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If your child shows signs of visual problems, such as difficulty reading, headaches and eyestrain, or visual inattention and distractibility, you may be referred to behavioral optometrist (also called a developmental optometrist). This is different from optician who works in an eyeglass store or an ophthalmologist who specializes in eye disease. A behavioral optometrist not only checks for eye health and visual acuity, but also how your child is using his eyes to process visual information. If there is an actual visual problem, the behavioral optometrist may recommend vision therapy, special therapeutic activities, or corrective lenses. How often your child may need to visit the optometrist depends on his needs. Some children go regularly for in-office vision therapy, while others are given eye exercises to do at home which are followed up with an office visit every so often.

Consider going to a behavioral optometrist even if no one offers you, because an undiagnosed vision problem is a major obstacle for any child. The American Optometric Association recommends vision exams at six months old, three years, before entering first grade, and then annually. Don’t rely on a quick vision screening at school or the pediatrician’s. Such a screening often just considers visual acuity from one distance (such as reading from a nearby chart of letters), and doesn’t identify the child who, for example, can’t read from the blackboard or follow a moving object. Instead, get a full vision evaluation.

Book title: Raising A Sensory Smart Child

Author: Lindsey Biel, Nancy Peske

Page 180 – 181

Mr Stanley and the staff at SunTime Vision Specialist (Neuro-developmental Optometry and Vision Therapy Services) are eager to help patients develop their vision to see the world at its best. If you, or someone you love, is experiencing less than adequate vision, please contact us at 03- 2110 3967, or [email protected]

Visual-perceptual Delays

It’s no surprise that visual-perceptual delays are common in children with Sensory Integration Dysfunction. Visual-perceptual skill refers to a person’s ability to interpret, analyze, and give meaning to what he or she sees. Normally more than 70 percent of classroom “underachievers” have problems processing visual information, even if they have 20/20 eyesight.

Visual discrimination allows the child to identify distinct features of objects such as color, shape, size, and orientation. This skill enables her or him to match and categorize objects. As she or he grows, she or he can perceive the difference between a triangle and a circle, or B and b. The child with visual discrimination problems may have trouble recognizing faces or noticing the difference between a rectangle and a square.

Visual attention allows a child to pay attention to what he or she is doing while blocking out extraneous stimuli. A child who is easily distracted has trouble sustaining visual attention. When reading, a child may feel compelled to look at any visual stimuli around him. Visually scanning around all the words on the page rather than just focusing on the words that he should read. Some kids have trouble shifting their visual attention and learning the information that they are looking at. Some of them may not notice when something else is happening around them. A visually hyporesponsive child may have problems in noticing a visual stimulus or sustaining visual interest and feel tired after a short time. For those children who are not paying visual attention have missed out those vital developmental opportunities. This is because they are not listening and digesting the information around them.

Visual memory allows a child to remember things he or she has seen. This is an essential skill for imitating new gestures and movements, sequencing writing and spelling tasks, recognizing words and people, and more. With a poor visual memory, he or she may have the excellent memory for life experiences rather than factual information and may have difficulty in relating new visual information to what he or she already knows.

Figure-ground allows a child to differentiate between foreground and background. This is essential to keep the child’s attention to the important visual stimuli and does not get distracted by the surrounding. For examples, this skill enables him to find his favorite dump truck in a box full of toys and keep his eyes on the teacher in a busy classroom. The child with figure-ground difficulty may have trouble reading because he cannot differentiate some specific words on a page when he or she is reading.

Visual closure allows a child to use visual clues to recognize objects without seeing the entire image. For instants, this skill enables ones to find a lunchbox even it’s partially hidden behind a milk carton, this skill also enable ones to recognize a complete word if he has only seen a part of that word (proficient readers do not have to look at every letter).

Form constancy allows a child to perceive things as the same regardless of environment, position, size, and other details. For examples, ones will know what is spoon after being taught regardless of its position of the spoon (upside down, turned sideways) and other details such as material (a silver tablespoon or a plastic toy spoon). In school, ones learn that the letter S is an S whether it’s handwritten or typed, in print or cursive, or sideways.

Laterality, directionality, and spatial vision:

Laterality allows a child to differentiate between right and left sides of his own body. Directionality allows the child to perceive the right and the left side of external objects. Both are essential to spatial vision, which tells the child on how an object is positioned in space. For example, with that skill, ones know how to differentiate between the lowercase b which has a line on the left side and the d has a line on the right side. A child with a poor spatial vision may have difficulty in playing with toys, learning to climb stairs and catch a ball (both require depth perception), and developing many self-care tasks. Ones may have persistent letter reversals (beyond age eight), be confused about the letter or number sequences, and have trouble understanding directional words such as up, down, in, out, under, and over, and have poor topographical orientation and lost easily.

A child also needs to develop her visual-motor integration skills. His or her eyes and body must work together to accomplish many developmental tasks, from stringing beads to catching a ball. The visual-motor integration skills are referred to as eye-hand coordination skills. The visual-motor integration is the term used for the interaction of motor skills, visual skills, and visual-perceptual skills.

We understand that you might have a number of questions, especially if this is the first time you have experience any eye problems.
Feel free to call our office- Sun Time Vision Specialist Centre Kuala Lumpur at 03-2110 3967 and our Behavioral and Developmental optometrists will be ready to help your vision problem.

  1. Biel, L., & Peske, N. K. (2005). Raising a sensory smart child: the definitive handbook for helping your child with sensory integration issues. New York: Penguin Books.)

Vision Therapy Helping Kids With Learning Disabilities

Vision therapy helping kids with learning disabilities

Posted: Feb 21, 2014 1:06 PM HKTUpdated: Feb 21, 2014 1:18 PM HKT

By Andrea Hubbell, Reporter – bio | email



There’s new hope for parents whose child may have been diagnosed with a learning disability or ADHD.

Fort Myers Eye Association is one of only few in Southwest Florida that offers vision therapy. According to Developmental optometrist Dave Dalesio, it’s an alternative method that was developed before the 1940s. It can treat an array of learning-related vision problems.

“Their eyes don’t work together. They don’t focus well. They’re not perceiving things, something is going on.” Dalesio said.

Chloe Dold, a third-grader, is one of only 16 children Dalesio is treating right now.

For years she struggled with migraines, watery eyes and fell behind in school. Chloe was falling fast in school and her grades showed it. “I didn’t know what to do, my eyes tickled.” Dold said. Her family tried everything from different eye doctors to eye glasses and more.

None of it was working. Then they found Dr. Dalesio. Chloe was in second grade at the time. “I couldn’t see the board. And it was really frustrating because I didn’t know what to do. It was really hard for me.” Dold said.

Chloe and her family learned she suffers from a learning-related vision problem. It’s one often mistaken for children being lazy, off task and sometimes even diagnosed with ADHD. “Low and behold she did have some vision issues that we could work with.” Dalesio said.

After three months of therapy and a grade later, Chloe’s grades skyrocketed.

“They were a C, now they’re an A.” Dold said. Her migraines and watery eyes soon disappeared.

Post Trauma Vision Syndrome, Visual Midline Shift Syndrome

Following a neurological event such as a traumatic brain injury, cerebrovascular accident, multiple sclerosis, cerebral palsy, etc., it has been noted by clinicians that persons frequently will report visual problems such as seeing objects appearing to move that are known to be stationary; seeing words in print run together; and experiencing intermittent blurring. More interesting symptoms are sometimes reported, such as attempting to walk on a floor that appears tilted and having significant difficulties with balance and spatial orientation when in crowded moving environments. These type of symptoms are not uncommon. Frequently, persons reporting these symptoms to eye care professionals (optometrists and ophthalmologists) have been told that their problems are not in their eyes and that their eyes appear to be healthy. What is often overlooked is dysfunction of the visual process causing one of two syndromes: Post Trauma Vision Syndrome (PTVS) and/or Visual Midline Shift Syndrome (VMSS).

Recent research has documented PTVS utilizing Visual Evoked Potentials (VEP). This documentation concludes that the ambient visual process frequently becomes dysfunctional after a neurological event such as a TBI or CVA. Persons can often have visual symptoms that are related to dysfunction between one of two visual processes: ambient process and focal process. These two systems are responsible for the ability to organize ourselves in space for balance and movement, as well as to focalize on detail such as looking at a traffic light. Post Trauma Vision Syndrome results when there is dysfunction between the ambient and focal process causing the person to over emphasize the details. Essentially individuals with PTVS begin to look at paragraphs of print almost as isolated letters on a page and have great difficulty organizing their reading ability. It has been found that the use of prisms and binasal occlusion can effectively demonstrate functional improvement, while also being documented on brain wave studies by increasing the amplitude (this is like turning up the volume on your radio).

Visual Midline Shift Syndrome also results from dysfunction of the ambient visual process. It is caused by distortions of the spatial system causing the individual to misperceive their position in their spatial environment. This causes a shift in their concept of their perceived visual midline. This will frequently cause the person to lean to one side, forward and/or backward. It frequently can occur in conjunction with individuals that have had a hemiparesis (paralysis to one side following a TBI or CVA).

The shifting concept of visual midline actually reinforces the paralysis, by using specially designed special lens that can be prescribed, the midline is shifted to a more centered position thereby enabling individuals to frequently begin weight bearing on their affected side. This works very effectively in conjunction with physical and occupational therapy attempting to rehabilitate weight bearing for ambulation.

Board Certified Neuro-Developmental & Behavioral Optometrists like Mr Stanley, is a health professionals who are expertly trained in Post Trauma Vision Syndrome and Visual Midline shift syndrome. Please contact us @ 03-2110 3967 or [email protected]

Evidence Based Medicine: Strabismus Surgery Outcomes

Evidence Based Medicine: Strabismus Surgery Outcomes
Evidence Based Medicine: Strabismus Surgery Outcomes

Dominick M. Maino, OD,. MEd, FAAO, FCOVD-A

Professor of Pediatrics/Binocular Vision Illinois College of Optometry/Illinois Eye Institute

Lyons Family Eye Care

When you require a new hip because your old hip is giving you significant pain, your doctor often recommends physical therapy first to see if the problem can be addressed in a non-surgical manner. If the therapy does not work as well as you would like it to, a surgical consultation is then required and perhaps a surgical intervention as well. After surgery, another round of physical therapy is often conducted. This sequence of treatment (therapy, surgery, therapy) ensures you do all you can to avoid surgery if possible. If surgery is needed however, post-surgical interventions such as physical therapy ensures much better outcomes for the patient.

This does not appear to be the route many doctors recommend for those with strabismus. All too often the first suggestion is to have surgery. Seldom is it recommended to intervene with vision therapy beforehand, yet alone after surgery is completed. This sequence of events might lead you to assume that surgery is highly successful.

Evidence based medicine clearly demonstrates that this is not the case, however. In general, no matter what kind of strabismus you may have, approximately 20-30% of those undergoing surgery will require a second surgery and of these, another 20-30% may need a third surgery.

Cochrane Reviews: Various Surgical Interventions for Strabismus

For those of you not familiar with Cochrane Reviews, it is an organization trusted to review the quality of research in health care and health policy. They are internationally recognized as providing reviews of the highest standards. Their reviews assess the literature that is published on various interventions for prevention, treatment and rehabilitation. Here is what they say about surgical interventions of strabismus.

Surgical Interventions for Intermittent Exotropia. Cochrane’s reviewers tried to find randomized controlled trials (RCT) of any surgical or non-surgical treatment for intermittent exotropia. These reviewers found one RCT that was eligible for inclusion. They report that the current literature is mainly retrospective case reviews and are difficult to interpret and analyze. The one randomized trial found noted that unilateral surgery was more effective than bilateral surgery. Unfortunately, any measure of severity was lacking which meant that the criteria for intervention were poorly validated. There also appears to be no reliable natural history data as well. So does operating on one eye yield better results for exotropia? They found that surgery on one eye had an 18% fail rate while surgery on both eyes failed 48% of the time. There are many studies of surgical intervention in the literature but the methods used make it difficult to reliably interpret the results.

For Adjustable versus Non-adjustable Sutures for Strabismus interventions Cochrane notes that they did not find any studies that met the inclusion criteria for their review, however, they did look at the results of non-randomized studies that compared these techniques. The author of the review concluded that: No reliable conclusions could be reached regarding which technique (adjustable or nonadjustable sutures) produces a more accurate long-term ocular alignment following strabismus surgery or in which specific situations one technique is of greater benefit than the other. High quality RCTs are needed to obtain clinically valid results and to clarify these issues. Such trials should ideally a) recruit participants with any type of strabismus or specify the subgroup of participants to be studied … b) randomize all consenting participants to have either  adjustable or non-adjustable surgery prospectively; c) have at least six months of follow-up data; and d) include re-operation rates as a primary outcome measure.

Botulinum Toxin for the Treatment of Strabismus. Cochrane reviewers found four RCTs that were eligible for inclusion. Two of these found no difference between the use of botulinum toxin and surgery for patients requiring retreatment for acquired esotropia or infantile esotropia. There was no evidence for a prophylactic effect in an article discussing an acute onset sixth nerve palsy, and that botulinum toxin had a poorer positive outcome than surgery in patients without binocularity with horizontal strabismus. Unfortunately there was a fairly high rate of complications that included ptosis and induced vertical deviations that ranged from 24% of the population in a trial using Dysport™ to 52.17% and 55.54% in trials using Botox.™

Other Risks Associated with Strabismus Surgery

These risks include damage to structures adjacent to muscles and scleral perforations; orbital inflammations and anterior segment ischemia; slippage of muscles; lost muscles; conjunctival cysts; and various wound irregularities. Additional complications can include nausea and vomiting; serious anesthesia complications and unwanted oculo-cardiac affects. My colleague, Dr. M.K. Randhawa, using appropriate references also notes that death, surgery on the wrong eye or patient, and even blindness can occur.

Long Term Outcomes of Strabismus Surgery

A study by Awadein A,  et al stated that only 45% of children had successful outcomes at an eight-year follow up.  They also noted that 20% of the children had to undergo repeated surgeries for the strabismus which were ultimately unsuccessful as well. Another study which was conducted 10 years post-surgical intervention by Pineles et al noted that 62% achieved only a fair or poor outcome and that 60% of the patients required at least one re-operation. They also went on to state that long-term surgical results in intermittent exotropia are less encouraging when sensory status outcomes (fusion) are taken into consideration.

So do we recommend surgery as an option for our patients? Of course we do, but we use surgery as one more tool in our optometric toolbox. We use vision therapy to make sure all monocular oculo-motor, hand-eye and accommodative abilities are normalized. We then start the biocular phase of therapy to reduce or eliminate any suppression improving the sensory aspect of the visual system and then begin the binocular phase of therapy. At this point surgical intervention may be warranted to bring a large angle strabismus to a more manageable size so that we can use motor fusion and eventually sensory fusion to keep the eyes straight.

As my colleague, Dr. Len Press noted on his blog: For those not young enough to remember… there were serious schisms between orthopedic surgeons and physical therapists.  If you went to an M.D. for an opinion about an injury such as a muscle tear or broken bone, you would essentially be told you either needed surgery or you didn’t.  Doing physical therapy was a waste of time and money, and there wasn’t sufficient research to support it.  If you consulted a physical therapist you would be given advice on a non-surgical approach to rehabilitation, and be cautioned about the invasiveness and lack of predictable outcomes of surgery…..

As easily deduced from the research above, surgical intervention alone is not a panacea for strabismus and the scientific evidence is absent or lacking in many areas. We should, however, follow the example of those who came before us within the medical and therapeutic arts.

What was past is now present for optometry and ophthalmology. It is time for us to work together for the benefit of our patients. Both vision therapy and surgery has a role to play when it comes to treating strabismus. A synergy often occurs between the orthopedic surgeon and the physical therapist. We should do whatever we can to make this happen between the two eye care professions as well.

Resources and References

A PowerPoint presentation on this topic can be found here: http://www.slideshare.net/DMAINO/strabismus-surgery-outcomes-29563247htt…

Treatment for a type of childhood strabismus where one or both eyes intermittently turn outwards: available from- http://summaries.cochrane.org/CD003737/treatment-for-a-type-of-childhood…

Adjustable Sutures: available at http://summaries.cochrane.org/CD004240/adjustable-versus-non-adjustable-…accessed 2-14

Botulinum Toxin: available at http://summaries.cochrane.org/CD006499/botulinum-toxin-for-the-treatment… accessed 2-14

Simon JW.Complications of strabismus surgery. Curr Opin Ophthalmol. 2010 Sep;21(5):361-6. doi: 10.1097/ICU.0b013e32833b7a3f.

Awadein A, Sharma M, Bazemore MG, et al. Adjustable suture Strabismus surgery in infants and children. J AAPOS 2008; 12:585–590

Pineles SL, Ela-Dalman N, Zvansky AG, Yu F, Rosenbaum AL.Long-term results of the surgical management of intermittent exotropia. J AAPOS. 2010 Aug;14(4):298-304.

Maino D. The number of placebo controlled, double blind, prospective, and randomized strabismus surgery outcome clinical trials: none!. Optom Vis Dev 2011;42(3):134-136.

reference from : http://covdblog.wordpress.com/2014/04/02/evidence-based-medicine-strabis…

What Are Primitive Reflexes

Primitive reflexes are automatic stereotypic movements directed from the brainstem and require no cortical involvement (thought). They are needed for survival and development in the womb and in the early months of life. However, as higher more sophisticated centers of the brain begin to mature, these primitive reflexes become a nuisance and must be abated in order for proper neurological organization of the brain to develop, which includes the development of vision.

Many children and some adults whose vision has not properly developed have retained primitive reflexes. Some of the primitive reflexes that affect vision are described below:

Moro Reflex (also called startle reflex)

This reflex is set off by excessive information in any of the baby’s senses. For example, a loud noise, bright light, sudden rough touch, sudden stimulation of the balance mechanism such as dropping or tilting.It is the earliest form of adrenal “fight or flight response”. This response prepares for fighting or running and if not integrated leads to hyperactivity.As the adrenal glands are a large part of our immune system; constantly being turned on can lead to adrenal fatigue and therefore asthma, allergies, and chronic illness.Retained Moro Reflex may lead to:

• Hypersensitivity to sudden noise, light or movement
• Difficulty with new or stimulating experiences
• Impulsive behavior
• Distractibility– has to pay attention to everything
• Anxiety, particularly anticipation anxiety
• Emotional and social immaturity
• Sensitivity to foods or food additives
• Inappropriate behavior
• Hyperactivity
• Adrenal fatigue, leading to allergy, asthma or chronic illness

Asymmetric Tonic Neck Reflex (ATNR)

In the neonatal display of the ATNR, the hand moves in conjunction with the head. This connection between touch and vision helps to establish distance perception and hand eye co-ordination. If retained, the hand and eye want to move together, making it difficult to look up at a blackboard and write. When walking, turning the head results in the straightening of the arm and leg on the same side, upsetting balance and normal walking pattern.Looking at the hand tends to weaken other muscles. This affects ability to catch a ball and other sporting activities.In early months, ATNR locks vision on to anything which catches the attention. If inappropriately retained, the child (or adult) is easily distracted by anything that attracts the attention.ATNR retention may lead to:

• Hand-eye co-ordination difficulty
• Poor handwriting
• Awkward pencil grip
• Difficulty copying from a blackboard
• Missing parts of a line when reading
• Difficulty catching a ball
• Unable to cross the vertical midline (for example, a right-handed child may find it difficult to write on the left side of the page)
• Discrepancy between oral and written performance
• Disturb the development of visual tracking (necessary for reading and writing)
• Balance may be disturbed
• Bilateral integration (integrated use of the two sides of the body) may be poor.
• Establishment of a dominant hand, eye or ear may be difficult
• Judgment of distance may be affected
• Poor at sports
• In adults there can be chronic shoulder and/or neck problems

Tonic Labyrinthine Reflex (TLR)

TLR involves the vestibular system which regulates our balance and our sense of position in space. If the TLR is not integrated by twelve months of age it will constantly interact with, and may disturb, the balance system. This may interfere with other sensory systems including visual function. The child who still has a retained TLR may:

• Experience difficulty in judging space, distance, depth, speed and walking security.
• Be more likely to slump when sitting at a desk or a table, sit on his legs or generally twist and turn resulting in what appears to be inattentiveness and possibly hyperactivity.
• Tend to be slow at copying tasks.
• Affect the integration of movement of the upper and lower limbs simultaneously such as when walking and swimming. These children are often diagnosed with dyspraxia (poor co-ordination) and ridiculed by other children for being clumsy.
• Suffer motion sickness. Integration of retained TLR often assists those susceptible to motion sickness.

Fortunately primitive reflexes can be “integrated”, or their effects minimized through occupational therapy and Vision Therapy. The Vision Specialist and staff at SunTime Vision Specialist can help. If your child is experiencing any of the problems noted above call our office and schedule a Neuro-Developmental vision exam.

information from: http://virginiavisiontherapycenter.com/what-are-primitive-reflexes/