The Risk/Reward for Adult VT Patients


Many of us have learned the hard way that adult vision therapy patients, and senior citizens in particular, can be very difficult to work with.  They often tend to hyper-focus on what they can’t do rather than on what they can do, and are loathe to acknowledge that any improvements are significant or meaningful.  That is, of course, a very harsh generalization.  There are thankfully many exceptions, one of whom is Laurel.  A 66 year-old when she first consulted with me three years ago, Laurel is a highly intelligent woman with a background in environmental science.  She related that at age four she was diagnosed with intermittent exotropia of the left eye, but nothing was done about it.  She recalls slipping into double vision very easily as a child, but always managed to deal with it.  In her mid 20’s Laurel began having difficulty controlling her diplopia, and was referred to an orthoptist to improve her fusion.  This served her well until her 40’s, when she again lost control and repeated her course of orthoptics.

Keep Calm

In keeping with her 20 year cycles, Laurel felt her left eye beginning to drift out of control again in her mid 60’s.  Her husband is an orthopedic surgeon, and she went to an ophthalmologic colleague who advised that she needed cataract surgery for the left eye.  In Laurel’s words, he neither did any binocular testing nor seemed concerned about her history of fusion difficiulties.  He operated on her left eye, but things did not go well.  Lens fragments that escaped during removal of the cataract set off a nasty inflammatory response, and I’ll spare you the nasty details.  Suffice it to say that Laurel decompensated into a large angle intermittent left exotropia at near.  She was no longer able to control her fusion through orthoptics, and was unable to fuse at near without prism.  This meant she could not wear PALs, to which she had been happily adapted, and needed several different pairs of glasses.  When I measured Laurel’s phoric posture, she was 3^ exo at distance and 24^ exo at near.

not-a-happy-camper

Laurel was referred to me by an ophthalmologist who had previously referred a significant number of senior citizens to us.  His attitude was always a healthy one of “see what you can do”, and invariably occurred after the patient had not responded adequately to orthoptic therapy.  Her goal was to be able to resume wearing her PALs, and her passion for reading the New York Times, particularly the Sunday edition that took a full week to digest properly.  Long story short, Laurel was able to acquire very good fusion control, and happily resumed wearing progressive addition lenses without the need for prism.  That is until recently, when she presented to my office with the feeling that she was beginning to regress.  She attributed this entirely to stress over health issues she had encountered during the past year, which included successful radiation therapy for breast cancer, trigeminal neuralgia with left side facial numbness (treated successfully with vitamin B12 and Cymbalta), and an abscess of the right parotid gland that required oral and IV antibiotics.

Determined to restore order to her binocular system, Laurel resumed some of the activities that she recalled were particularly helpful when previously finishing therapy with us.  She was meticulous about keeping track of exactly how she did with reflex fusion activities on the life saver card, doing a cover/uncover (winking one eye shut) for 10 seconds and measuring the time to recover fusion.  She would say “now”, and her husband would time her in seconds and notate on an Excel spreadsheet she made specifically for that purpose!

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Here is one of the completed spread sheets she used to track her results: Chart2-LJP

Laurel felt that she was already making significant improvements (she was), and merely wanted to review with me what she had been doing.  Among Laurel’s many challenges this past year was experiencing benign essential hand tremor.  We discussed taping the targets or putting them in a holder so that she could do the procedure, and some others that we advised, hands-free.  With her permission, I called in one of our therapists and made a big fuss of how well Laurel was managing all this, and how resourceful she was in documenting her experiences.  During our weekly case conference next Tuesday, we’re going to share this with the entire staff, and celebrate the indomitable spirit of a very special senior citizen.

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