Home therapy is efficacious when parents are trained as therapists

Jessica Liedke, COVT, and Dr. Juanita D. Collier, MS, OD, FCOVD

4D Vision Gym, Cheshire, CT

Correspondence: [email protected]

860.632.8243

 

Financial Disclosure: Jessica Liedke and Dr. Collier are reporting Case Studies of patients who have utilized the 4D Built to Read program created by their employer, 4D Vision Gym.

 

Abstract

In-office vision therapy under the guidance of a Behavioral or Developmental Optometrist is proven to be the most effective method of treating many visual issues, especially Convergence Insufficiency. Various attempts at home-based therapeutic approaches have been prescribed to patients with different visual presentations (usually of mild severity), including computer-based systems, video-conference sessions, and written instructional activities, with various levels of engagement and success. The training is often screen-based (exacerbating accommodative/binocular issues and increasing the likelihood of myopia), lacking in human interaction and engagement, or of such small financial and emotional investment that interest and consistency wane quickly before progress is made. In our office, we have not seen significantly high quantitative or qualitative levels of outcomes in patients that have undergone treatment primarily through these channels. However, a home-based program that sequentially addresses the fundamental skills of visual development, while minimizing the weaknesses of previously-prescribed home interventions, may have a deeper effect. We trained parents to be the primary therapeutic provider for their children to help build foundational skills, emphasizing the importance of daily practice and educating them on the implications of their development. At the time of this submission, this program was administered without variation to four children with four different visual presentations. Symptoms were varied, with a wide range in academic success and interventions needed, and with diverse past medical and visual histories.  All children presented with a binocular visual delay, but expression varied widely among them- along with various degrees of accommodative, oculomotor, and perceptual delays. Families began intervention and all found significant subjective and objective improvements at the conclusion of 12 weeks. In fact, the child with the most severe quantitative findings experienced the most subjective improvement in symptoms. Home therapy can be incredibly efficacious, regardless of diagnosis, when focused on foundational visual skills instead of treatment of diagnoses and when daily practice with a trained provider is prioritized.     

Background

Office-based Optometric Vision Therapy is an effective method of treatment for children with visual developmental delays manifesting as Convergence Insufficiency (Convergence Insufficiency Treatment Trial Study Group, 2008) and other binocular, accommodative, and oculomotor deficiencies (Cooper, 2003).  As the widely-cited CITT study found, basic Convergence Insufficiency may be treated with clinically-significant quantitative gains after 12 in-office sessions, better than other tested methods such as computerized exercises, pencil pushups, and placebo therapy. Many patients that appear in Vision Therapy clinics throughout the world enter therapy with a diverse set of needs, symptoms, development, and presentation. In-office treatment is typically individualized to these needs, and while effective, is costly and time-consuming to both clinics and patients. Most in-office treatment programs are not daily, and even when daily home practice is emphasized, parents and caregivers are rarely given the opportunity to be fully trained in the exercises and purpose behind each- so practice may be lackluster in effect.

Computerized programs that utilize methods of behavioral modification in an operant conditioning paradigm have been prescribed in our office, yet have not proven to be effective methods of treatment for our patients. Some patients described the exercises as too simple or difficult (even after modification of challenge level by the treating doctor or therapist). Other patients became disengaged after a short period, and still others bought the program but never engaged at all. Additionally, prolonged exposure to screens can exacerbate visual difficulties (Collier, 2011), making screen-based therapeutic treatment less than ideal. The typical patient profile prescribed this type of home program at our office were generally older than school-aged (though the youth that did attempt this style were usually even less engaged than the adults), neurotypical, and with visual concerns that could be qualified as less severe than many seen in the office.  The treatment is simple, targeted specifically to the patient’s visual diagnoses, without further visual perceptual enhancement or particular effort to address remaining visual developmental delays. Further, the financial investment by the patient was minimal; just higher than the cost of one in-office Vision Therapy session, and thus easy to be disregarded as inconsequential. Though daily practice may be prescribed, these programs do not provide daily interaction with a therapist.

The global pandemic caused by COVID-19 forced Vision Therapy clinics to utilize creative and low-contact ways to deliver effective Vision Therapy instruction and treatment without endangering therapists or patients. Though the aforementioned challenges of screen-based therapy remain very real threats to patient progress, many offices turned to individualized sessions via video chat platforms. Providers in this setting face challenges to programming, space, equipment, and, in many cases, patient engagement. Vision Therapists and Optometrists commiserate over message boards and listservs about the challenges of the new normal, citing the extra creativity, preparation, shipping, technical issues, and ultimately, cost of delivering such individualized remote care, only to be met with more challenges when a loss of a job or illness in the family created barriers to participation, or when a child lost interest in yet another face on a screen and disappeared before symptom or diagnosis resolution. As is the case with in-office treatment, parents and caregivers are generally not given an opportunity for extensive education on therapy activities or their purpose, so the incidence of impactful home practice is low.

Once the immediate dangers of the pandemic were more readily met in person with adequate mitigation, the return to in-office treatment reminded offices of more routine challenges to therapeutic care: insurance coverage (or lack thereof) and financial constraints of patients seeking help, timing and availability of appointments, and newer challenges concerning staffing of clinics and the extra time and expenses associated with appropriate sanitizing protocols and social distancing. The incidence of myopia progression and vision disorders have been impacted by the pandemic and associated distance learning and quarantining periods (Wang W, 2021), and learning delays have been more apparent as parents have witnessed their children struggle academically at home, increasing the demand for appropriate interventions.

To meet this demand, we developed a program for parents of children aged 6-9 to address the fundamental visual building blocks of reading and learning success. A series of videos was created to teach caregivers to be the therapeutic providers to their children, giving them access to a sequence of activities that addressed each step of visual development: creating strong fixations, pursuits, saccades, accommodative amplitudes, accommodative and vergence facility, binocularity and depth perception, visual perceptual skills, and integration. The parents were given education about the importance of each of the skills that were being built and the implications for strengthening them in their children’s ability to read and learn. We supplied them with step-by-step written instructions and demonstrations, as well as ideas for loading or simplifying as appropriate. The videos were available on an internet-based platform, only releasing each phase of the process every 2 weeks to ensure adequate time was spent on each piece before progressing to the next. The activities were presented in 6 phases designed to be completed over 12 weeks, though families could choose to perform any phase for longer than 2 weeks, or complete the program at a slower pace. Families were instructed to complete home practice for 15 minutes daily. Equipment, paper worksheets and charts, and web-based extras were supplied with the program, so each activity could be performed without viewing a screen. Equipment provided did not include therapeutic lenses or prisms other than red/green anaglyph glasses. Each family had access to one 30-minute video chat with a Certified Optometric Vision Therapist midway through their program to address specific concerns and gain clarity on goals and methods for successful completion. The program was administered without variation to many families, four of whom are described below.

 

Case Summary: Patient 1

History

A 7-year-old male was referred to 4D Vision Gym by his mother’s routine care Optometrist after she had anecdotally expressed concerns about her son’s binocular vision as noted by his Occupational Therapist. The patient presented a medical history positive for Hyperinsulinism and delays that have been addressed with physical therapy, speech therapy, and occupational therapy since the age of 6 months. His incoming visual concerns included covering an eye or tilting his head, holding reading material closely, being bothered by light, and having difficulty making eye contact. Reading difficulties included feeling tired or falling asleep when reading, trouble recalling words or pictures just seen, getting lost in books, reading slowly, moving his head when reading, using a finger when reading, reversing words or numbers, skipping words or losing place, and poor reading comprehension. Motor concerns included poor handwriting, inconsistencies in balance and falling over, difficulty with ball sports, and challenges with scissors, shoelaces, zippers, or buttons. Cognitively, he felt the need to switch activities after a short time, had a hard time paying attention to one activity for 15 minutes, said “I can’t” before trying something new, had trouble following written directions, confused left and right, and performed most activities slowly.

Findings

Visual Skill	Expected Norms	Skill Status Prior To Treatment	Skill Status After Home Program
Visual Acuity	Distance: OD: 20/20 OS: 20/20 OU: 20/20  Near: OD: 20/20 OS: 20/20 OU: 20/20	Distance sc: OD: 20/25 OS:  20/40- OU:  20/25 Near sc: OD: 20/20 OS: 20/20 OU: 20/20	Distance sc: OD: 20/20 OS:  20/25 OU: 20/25 Near sc: OD: 20/20 OS: 20/20 OU: 20/20
Eye Movements –Pursuit and Saccadic tracking	Steady fixation, smooth pursuits, accurate saccades	Unsteady fixation, poor pursuits, inaccurate saccades	Steady fixation, poor pursuits, inaccurate saccades
Amplitudes of Accommodation	Bell 16” or 15.00 Diopters	OD/OS: Bell 12”	OD/OS: 14.00 Diopters
Accommodative Facility	Pass +/Pass -	Pass +/Pass -	Pass +/Pass -
Depth Perception	250 Seconds of Arc, 3/3 Animals, 8/10 Wirt Circles	0 Seconds of Arc, 0/3 Animals, 4/10 Wirt Circles	1/500 Seconds of Arc, 3/3 Animals, 4/10 Wirt Circles
Cover Tests	Distance: Orthophoria Near: 4-6 Exophoria	Distance: Orthophoria Near: 10 Exophoria	Distance: Orthophoria Near: 2 Exophoria
Near Point of Convergence	2”/3”	6”/8”	3”/5”
Vergence Facility	Pass BI/Pass BO	Unable to perform	Pass BI/Pass BO
Distance Vergence Ranges	BI x/7/4 BO 9/19/10	BI x/14/12 BO x/8/2	BI x/10/6 BO x/10/8
Near Vergence Ranges	BI 13/21/13 BO 17/21/11	BI x/30/16 BO x/14/8	BI x/14/10 BO x/16/10

 

Diagnoses

1. Binocular Vision Disorder
2. Accommodative Insufficiency
3. Oculomotor Dysfunction
4. Visual Perceptual Deficits

Treatment Plan

12 weeks of the 4D Built to Read home-based, self-paced therapy program before reevaluation. The patient’s mother reported that home practice was completed most days, but had to contend with patient cooperation and limited ability. She reported that they moved on from the phases that addressed oculomotor skills before they were fully cemented because of compliance and particular difficulty with these activities.

Outcomes

At the conclusion of the 12 weeks, the patient’s mother had noted improved tracking control, attention, and eye contact. Quantitative findings of note include improved fixations, amplitudes of accommodation, stereopsis, near phoria, near point of convergence, vergence facility, and convergence at near and far. The patient began in-office treatment to resolve the remaining qualitative and quantitative areas of concern, but is expected to complete therapy faster than had he completed all therapy in the office. His mother shared with joy that he was now able to attend to a book from cover to cover- a feat he had never accomplished before in his life. She beamed that he worked through an I Spy book for half an hour, longer than he had ever paid attention to anything.

 

Case Summary: Patient 2

History

A 9-year-old female was referred to 4D Vision Gym by her primary care Optometrist. She had a medical history of migraines that was otherwise unremarkable. The patient was reported to be an avid reader but an average student, and received no interventions or other therapies. Her incoming visual concerns included double vision, blurry vision far away, eyestrain or fatigue, pulling feelings around the eyes, words and pictures swimming or moving when reading, being bothered by light, and difficulty making eye contact. Reading difficulties included trouble recalling words or pictures just seen, and making errors in copying. Motor concerns included poor handwriting, disturbances in gait, falling or tripping when walking on stairs, and difficulty with ball sports. Cognitively, she was distractible and inattentive, had difficulty organizing tasks and activities, and confused left and right.

Findings

Visual Skill	Expected Norms	Skill Status Prior To Treatment	Skill Status After Home Program
Visual Acuity	Distance: OD: 20/20 OS: 20/20 OU: 20/20  Near: OD: 20/20 OS: 20/20 OU: 20/20	Distance sc: OD: 20/30+ OS:  20/25+ OU:  20/20+ Near sc:  OD:  20/40 OS:  20/50 OU:  20/50	Distance sc: OD: 20/15 OS:  20/15 OU: 20/15 Near sc:  OD: 20/20 OS: 20/20 OU: 20/20
Eye Movements –Pursuit and Saccadic tracking	Steady fixation, smooth pursuits, accurate saccades	Poor fixation, poor pursuits, inaccurate saccades	Steady fixation, smooth pursuits with some jaw movement, impulsive saccades
Amplitudes of Accommodation	Bell 16” or 15.00 Diopters	OD: 4.50 Diopters OS: 3.25 Diopters	OD: 14.00 Diopters OS: 13.50 Diopters
Accommodative Facility	Pass +/Pass -	Fail +/Fail -	Pass +/Pass -
Depth Perception	250 Seconds of Arc, 3/3 Animals, 8/10 Wirt Circles	250 Seconds of Arc, 3/3 Animals, 6/10 Wirt Circles	250 Seconds of Arc, 3/3 Animals, 9/10 Wirt Circles
Cover Tests	Distance: Orthophoria Near: 4-6 Exophoria	Distance: 6 Exophoria Near: 14 Exophoria	Distance: Orthophoria Near: 4 Exophoria
Near Point of Convergence	2”/3”	Unable to fuse	2”/3”
Vergence Facility	Pass BI/Pass BO	Fail BI/Fail BO	Pass BI/Pass BO
Distance Vergence Ranges	BI x/7/4 BO 9/19/10	BI x/10/4 BO x/8/1	BI x/10/6 BO x/14/10
Near Vergence Ranges	BI 13/21/13 BO 17/21/11	BI 18/24/12 BO x/2/-5	BI x/24/17 BO x/24/10

 

Diagnoses

1. Convergence Insufficiency
2. Accommodative Insufficiency
3. Accommodative Infacility
4. Oculomotor Dysfunction
5. Visual Perceptual Deficits

Treatment Plan

12 weeks of the 4D Built to Read home-based, self-paced therapy program before reevaluation. The patient was also prescribed reading glasses for all near work. Her mother reported that she was fairly independent in her practice, but she was able to observe progress in her ability to perform the exercises.

Outcomes

At the conclusion of the 12 weeks, the patient noted fewer and less intense headaches. The patient also reported less double vision. Quantitative findings of note include improved fixations, amplitudes of accommodation, accommodative facility, stereopsis, near phoria, near point of convergence, vergence facility, and convergence at near and far. The patient began in-office treatment to resolve the remaining qualitative and quantitative areas of concern, but completed therapy after 14 sessions, faster than the 12-18 months we estimated at her initial exam, had she completed all therapy in the office.

 

Case Summary: Patient 3

History

A 9-year-old male presented to 4D Vision Gym from referral by a family member based on longstanding amblyopia with high astigmatism. Otherwise, he presented with an unremarkable medical history. The patient was reported to be an avid reader and an above-average student, who received no interventions or other therapies. His incoming visual concerns included blurry vision at distance. The patient was reported to never have been able to be corrected to 20/20 and had failed school vision screenings three times.

Findings

Visual Skill	Expected Norms	Skill Status Prior To Treatment	Skill Status After Home Program
Visual Acuity	Distance: OD: 20/20 OS: 20/20 OU: 20/20  Near: OD: 20/20 OS: 20/20 OU: 20/20	Distance cc: OD: 20/20- OS:  20/20 OU: 20/20- Near cc:  OD:  20/20 OS:  20/20 OU:  20/20	Distance cc: OD: 20/20- OS:  20/20- OU: 20/20+ Near cc:  OD: 20/20 OS: 20/20 OU: 20/20
Eye Movements –Pursuit and Saccadic tracking	Steady fixation, smooth pursuits, accurate saccades	Steady fixation, smooth pursuits, accurate saccades with jaw movement	Steady fixation, smooth pursuits, accurate saccades without jaw movement
Amplitudes of Accommodation	Bell 16” or 15.00 Diopters	OD: 7.50, 12 Diopters OS: 10.50 Diopters	OD: >15.00 Diopters OS: >15.00 Diopters
Accommodative Facility	Pass +/Pass -	Fail +/Fail -	Pass +/Pass -
Depth Perception	250 Seconds of Arc, 3/3 Animals, 8/10 Wirt Circles	0 Seconds of Arc, 2/3 Animals, 1/10 Wirt Circles	250 Seconds of Arc, 3/3 Animals, 10/10 Wirt Circles
Cover Tests	Distance: Orthophoria Near: 4-6 Exophoria	Distance: Orthophoria Near: Orthophoria	Distance: Orthophoria Near: Orthophoria
Near Point of Convergence	2”/3”	To the nose with good regrasp	To the nose with good regrasp
Vergence Facility	Pass BI/Pass BO	Fail BI/Fail BO	Pass BI/Pass BO
Distance Vergence Ranges	BI x/7/4 BO 9/19/10	BI x/10/6 BO 15/20/13	BI x/12/8 BO 16/24/20
Near Vergence Ranges	BI 13/21/13 BO 17/21/11	BI x/21/15 BO x/32/28	BI x/21/12 BO 30/36/32

 

Diagnoses

1. Refractive Amblyopia OD
2. Accommodative Insufficiency
3. Accommodative Spasm
4.  Oculomotor Dysfunction

Treatment Plan

12 weeks of the 4D Built to Read home-based, self-paced therapy program before reevaluation. The patient was advised to keep his current prescription for the duration of the program.

Outcomes

At the conclusion of the 12 weeks, the patient did not note any large changes in his vision. However, quantitative findings of note included saccades without motor overflow, amplitudes of accommodation, accommodative facility, stereopsis, vergence facility, and distance acuity. The patient and his family were advised to revisit the phases of the program addressing integration and visual processing 3 times a week for 3 months before returning for another evaluation. His prescription at this reevaluation was lowered, and he was able to read 20/20 without any difficulty. The patient and his family were very proud of the progress that had been made. At a follow-up visit, the boy shared with us that when he went skiing, he was able to see details on a trail that he had previously fallen repeatedly on. Now that he saw it with depth, he did not fall at all.

 

Case Summary: Patient 4

History

A 7-year-old male was referred to 4D Vision Gym by his Occupational Therapist. The patient presented a medical history positive for amblyopia, which was resolved by patching. He was reported to work very hard to be an average student, who does not choose to read. He was receiving Occupational Therapy to address fine and gross motor concerns, as he had poor handwriting and difficulty crossing his midline. The patient reported no incoming visual or reading concerns, but was reported to tire easily, and experience car sickness and nausea. He had poor handwriting, a fear of heights, challenges with scissors, shoelaces, zippers, or buttons, and said “I can’t” before trying something new.

Findings

Visual Skill	Expected Norms	Skill Status Prior To Treatment	Skill Status After Home Program
Visual Acuity	Distance: OD: 20/20 OS: 20/20 OU: 20/20  Near: OD: 20/20 OS: 20/20 OU: 20/20	Distance cc: OD: 20/20- OS:  20/15- OU:  20/15 Near cc:  OD:  20/20 OS:  20/20 OU:  20/20	Distance cc: OD: 20/15 OS:  20/15 OU: 20/15 Near cc:  OD: 20/20 OS: 20/20 OU: 20/20
Eye Movements –Pursuit and Saccadic tracking	Steady fixation, smooth pursuits, accurate saccades	Steady fixation, smooth pursuits, accurate saccades	Steady fixation, smooth pursuits, accurate saccades
Amplitudes of Accommodation	Bell 16” or 15.00 Diopters	OD: 11.50 Diopters OS: 15.00 Diopters	OD: 10.75 Diopters OS: 13.50 Diopters
Accommodative Facility	Pass +/Pass -	Pass +/Fail -	Pass +/Pass -
Depth Perception	250 Seconds of Arc, 3/3 Animals, 8/10 Wirt Circles	250 Seconds of Arc, 3/3 Animals, 10/10 Wirt Circles	250 Seconds of Arc, 3/3 Animals, 10/10 Wirt Circles
Cover Tests	Distance: Orthophoria Near: 4-6 Exophoria	Distance: Orthophoria Near: Orthophoria	Distance: Orthophoria Near: Orthophoria
Near Point of Convergence	2”/3”	To the nose with good regrasp	1”/2”
Vergence Facility	Pass BI/Pass BO	Fail BI/Pass BO	Pass BI/Pass BO
Distance Vergence Ranges	BI x/7/4 BO 9/19/10	BI x/6/1 BO 18/28/16	BI x/10/6 BO x/20/12
Near Vergence Ranges	BI 13/21/13 BO 17/21/11	BI x/17/8 BO 14/24/10	BI x/20/14 BO x/20/12

 

Diagnoses

1. Convergence Excess
2. Binocular Vision Disorder
3. Accommodative Insufficiency

Treatment Plan

12 weeks of the 4D Built to Read home-based, self-paced therapy program before reevaluation.

Outcomes

At the conclusion of the 12 weeks, the patient did not note any large changes in his vision. However, quantitative findings of note included improvements in base in ranges, vergence and accommodative facility, and acuity. The patient was instructed to complete 2 weeks of each of the program’s phases centered on developing endurance and facility before returning for another evaluation. At his next reevaluation, the patient’s mother reported that he was reading more for pleasure, and enjoying his activities as they got easier. His prescription was lowered at this exam, and he will return in 6 months to ensure his new skills have been maintained.

 

Discussion

Visual diagnoses are indicative of a person’s behavioral response to skipping developmental stages. Common symptoms, such as difficulty with reading and academic performance, are easier to treat when approached from a developmental perspective, instead of treating symptoms and diagnoses, specifically. More research is warranted, but our small sample indicates that home therapy can be efficacious, regardless of diagnosis, when fundamental steps are the focus of treatment, and when patients have daily reinforcement of skills with a trained provider- even when that provider is a non-professional. Four children with vastly different visual presentations completed Vision Therapy treatment faster than most patients that are seen primarily in the office. Theories that contribute to this success (and areas for potential further study) include the engagement of parents in their child’s treatment, consistency of practice and commitment, and investment (financial and emotional) in the outcome of the child’s success. The program required face-to-face interaction with a trusted caregiver instead of a purely impersonal digital design, and asked parents to engage and adapt treatment to fit their child’s personality and needs, as they most intimately understand them best. Parents were empowered and supported, and invested enough financially that it was important to them to see the program through instead of considering it a “sunk cost,” but not as expensive as traditional in-office Vision Therapy that can be a prohibitive factor to care for many families. In the case of the children that did still need in-office care, their programs of therapy were still considerably less expensive and time-consuming than many who only pursue in-office therapy. One possible explanation is the commitment and routines that had been established by the families during the initial program at home, but it is also probable that the foundation of fundamental visual skills built by the program created the condition for a robust range of motion and sensory adaptation. The parents who completed the program with their child reported a deeper understanding of their child’s strengths and challenges, and had a better ability to relate to them.

 

 

REFERENCES

Convergence Insufficiency Treatment Trial Study Group. (2008). A Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children. Arch Ophthalmol., 1329-1336.

Collier, J., et al. (2011). A Comparison of Symptoms After Viewing Text on a Computer Screen and Hardcopy. Ophthalmic Physiol Opt., 29-32.

Cooper, Jeffrey. (2003). Summary of Research on the Efficacy of Vision Therapy for Specific Visual Dysfunctions. Adapted from The Journal of Behavioral Optometry 1998; 9(5):115-119.

Wang W, Zhu L, Zheng S, et al. (2021). Survey on the Progression of Myopia in Children and Adolescents in Chongqing During COVID-19 Pandemic. Front Public Health.2021 Apr 28;9:646770.