manner.

A History of Orthoptics in the United States, Part I: "If You Build It, They Will Come"

The year 2015 marks the 75th anniversary of the American Association of Certified Orthoptists (AACO), the second oldest orthoptic professional organization in the world. Since its inception, October 7, 1940, approximately 90% of all certified orthoptists (C.O.) have consistently maintained membership in their professional society. Approximately 80% of AACO members attend AACO-sponsored scientific meetings at least once annually. And 17-20% of members are actively involved in AACO leadership, management, and activities.Eye care has changed dramatically over the last 75 years, and orthoptics has successfully adapted to survive due to the fortitude and resilience of its practitioners. The AACO has weathered opposition from much more powerful competitors, ever-increasing health care regulation, and an evolution in the standard management of strabismus, only to emerge transformed and even more durable. One constant remains: the qualities that inspired thirty-three individuals to create a profession and a society dedicated to the care of patients with strabismus and disorders of binocular vision, and the education of parents, orthoptists, and ophthalmologists exist in every orthoptist today. These qualities are determination, creativity, dedication, and passion.

Orthoptics and craniofacial syndromes

Craniofacial syndromes in children present with a variety of ophthalmic manifestations in which an orthoptist would be a part of the team of health professionals taking care of these patients. The significant role that the orthoptist would have in the evaluation and treatment of these patients will be discussed.

Relief of asthenopic symptoms with orthoptic exercises in convergence insufficiency is achieved in both adults and children

Background

Asthenopic symptoms associated with convergence insufficiency (CI) may compromise a person's ability to work or study. We investigated the effectiveness of orthoptic exercises in relieving symptoms related to CI and long-time results in adults and children.

Methods

The data were retrospectively gathered from the patient clinical files. A total of 135 patients met the inclusion criteria of suffering asthenopic symptoms and CI but had not received prior strabismus surgery or orthoptic exercises.

Results

The mean age was 26 ± 17 years, 74% of them were female. The patients (N = 135) suffered from CI and had at least one of the following symptoms: eyestrain, blurring of vision, problems in reading and while doing work-up at close distance or headache. In the two-year follow-up time, 4% of the patients needed to be retreated and 3% of the patients required strabismus surgery. There were no significant differences between adults and children in near point of convergence (NPC), number of visits needed or fusional vergence at the end of treatment nor did the outcome depend on the number of visits. 59.5% of children vs. 51.9% of adults were free of symptoms when completing the exercises.

Conclusions

In conclusion orthoptic exercises are effective in relieving asthenopic symptoms in adults and children. The effects of orthoptic exercises on NPC and fusional vergence were equal in adults and in children and not dependent on the number of visits needed for successful outcome. With orthoptic exercises it is possible to achieve longstanding relief on the symptoms of CI.

Randomized clinical trial of treatments for symptomatic convergence insufficiency in children

OBJECTIVE

To compare home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), and office-based placebo therapy with home reinforcement (OBPT) as treatments for symptomatic convergence insufficiency.

METHODS

In a randomized clinical trial, 221 children aged 9 to 17 years with symptomatic convergence insufficiency were assigned to 1 of 4 treatments.

MAIN OUTCOME MEASURES

Convergence Insufficiency Symptom Survey score after 12 weeks of treatment. Secondary outcomes were near point of convergence and positive fusional vergence at near.

RESULTS

After 12 weeks of treatment, the OBVAT group's mean Convergence Insufficiency Symptom Survey score (15.1) was statistically significantly lower than those of 21.3, 24.7, and 21.9 in the HBCVAT+, HBPP, and OBPT groups, respectively (P < .001). The OBVAT group also demonstrated a significantly improved near point of convergence and positive fusional vergence at near compared with the other groups (P

CONCLUSIONS

Twelve weeks of OBVAT results in a significantly greater improvement in symptoms and clinical measures of near point of convergence and positive fusional vergence and a greater percentage of patients reaching the predetermined criteria of success compared with HBPP, HBCVAT+, and OBPT. Application to Clinical Practice Office-based vergence accommodative therapy is an effective treatment for children with symptomatic convergence insufficiency.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00338611.

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Key Words

• convergence insufficiency
• asthenopia
• vision therapy
• orthoptics
• vergence/accommodative therapy
• pencil push-ups
• computer vergence/accommodative therapy
• placebo therapy
• exophoria
• eyestrain
• symptom survey

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MESH Headings

• Adolescent
• Child
• Confidence Intervals
• Convergence, Ocular
• Female
• Home Nursing
• Humans
• Male
• Multivariate Analysis
• Ocular Motility Disorders/diagnosis
• Ocular Motility Disorders/therapy
• Office Visits
• Ophthalmology/methods
• Orthoptics/methods
• Patient Compliance
• Probability
• Recovery of Function
• Reference Values
• Sensitivity and Specificity
• Severity of Illness Index
• Strabismus/diagnosis
• Strabismus/therapy
• Treatment Outcome
• Vision, Binocular
• Visual Acuity

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Grants

• U10 EY014712 NEI NIH HHS
• U10 EY014676-02 NEI NIH HHS
• U10 EY014712-04 NEI NIH HHS
• U10 EY014659-03 NEI NIH HHS
• U10 EY014676-01A1 NEI NIH HHS
• U10 EY014713-01A2 NEI NIH HHS
• U10 EY014713-02 NEI NIH HHS
• U10 EY014715-01A1S1 NEI NIH HHS
• U10 EY014716-04 NEI NIH HHS
• U10 EY014710-04 NEI NIH HHS
• U10 EY014676 NEI NIH HHS
• U10 EY014706-01A1S1 NEI NIH HHS
• U10 EY014713 NEI NIH HHS
• U10 EY014709 NEI NIH HHS
• U10 EY014659-01A2 NEI NIH HHS
• U10 EY014715-04 NEI NIH HHS
• U10 EY014712-01A1 NEI NIH HHS
• U10 EY014713-03 NEI NIH HHS
• U10 EY014706-01A1 NEI NIH HHS
• U10 EY014715-02 NEI NIH HHS
• U10 EY014709-03 NEI NIH HHS
• U10 EY014715-03 NEI NIH HHS
• U10 EY014676-04 NEI NIH HHS
• U10 EY014715 NEI NIH HHS
• U10 EY014716-03 NEI NIH HHS
• U10 EY014710-02 NEI NIH HHS
• U10 EY014709-04 NEI NIH HHS
• U10 EY014716-02 NEI NIH HHS
• U10 EY014716-02S1 NEI NIH HHS
• U10 EY014706-02 NEI NIH HHS
• U10 EY014713-04 NEI NIH HHS
• U10 EY014709-02 NEI NIH HHS
• U10 EY014712-03 NEI NIH HHS
• U10 EY014706-04 NEI NIH HHS
• U10 EY014710-01A1S1 NEI NIH HHS
• U10 EY014710-01A1 NEI NIH HHS
• U10 EY014659-04 NEI NIH HHS
• U10 EY014676-03 NEI NIH HHS
• U10 EY014712-01A1S1 NEI NIH HHS
• U10 EY014659-02 NEI NIH HHS
• U10 EY014676-01A1S1 NEI NIH HHS
• U10 EY014716-01A1 NEI NIH HHS
• U10 EY014709-01A1 NEI NIH HHS
• U10 EY014706-03 NEI NIH HHS
• U10 EY014716-01A1S1 NEI NIH HHS
• U10 EY014716 NEI NIH HHS
• U10 EY014715-01A1 NEI NIH HHS
• U10 EY014709-01A1S1 NEI NIH HHS
• U10 EY014712-02 NEI NIH HHS
• U10 EY014710-03 NEI NIH HHS
• U10 EY014659 NEI NIH HHS

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