The VisionHelp Blog

Doctors Make Mistakes: Can We Talk About That?

Len Press — Thu, 26 Jan 2012 22:04:43 +0000

Many years ago, much earlier in my career, an 18 year-old by the name of Stephanie was referred to me by a colleague for management of convergence insufficiency. She had previously seen an ophthalmologist who prescribed +1.00 reading glasses to help her with close work. My optometric colleague recognized that she had CI, and she experienced what we thought was a successful outcome at the time. Except a few months after she completed therapy she seemed to regress. She had previously shown normal eye health and visual fields, but when her eye began to turn inward instead of outward, we knew something was seriously wrong and immediately referred her to a neuro-ophthalmologist to coordinate care. This MRI is not Stephanie’s, but shows the same type of massive brain cancer that was silently doing damage over the course of her young years. A beautiful soul with an extraordinary singing voice, Stephanie was married in a bedside ceremony at the hospital several months later, in the wee hours of morning just before she died.

Her parents knew how much I cared, and as much as I beat myself up in retrospect for any signs or symptoms that I might have missed, it was little consolation to me that both an ophthamlologist and an optometrist who preceded me in her care had no suspicion of the tumor that was to overcome her. Her mother had only one request of me: that I share her case with other doctors, and that would be part of Stephanie’s legacy. I have done so, many times, in a continuing education lecture that I give on binocular vision disorders masquerading as disease, and vice-versa. In this way I continue to remember Stephanie, and honor her memory.

Though the implications of a virulent tumor escaping detection are obvious, and certainly not all tumors that are detected can be treated successfully by the time there is sufficient index of suspicion for brain imaging, the converse happens all too often as well. Patients with significant functional vision problems are written off dismissively as “psychosomatic ” because they don’t have a “real disease” to contend with.

Physicians need to be re-defined, and this re-definition begins one physician at a time until it coalesces into a culture. Re-defined physicians are those who acknowledge that they are human beings, and that human beings make mistakes. We need places where everybody who’s observing in the health care field can point out potential mistakes, and is rewarded for doing so. Not the circling of wagons to attack those who point out the poison of insularity, of the “good ol’ boys network”, and the myth of medical perfectionism. This is not me talking. It is Brian Goldman, M.D., and he is a re-defined physician. His message will resonate deeply for you: “I do remember”.

- Leonard J. Press, O.D., FCOVD, FAAO

Wold Behavioral Vision Seminar

Len Press — Wed, 25 Jan 2012 20:54:21 +0000

Wow. I did a Google image search for Robert Wold, O.D., and this guy’s photo came up. Trust me, Bob Wold was a brilliant behavioral optometrist, but he would never be mistaken for this gentleman. Now that I’ve got your attention, however, I want to urge you to attend this year’s 50th Robert Wold Southern California Behavioral Vision Seminar.

The seminar, being held in beautiful San Diego well ahead of June Gloom will feature a star-studded lineup of therapists on March 9 & 10 of Jenny Garbus, Lyna Dyson, Diana Eastman-Ludlam and Rene Moreno, in addition to my good colleague and co-author Dr. Bob Sanet. Then on March 11 & 12 Diana Eastman-Ludlam teams with applied optometric researcher extraodinaire, Dr. Ken Ciuffreda, for a great array of topics. You can download OEP’s brochure for the program here.

Trust me. Were I not pre-scheduled well in advance for a stretch of rest and relaxation on Clearwater Beach during that week, I’d register for the program in a heartbeat. It’s wonderful to see Dr. Robert Wold’s name carried on in this fine tradition, and something tells me a few of his rays will be shining on San Diego in March. Don’t miss it!

- Leonard J. Press, O.D., FCOVD, FAAO

The Dyslexia Paradox

Len Press — Tue, 24 Jan 2012 17:03:50 +0000

Well here’s an interesting Freudian slip for you. A team from Children’s Hospital Boston announced that they could see signs of dyslexia on brain scans in children as early as 4 and 5 years old, which the lead researcher characterizes as a dyslexia paradox. Older children and adults with dyslexia have dysfunction in these same areas of the brain, which include the junctions between the occipital and temporal lobes and the temporal and parietal lobes in the back of the brain. The Fox News coverage of this has a quote from Sally Shaywitz, one of our favorite nemeses: “The beauty is spoken language can present before written language so people can look for symptoms,” said Dr. Sally Shaywitz, a director of the Center for Dyslexia and Creativity at Yale University. If you place your cursor over the highlighted word “symptoms” in the article, up pops an ad for the heartburn medication, Prevacid.

- Leonard J. Press, O.D., FCOVD, FAAO

What Word Has 2 A’s, 2 C’s, 2 M’s, 3Os, and a Single D,T,I,N?

Len Press — Sun, 22 Jan 2012 16:16:09 +0000

Accommodation. A special word when it comes to the information our visual system takes in at near. Particularly within arm’s length. We say it’s due to a change in the shape of the lens inside the eye, though that’s really an oversimplification. The size of the iris plays a big role too, with its size controlling the amount of light getting through the pupil space in the first place, which controls your depth of focus. For years we measured it with a retinoscope, though I find myself increasingly drawn to our Grand Seiko Open View Autorefractor (OVA) to objectively document what the patient is doing. The OVA give you a real-time pattern that is easy to demonstrate to parents and other professionals.

First I’ll show you a few pictures of the OVA so you get a feel for what I’m referring to.

Here’s the instrument from a side view. Note the open view of the rectangular opening, in this instance having a nearpoint card suspended on a rod at a 33 centimeter viewing distance from the patient’s eyes. The viewing screen tells the examiner when the patient’s eyes are centered.

The patient above has his head on a chin rest, with his forehead positioned against he upper bar. He looks at letters on the nearpoint card and is instructed to keep them clear. For younger children you may use pictures. You can ask the patient questions about the near target if attention is a factor. The examiner can watch the patient’s pupil centered in the viewing screen, and it should constrict as the patient is accommodating.

We typically record distance measures of focus, while the patient is looking through a window across the room. You need enough unobstructed space to make sure the patient isn’t accommodating, but you’ll also be able to judge that by looking at the numbers on the screen as focusing state is being recorded.

So here’s a printout of a representative recording. Right eye is the upper and left eye is the lower. The computer samples five times and then gives its best fit result. We are more interested in the consistency or variability of the five readings than in the best fit data. The printout to the far left has the distance findings. For the R eye, the last four of the five findings are +0.25-0.50cx140-ish, so it’s a good bet that is the “true” distance finding as the best fit singular number under the line shows, and that the accommodative posture was at its resting state. For the L eye, the same holds true except the value is Pl-0.25.

The printout to its right is for near, and it shows accommodative flux for both eyes. No two findings in succession match each other. That flux is more important to us than the best fit singular finding. If you repeat the finding through a tentative nearpoint plus lens addition, and/or yoked prism trial, you can look for increased stability of the accommodative profile. Ultimately the results of vision therapy are aided by progress evaluations showing change in the data from baseline values.

When talking to parents about this, you can demonstrate the data rather than trying to describe what your retinoscope shows which is very valuable and insightful, but relatively abstract to a patient. For the accommodative system, it’s the cardiac analog of stethoscope sounds vs. an EKG printout. One isn’t necessarily a substitute for the other.

A few other applications. When there is pseudomyopia, or accommodative spasm tendencies, the distance findings will show fluctuations in value similar to the near values above, where they will differ from one another by a diopter or more. When the patient has amblyopia, the values between the right and left eyes often differ, because accommodation is usually substandard through the amblyopic eye. Similarly for ABI, or any other condition affecting accommoodation, sequential objective measures that are demonstrable in printout form are very valuable.

Preparing this piece took me back nine years ago to the lovely editorial that Dr. Irwin Suchoff, then editor of the Journal of Behavioral Optometry, wrote about the book from which these concepts are derived, and what a joy it was to work with my co-author, Dr. Werner. The cover graphic was designed to celebrate the intelligent use of auto-refraction as smart retinoscopy.

- Leonard J. Press, O.D., FCOVD, FAAO

Convergence insufficiency and “tracking problems”…How hard can it be to spot these kids?

D.Fortenbacher, OD FCOVD — Sun, 22 Jan 2012 00:26:24 +0000

Sometimes the vision problems that involve poor eye coordination seem to be missed or mistaken during a regular eye examination. Parents who have such a child with a previously undetected binocular or oculomotor problem are often surprised and ask, ”Why was this not spotted before?” After many years of seeing hundreds if not thousands of these children and with the plethora of research and body of knowledge readily available, it is becoming more and more difficult for me to explain to a parent why the previous eye doctor, whether ophthalmologist or optometrist did not see this. After all, how can a child with complaints of words overlapping while reading and trouble concentrating on a reading tasks not raise a red flag to test for problems in eye coordination??

To show how easy it is to test for this condition, take a look at the video below to see our patient Josh before and after his vision therapy treatment. While there are about 17 clinical tests typically performed by the doctors who specialize in Developmental Vision to make the correct diagnosis, there are 2 easy chair-side tests that nearly anyone can perform that will often show if a child has convergence insufficiency (CI) and/or oculomotor dysfunction (tracking problems).

The first test is a simple “tracking” test where Josh is asked to follow a bead on a stick. Notice at first he starts out pretty good, but as I begin to ask him questions and he has to think, in less than a minute he begins to show signs of significant fatigue, loss of fixation and furrowed brow showing stress.
In the second clip Josh is wearing red-green glasses (over his own glasses). He is then asked to look at a “penlight” as it is brought closer to his nose. This test is described and published by the American Optometric Association. Read more by clicking here. Notice that in this second clip that Josh reports double (two lights -one red, one green) at about 20 inches. What’s normal on this test? Double at 2-4 inches. To see the research and normative data …click here

Just as so many other children are affected (research shows 1 in 12) by this vision problem known as Convergence Insufficiency (CI), Josh also struggled. The impact on him was that he had double vision and loss of interest for reading. It also made it difficult for him to play baseball or most any ball sport. As a result Josh lacked confidence at school and on the playground. Now after successful completion of his office-based optometric vision therapy Josh no longer sees double when reading, his comprehension and reading speed has significantly improved and he is gaining skill and confidence in sports. Now that he has good binocular vision, Josh no longer struggles and is a happy kid!

Joshua’s Before and After

This movie requires Adobe Flash for playback.

Dan L. Fortenbacher, O.D., FCOVD

$15,000 and Paul Karpecki – Part 3

Len Press — Tue, 17 Jan 2012 05:19:33 +0000

Part 1 and Part 2 introduced Opt-Align and the Krall & Karpecki collaboration that is resurrecting awareness in our profession to the balance needed between disease and functional approaches to visual discomfort. In a previous blog post I wrote about the case of child who was diagnosed as having a dry eye so that the doctor could dismiss the child’s complaints, when there was no objective evidence of dry eye whatsoever. As Dr. Krall wrote in his article, most “dry eye complaints” are related to meibomian gland dysfunction or aqueous tear layer deficiencies. Yet the growing popularity of ocular surface disease as a wastebasket for chair-time complaints related to headaches, asthenoopia, and physical discomfort in or around the eyes tends to mask binocular vision problems that are increasingly overlooked.

It really shouldn’t be all that surprising that ocular motor/proprioceptive control issues show up at the masquerade ball in dry eye clinics. To review, here’s why. The eye is a specialized joint adapted for sight. It’s kinematics operate as a ball-in-socket joint. Its movements are constrained by the walls of the orbit or socket in which it is contained, as it pivots based on its intricate muscles, ligaments and pulley systems. Unlike other joint spaces in the body, the eyeball is the only one that is exposed directly to air. So its need for lubrication is at a premium.

Hyaluronic acid is a protein that is an essential component of the synovial fluid of articular joints for lubrication, the vitreous humor of the eye, and on the ocular surface. It acts as a shock absorber for the eye, and also serves to transport nutrients into the eye. Applied to the surface of the eye, hyaluronic acid reduces the symptoms and damage associated with dry eye. Think of the terms used when the ocular surface dries to the point of structural damage to the cornea/sclera interface, such as erosion and pannus. Those are commonly used terms on rheumatology, when joint spaces lose essential lubrication and shock absorption due to chronic inflammatory disease.

So it should come as no shock that many patients with arthritis have dry eyes — not because there is a gee whiz co-morbidity between the two conditions, but precisely because the eye is a specialized joint adapted for seeing, and chronic inflammation takes a toll on all joint spaces. Many dry eye patients will present with the corneal surface looking reasonably good, but be uncomfortable because the sclera is excessively dry. Touch it with a fluorescein strip and under UV light it looks like you dabbed it with a paint brush.

The approach to dry eye treatment has therefore become much more holistic. Treating the eye from the outside, or on its ocular surface, often offers only palliative relief. Steroid eye drops may provide temporary relief because they quell inflammation in the joint space where the kinematic structures have become even slightly edematous or engorged. What distinguishes dry eye practices now are not drugs and plugs. Nouveau dry eye clinics incorporate lifestyle changes, and they are the same as offered for rheumatoid conditions. Treat dry eye as a problem of inadequate joint nutrition – in other words, lubricate and adopt anti-inflammatory strategies for the eye’s joint spaces from within, such as drinking more fluid, exercise, flax oil, omega-3 fatty acids, anti-oxidants, etc.

In part 4 we’ll wrap up this concept of pain-in-the-asthenopia.

- Leonard J. Press, O.D., FCOVD, FAAO

$15,000 and Paul Karpecki – Part 2

Len Press — Sun, 15 Jan 2012 15:13:06 +0000

In Part 1 we introduced Stereo Optical’s Opt-Align, the brainchild of Dr. Jeff Krall who captured the interest of Dr. Paul Karpecki with the reminder that there is basis for eyestrain beyond the ocular surface. Only good can come from Optometry and frankly Ophthalmology, coming full cycle, back to our roots of addressing asthenopia at all levels of origin. Jeff Krall does a great job of reviewing this in a recent PowerPoint lecture he put together on the subject, a complement to the nice video that Stereo Optical has on its website:

In fact, you can get a nice series of videos here, including a useful monograph prepared by the Corcoran Consulting Group on “Reimbursement for Evaluation and Treatment of Binocularity Defects”. As Dr. Krall reviews in an interview, his interest in this subject was piqued by his father’s ability years ago to address visual performance problems by adding some base-in prism to lenses. This led him, together with an ophthalmologist, to develop a progressive addition lens manufactured by Kodak with a small amount of base-in prism incorporated and prescribed as “anti-fatigue lenses“, backed by a study at ICO.

Well if all this sounds a bit familiar to you, it may be because a colleague of ours, Dr. Merrill Bowan, has been talking about this for the past 15 years in the form of muPs, or small amounts of base-in prism with or without plus lens power. Dr. Bowan’s concept has been for the power to act throughout the lens, rather than confined to a region. Nor would behavioral optometrists agree that a progressive lens would be the best solution as a performance lens for all individuals. The point here is that Drs. Krall and Karpecki are helping to turn the wheel at a pivotal time in the evolution and maturation of our profession. I’ll have more to say about this crucial borderland between disease and functional vision in part 3.

- Leonard J. Press, O.D., FCOVD, FAAO

What Can You Get for $15,000 and Paul Karpecki?

Len Press — Sat, 14 Jan 2012 22:34:23 +0000

Dr. Paul Karpecki is a widely regarded continuing education lecturer in Optometry, who was one of the first practitioners in the country to establish a practice dedicated primarily to “Dry Eye”. He co-authored a nice CE article on the subject, which pointed out the potentially lucrative nature of dry eye practices. When Paul Karpecki speaks, people listen – and for good reason. He is knowledgeable, insightful, well-reasoned, and well-spoken. I’ve had the pleasure of chatting with Paul on the lecture circuit and participating in some think-tanks with him.

I was therefore intrigued when my old buddy, Dr. Brian Berliner, emailed me to ask what I thought about Stereo-Optical’s new Opt-Align system. I hadn’t heard of it before, but then again I missed going to Vision Expo this year where the company unveiled the product. When I visited the website I was surprised to see Paul Karpecki’s visage front and center, and even more so when I listened to the content of the video. I normally don’t associate Dr. Karpecki with functional vision problems, but have a look and listen to this well-done video:

“I heard about opt-align actually from an ophthalmologist named Vance Thompson who is discussing on a conference call we were all on that he’d had this incredible success on a series of post-refractive surgery patients who had significant dry eye type symptoms, and the success wasn’t related to dry eye treatment itself, it was actually related to eye alignment, and he introduced me to an individual named Dr. Jeff Krall. What was fascinating about that – and in trusting Vance and knowing him for alot of years I knew there was something to this, but what really convinced me was one day when Dr. Krall visited my practice he told me to line up about 10 patients who I’d been treating with significant symptoms ranging from headaches to irritation late in the day to grittiness to sandy-type eyes, and because I have a very large dry eye practice it was easy to line up those patients. They all seemed to test normally but all had these symptoms. And he spent a day with me going through each patient and tested their alignment, incorporated the opt-align, was able to diagnose the proprioception and the alignment issues and amazingly solved all of their problems. And these patients were ecstatic. Some were crying, a big guy was hugging him, it was an incredible response! I was convinced after the second patient, but by the 7th or 8th I was amazed.”

I’m going to answer Brian’s question, though I’ll have to do it in another blog piece. Going through Dr. Karpecki’s video prompted enough thoughts for this one. Take particular note of several things:

1) When it comes to ocular disease treatment, the most-respected gurus are often influenced not by prospective double blind studies, but by the opinions of colleagues they trust, and by anecdotal evidence. We’ve discussed this before in the context of the disingenuousness of those who dismiss VT because of a supposed lack of research.

2) As you listen to the entire video, note how Dr. Karpecki is intrigued by the overlap in signs and symptoms of dry eye with functional vision problems, particularly those influence by the proprioceptive system. As I listened to him, I was reminded that this isn’t the first time Dr. Karpecki has discovered principles of optometric vision therapy through post-surgical and disease portals.

- Leonard J. Press, O.D., FCOVD, FAAO

The Success Stories Keep Coming

Len Press — Sat, 14 Jan 2012 14:00:07 +0000

We were skeptical about starting 8 months of intensive vision therapy because of cost and time, but thank God we did.

“My 13 year old daughter has made dramatic changes since completing vision therapy. In years past, she complained about her vision and said she needed glasses. An eye exam (not at Dr. Press’s office) revealed ‘normal’ vision. Jolie complained of blurry vision and words moving when reading. We were annoyed at her for saying she needed glasses when she didn’t. We thought she just wanted glasses because the other kids had them. A few years later, the same thing …

Jolie said her eyes were playing tricks and she needed glasses. We took her for another eye exam, and the same result. ‘Her eyes were fine.’ Praise to God that we found Dr. Press who discovered her eyes were not processing information at the same time. They were out of synch. They weren’t ‘teaming’ properly.

We were skeptical about starting 8 months of intensive vision therapy because of the cost and time, but thank God we did. It has had an enormous effect on her ability to learn. She struggled in school previous to vision therapy, but now does very well in school without our help! My wife and I no longer have to do homework with her every night. Also, her aptitude test scores have sharply increased into the normal range.”

- Dr. Albert Wolyniec

The Court of Public Opinion

Len Press — Wed, 11 Jan 2012 20:31:16 +0000

We’ve made the point many times that research is always welcome in a field, but when dealing primarily with behavioral and developmental issues, it is often the court of public opinion that determines what kind of care children receive. We are non-conformists by nature. At one point in my career I was concerned about lots of variables that I couldn’t control. While it’s ingrained in me to help spread factual information about vision therapy, ultimately there will be those who have their own agenda and who I will not influence. My main interest now resides in the court of public opinion, such as the mothers who meet for coffee at Starbucks in the morning after the kids are off to school. A big smile snuck across my face as I was sipping my cup in the corner this morning, overhearing several moms talking about issues they were having with child development. They weren’t dwelling on what research showed; they were dwelling on a mothers’ sixth sense.

Awhile back I authored the following Clinical Pearl in a textbook: A vision therapy patient who is pleased with the outcome of his treatment is an anecdote. A small group of satisfied and contented patients is a trend. An aggregate of patients who have been helped through vision therapy is a successful practice. It is no less true today than it was 15 years ago when I first wrote it.

- Leonard J. Press, O.D., FCOVD, FAAO