VISUAL REHABILITATION- TOPIC 2 (DOC SHANE)
and adapt in response to new experiences.
VISION THERAPY
Vision therapy (vision training, visual training) involves
the use of therapeutic procedures to modify visual
function.
- basically, this is a series or exercises to
improve visual function
- for example, patient has amblyopia, not only
reduced VA but also affects visual skills. Let’s
say the patient OD is amblyopic and OS is
normal. OS can sustain. If you compare it to the
amblyopic eye, it cant sustain. In vision therapy
not only VA but also other visual skills. Identify
visual skills that are deficit and conduct
exercises that may help their work
- TRAIN WITH EXERCISES IF DEFICIT
Vision rehabilitation- maximizes visual functioning, so
the patient can achieve their visual goals and improve
the quality of their life
- from the word rehabilitation, its root word is
“rehabilitate”
- we are teaching the patient to relearn
something that they lost or what is left because
of the condition
- for example, a patient has a trope, and its effect
is imbalance. Because of a trope, the space is
altered. In this, we will teach the patient to
relearn or make use of whatever skills he has
left. Or to also let them learn how to use the
abilities left.
- USUALLY BECAUSE OF THE CONDITION,
WE RETEACH THE PATIENT OR MAKE USE
OF WHATEVER IS LEFT
• Vergence (Simultaneous movement of both
eyes) and Accommodation (near work)
dysfunctions
• Amblyopia
• Strabismus
• Double vision (usually associated with strab)
• Eye teaming and tracking problems
o Smooth Pursuits - follow slowly
o Saccades - one point to another
• Eye fatigue
• Depth perception and 3D vision difficulties
• Eye-hand coordination difficulties
• Visual perception and processing issues
o associated with pedia patients.
o For example, 10 year old but difficult in
differentiating b d p q.
• Traumatic brain injury - like concussion, trope
Vision Training
- it is about enhancement. The skills are already
there and we enhance them. It is like in sports
vision.
- ENHANCEMENT OF THE SKILLS THAT THE
PATIENT ALREADY HAS
Neuroplasticity refers to the brain’s ability to change
- In vision therapy, we are not strengthening the
muscles.
- For example, a strabismus patient. OD:
esotropia. In vision therapy, one of our goals, is
ortho and straight eyes. We must keep in mind
that we are not addressing the muscles of the
eye but the brain because the muscles are
innervated by the brain like Lateral Rectus in
innervated by CN #6 (Abducens).
It was once thought that the nerve fibers in the brain
were incapable of adaptation or change above the age
of eight— when the brain was thought to be completely
developed.
- before they say that the brain is fully developed
at 8
- but later on, they realized, the brain can still
learn new things.
- For example, the patient has Esotropia at a
young age and the intervention done was
surgery. Cosmetically, okay but they missed
addressing the 3D vision of the patient. And so,
the practitioners before told her she would
never gain 3Dvision. However, when she
reached 40 years old, through BROCK
STRING, she was able to gain 3D vision.
- Critical Period - they defined this as the brain
not being able to learn but this was debunked.
With modern science and technology, we now
understand that the brain can in fact adapt and change.
This is the principle of neuroplasticity.
Neuroplasticity allows you to constantly create neural
pathways every time you learn something new.
NEAR-POINT STRESS DISORDERS
- problems we encounter in prolonged near work
Categories of Vergence Disorders
▪ If convergence, high phoria at near compared to
distance.
▪ If divergence, high phoria at distance compared to
near
Convergence insufficiency
o orthophoria or low exophoria at a
distance
o high exophoria at near
Convergence excess
o orthophoria or moderate esophoria at a
distance
o high esophoria at near
Divergence insufficiency
o high esophoria at a distance
o less esophoria at near
Divergence excess
o high exophoria at a distance
o equal or less exophoria at near
Accommodation
Accommodative insufficiency
o Difficulty efficiently sustaining focus at
near
Accommodative excess
o a tendency to focus closer in than the
page being read, ie the individual will
focus as if the book is closer than it
really is
Accommodative infacility
o Difficulty efficiently switching focus
between near and far and back
o example, we look at a pen then we
fixate a bag from afar. For a patient
who has AI, if she looks at near dugay
clear, at distance dugay clear
o this can be tested using FLIPPERS.
Accommodative spasm
o A spasm of the focusing muscle which
prevents the focusing muscles from
fully relaxing.
o usually occurs in the young patients.
o Example, 20-year-old female. CC is
BOV @ Far intermittent. OU Plano. But
she complains blurry vision @
distance. Suspect is that Px has
Accommodative spasm, it is because
the patient is exposed to near work for
a long time.
o If patient keeps staring at near, the lens
will bulge, in a long period of time that
it is bulging, after near work, it will take
time to relax and that is why there is a
spasm.
o intermittent blurry of vision either at far
or near
o Eye drops or wet refraction can be
done to relax the spasm
TWO MAJOR NEAR-WORK THEORIES EXIST:
The two theories have similarities and differences.
Near-work theories hold that the visual system is
biologically unsuited for the sustained near-work
demands of our culture, and that repeated exposure to
such demands leads to the development of vision
disorders!
- our visual system is not suitable for near work
that is why our eyes adopt.
The use-abuse theory is specific to myopia, attributing
myopia to abuse of the visual system caused by
excessive use of the eyes for close work.
- because of a long period of near work, the
result is Myopia. This is also true to kids these
days because of gadgets
Skeffington's model holds that not only myopia, but
also a broad variety of vision disorders occur because
the nearpoint tasks imposed by our culture are
incompatible with human physiology.
THE USE-ABUSE THEORY
This theory is often attributed to Cohn (1867), who
ascribed myopia to repetitive overuse of
accommodation.
Evidence suggests that myopia increases in prevalence
and degree throughout the school years; that myopes
read more, perform more near work, and achieve
educationally at higher levels than non myopes; and
that adults engaged in college studies and in
occupations requiring extensive close work
demonstrate greater incidence and progression of
myopia than those who perform less close work. Myopia
that results from near work has been attributed to
increasing in tonic accommodation, accommodative
spasm, and accommodation-induced increase in axial
length.
- those who are exposed to near work for a
prolonged time are more prone to Myopia.
- i.e. students, call center agents
- this theory can be related tot Accommodative
spasm because of near work, our crystalline
lens wasn’t able to relax thus myopia occurs.
Evidence that myopia may be induced by
accommodation is found in studies of the influence of
sustained near work on tonic accommodation (TA).
TA is the resting position assumed by accommodation
in the absence of an adequate visual stimulus, for
example, in a darkroom or an empty field.
Ebenholtz (1983) found that sustained near work
induces an increase in the level of TA. This effect is
relatively long-lasting; accommodation fails to relax
completely for several hours after even brief periods of
sustained accommodation. Ebenholtz suggests that this
hysteresis or aftereffect of accommodation may serve
as a precursor for induced myopia. Myopia may occur
because accommodation fails to relax completely
following sustained near work.
THE SKEFFINGTON NEARPOINT STRESS MODEL
Skeffington (1928-74) postulated that the near-work
demands imposed by our culture are incompatible with
our physiology and provoke a stress response
characterized by a drive for convergence to localize
closer than accommodation.
3 Synkinetic Actions
1. Convergence of the eyes
2. Constriction of the pupils
3. Contraction of the Ciliary Muscles
In Accommodation, we focus on the convergence of the
eye and accommodation (contraction of the ciliary
muscles).
During near work, convergence and accommodation
occur together, However during a long period of near
work, Convergence occurs first than Accommodation, It
is because the Medial Rectus is controlling
convergence which is a striated muscle and has a
faster/quicker action.
Accommodation is controlled by the ciliary muscle and
it is a smooth muscle, slower in action.
For example, supposedly convergence and
accommodation occur together but because of
prolonged near work, Accommodation is exactly on
the target but convergence is nearer to the eye, it
localizes near compared to the target and so a
MISMATCH occurs between A and C thus resulting
to OVERCONVERGENCE.
and because of overconvergence, our eyes adapt to
new changes such as; (According to Skeffington
Model, this is the Adaptation of Eyes caused by
prolonged near point)
1. Orthophoria
2. Esophoria
3. High exophoria
4. Myopia
Question: Why is NPA bigger than NPC in the diagram?
- the reason why NPA is bigger is because of
prolonged near vision.
- BUT SUPPOSEDLY they come together.
- ALSO in doing the prelim tests, blur comes
before the double.
- it is not normal that convergence comes first.
The resulting mismatch between vergence and
accommodation interferes with visual efficiency and
information processing and may lead to adaptive
changes within the visual system.
THE SKEFFINGTON NEARPOINT STRESS MODEL
Accommodation
Convergence
The demands for sustained near vision tasks, provoke
a stress response characterized by a drive for the
centering process to localize closer to the
individual than identification, and for the effector
mechanism of convergence to localize closer than
accommodation —> mismatch between convergence
and accommodation
The Skeffington Nearpoint Stress Model
Effort directed toward resolution of the effector system
mismatch:
- diminishes information-processing capacity,
- impairs comprehension, and
- decreases efficiency of task performance.
That is why if we encounter a near point disorder
patient, we must prescribe a low plus. Of course, we
should try testing low plus. Especially for those who
have accommodative spasm.
Phoria Distance (3 and 8) - 0.5 exo
Phoria Near (13A and B) - 6 exo
Inefficient visual function causes asthenopia and
inability to sustain. Many individuals avoid close work,
demonstrating patterns of disinterest and withdrawal.
Others adapt within the visual system, developing
myopia or skews in vergence and accommodative
function, as means of resolving the drive for
convergence to localize closer.
The prescription of low-plus lenses for near use is a key
element of the Skeffington model. Low-plus lens
prescription aids in the resolution of the drive for
convergence to localize nearer than accommodation,
improves visual efficiency, minimizes interference with
cognitive function, and eliminates the need for
adaptation
BUFFER (reserve)
• Exophoria- buffer area for CONVERGENCE
PATTERN
• Hyperopia- buffer area for ACCOMMODATIVE
PATTERN
Buffer is a reserve in case our eyes are stressed, we
can use this to still be efficient at near work.
Example:
1. 1 year old +2.00D - buffer of Px
o this is not abnormal but expected
o we can consider that this is the buffer
of the patient
o because when we reach 5/6, the grade
decreases
o 25/6 - plano already thru the process of
Emmetropization
o Low hyperopia is ideal.
o not all emmetropia is ideal
Ideal: Low Hyperopia and exophoria.
 2. 1 year old and has -2.00D
o this is not the expected value
o thus, probably when the patient is
around 5/6 their RefError is -4.00
That is why we need a hyperopia buffer so if it is used,
we can still be emmetrope
Low hyperio is ideal compared to emmetropia. Ideal
+0.25 or +0.50 hyperopia
EXOPHORIA
Divergence - is used when we look at distance.
Convergence - is used at near.
Why do we have a 0.5exo hyperopia at far and 6exo
at near? Because if we look at far, in case we use
convergence, we still have a reserve. We can still be
ortho. If we look at far, we don’t use convergence, that’s
why small expected value. Whereas at near, we need
convergence and in case we are exposed to prolonged
near work, we still have a reserve of 6exo.
Example, 3 hrs. looking at phone, there is a possibility
of using this, we still have a Exo.
• Not all ortho are ideal
• only at W4D and Hirschberg.
• When it comes to phoria and especially at 21
steps, 6exo is ideal, we still have a reserve
• The reason why the amount of exo for distance
is low (0.5exo) because we do not converge our
eyes.
• At near, we need convergence that is why the
expected amount is bigger (6exo) so that in
case we use our buffer, it would still be plentiful
in such a way that there will still be 6/5/4/3/2/1
before ortho or esophoria.
Example. Why is Hyper and Exo ideal? It is because
if a patient at 1 year old has a +2.00(ideal) if they reach
5 years old, usually they will use their reserve 2.00, next
to hyperopia is emmetropia then myopia. That is why if
the patient is already 2.00 at 1 year old, at about 5 years
old, she will have a high degree of myopia. That is why
it is better to have hyperopia rather than myopia at a
young age.
Example. A patient that has 1 yr old +0.50, at 6years
old either Plano or myope
Hyperopia -> Emmetropia -> myopia
+0.50DS -> eme/myope -> high myopia
PL -> myopia -> high myopia
Myopia -> high myopia -> highestest myopia :<
exo -> ortho -> eso
*There is a possibility that a plano can go back to
hyperopia but usually for kids, unlikely.
*Case-to-case basis
Increase accommodation = increase convergence, then
we can use the buffer.
Hyperopic and exophoric buffers operate to protect the
mechanisms of accommodation and convergence from
systemic influences
Low hyperopia and exophoria are viewed as desirable
attributes, not at defects or errors.
increased accommodation = increase in convergence,
which leads to absorption of exophoria
• When an individual is forced to maintain
concentration at near for prolonged periods, the
magnitude of these buffers gradually
decreases, resulting in emmetropia and
orthophoria.
• Convergence first occurs than accommodation
(but not applicable for Push-Up, blur first then
double)
• Accommodation is inadequate if prolongedd,
ciliary muscle fatigues faster than EOM.
ADAPTATIONS
BASIS FOR NEAR ONLY
According to Skeffington, our desirable exophoria at
near is between 4-6 exophoria. If it goes beyond that
value, our visual system becomes inadequate because
the buffer has been used.
ORTHOPHORIA. If the patient has orthophoria,
Skeffington sees this as inadequate because she has
used her buffer. Or ORTHO is from esophoria but it
reveals the buffer so that is why it became ortho.
Inefficient state.
ESOPHORIA. because of overconvergence, too much
demand at near. Esophoria misaligns in order to for the
demand to not be too high at near. It becomes
esophoria all the time compared to always converge.
HIGH EXOPHORIA. This is not okay because too much
buffer. Because of overconvergence, because high
demand for near work. SO what happened is htat it
revealed a buffer area. High exo will cause the eyes to
suppress. So not to high or low. It must be enough, not
3 nor 7, between 4-6 only.
Is it a conscious effort to reveal the buffer area? No.
It only occurs in the visual system (or eyes).
Other cases will adapt differently like esophoria and
myopia. Eyes adapt differently.

MYOPIA. According to Skeffington, MYOPIA is a highly
effective adaptation because constant near, it chooses
near vision but it sacrifices distance vision.
This is more complex because of the presence of
accommodation.
Emmetropia:
• At far = focus exactly in the retina
• Near with relaxed accomm. = more behind
(behind fovea)
• Near with stimulated accomm. = more front
Myopia (Adaptation of Near point stress)
• At far = in front
• Near with relaxed accomm. = exactly
• Near with stimulated accomm = in front
o that’s is why myopia adopted, if always
accom, always in front thus more myopic.
o that is why myopia chose the middle circle in
order for clear and decreased
accommodation, less myope.
o sacrificed far.
Hyperopia
• At far = behind
• Near with relaxed accom = more more behind
• Near with stimulated accom = behind
o unless accom is increased, it will be exact.
That’s why for kids, esotropia, because
they need to accommodate more, (together
with convergence, inwards)
Accommodative Insufficiency - low Positive Relative
Accommodation and Amplitude of Accommodation.
PRA (20) and AA (19) - these are tests to stimulate
accommodation, we use minus lenses for PRA.
Therefore, low PRA = lack of accommodation.
Convergence Insufficiency - high exo at near, PFC is
low, NPC is far.
CASE HISTORY
The practitioner determines the:
• patient’s symptoms and complaints
• degree of interest and involvement in near-
vision tasks
• academic achievement
• ask their performance in school
• during study, etc.
• we must be very specific about their near work,
and identify their near work. By knowing what
they do, you will know if they are exposed to
near work. i.e. cashier, call center
• In case the patient denies and they are okay,
we must still ask because theres a possibility
that they are doing “avoidance”
Examiner should ask:
• chief complaint
• symptoms during near work
• comfort during near work
• interest in reading/ avoidance
• occupational visual demands
Many of the problems that the patients bring to you
are generated at near, though they may manifest
themselves at other distances.
Eye Movement Assessment - testing the functional
integrity of the oculomotor system
At near work we use these Visual Skills
1. smooth pursuit
2. saccades - more involve in reading because
jump2
PURSUITS - in performing this, mono then bino
• Ductions- monocular
• Versions- binocular
At first, do not instruct the patient
to not move his head but only the
target. After this, proceed to
steady head.
Instruct the patient to follow a
target (Wolff wand, pen, penlight)
at 16 inches or Harmon distance, through the horizontal,
vertical, and diagonal meridians.
A sphere top is followed by the patient or a pen/penlight
at all quadrants (Broad H). For kids, flower.
Observation: quality: jerky, lag, ask if eyes hurt
Recording: Smooth, Accurate, Full, Extensive
Groffman Tracing Test
• try first using eyes then with pencil.
• Patient must track everything from A-E.
Time, Observation and Recording
Saccades
• rapid, conjugate, eye movement that shifts the
center of gaze from one part of the visual field
to another
• saccadic eye movements and not pursuits play
a direct role in reading
• the examiner holds two targets approximately
16 inches apart and rhythmically directs the
patient to shift fixation from one to the other on
command. (horizontal, vertical, diagonal
meridians) (monocular and binocular)
• Can also use Metronome (a beat to be
followed by the Patient)
HART CHART (10x10)
• The patient reads the first
and last letter in each row.
• Score: based on time and
errors
• For Saccades and
Accommodative Insufficiency training
• For Accomm. Insufficiency, from near to far
• Done by OD, OS, OU
• Observation, Recording (Hori & Vertical)
King-Devick Test (K-D Test)
• potential rapid screening for concussion
(traumatic brain injury) usually at sports.
• Usually affects eye movement control
• Like helmets of both players. What happens here is
that the brain moves toward the frontal area of the
skull.
• Can be used as a screening
• 4 cards:
o 1st card, demonstration (inform the patient about
it)
o Records test 1,2,3
• Observation, Recording (*time)
Developmental Eye Movement Test (DEM)
- has Test A, B and C
- Test A and B - hori
- Test c- vertical
- this is a score sheet
Convergence Insufficiency 1. It is a type of vergence
disorder in which there is high exophoria at near, and
orthophoria or low exophoria at distance
Accommodative Infacility 2. Condition in which there is
difficulty in switching focus between near and far and
back
Neuroplasticity 3. Refers to the brain’s ability to change
and adapt in response to new experiences.
Divergence Excess 4. Vergence condition in which
there is high exophoria at distance and equal or less
exophoria at near
Use-Abuse Theory 5. The ____ theory is specific to
myopia, attributing myopia to abuse of the visual system
caused by excessive use of the eyes for close work.
Skeffington Model 6. _________, holds that not only
myopia, but also a broad variety of vision disorders
occur because the nearpoint tasks imposed by our
culture are incompatible with human physiology.
Exophoria 7. _______ is the buffer area for
CONVERGENCE PATTERN
Hyperopia 8. _______ is the buffer area for
ACCOMMODATIVE PATTERN
-0.5 exo 9. Normal phoria at distance
6 exo 10. Normal phoria at near