I was contacted by Laura (age 34) as she had been experiencing extreme visual distress following a car accident. I would like to share this story (written jointly with Laura) to show both the patient’s experience of her visual difficulties and the impact optometric vision therapy has had on her quality of life, and from my side as the optometrist dealing with her difficulties
Background
Laura Lupton: ‘Following a car accident in 2012, I started to become aware of a pulling sensation in my left eye. If I gave in to the sensation I found that my eye would in fact turn in and I would get severe double vision. I had to make a conscious effort to keep my eyes ‘straight’ which in itself, caused symptoms such as severe eye strain, motion sickness and pain. This was when it all began… what ended up being a very frustrating, five-year journey around various different NHS establishments in the UK.
As time went on, while being passed from one hospital to another, I started to notice the problem worsening and other symptoms beginning to join the mix. I was turned away from so many people, being told ‘there was nothing that could be done for me and that I would have to live with the conditions.’
I now know I had something called esophoria, anisometropia and a lazy eye; as well as focusing, field and fixation problems. I got in touch with Geoff and discussed the symptoms.’
History
- Patient aware of ‘pulling sensation’ three months subsequent to a car accident which developed into diplopia (‘left eye turning in’).
- Local ‘optician’ prescribed a ‘small prism’ in full time wear spectacles.
- Symptoms worsened so patient requested a referral to hospital eye service – this was initially refused but, after complaint from the patient, a routine referral resulted with an appointment some months later at the hospital eye unit in Lincoln.
- Initial hospital assessment suggested the prism base was in the wrong direction, and Fresnel temporary prisms were tried which ‘looked ridiculous and didn’t seem to help’. A diagnosis of ‘accommodative spasm’ was made and atropine cycloplegia undertaken. The drops ‘completely knocked out all focusing ability and gave me severe anxiety because the effects of the drops lasted for three days and I was told to put them in once a day for seven days. After day two my anxiety from the drops was that bad that I could not continue to put them in.’
- On return to the hospital, patient was told symptoms were likely to be stress-related and was advised to see her GP for anti-depressants.
- ‘I spoke to my GP and explained what had happened, she agreed that I was not suffering with any sort of depression other than the stress that my eye problem was giving me. The GP referred me to Moorfields Eye Hospital (outreach clinic in Bedford) where I then visited every three months for around three years.’
- Symptoms suggested as likely due to blepharitis, ‘but didn’t give me a diagnosis on the visual processing difficulties I was experiencing.’
- A variety of refractive corrections were tried, ranging from +3.00DS to +1.50DS for the left eye, the sphere being reduced each occasion to overcome binocular intolerance to the aniseikonia. ‘At no point was a contact lens recommended to me, until I asked about using one purely for the reason of not having to wear glasses. I did find out recently that the contact lenses are a much better way of correcting an uneven prescription because the magnification doesn’t work the same as with glasses.’
- ‘For three years I was regularly seeing an orthoptist (every three months) who carried out various tests of my accommodation and vision, and gave me some vision exercises to do at home. The benefits of vision therapy and how it can help wasn’t explained to me and neither was the problem that I was experiencing. The exercises they gave me were a cat stereogram and a Hart chart and it was really hard to judge how much time to spend doing it and what the benefits were. I wasn’t given a through treatment plan and I never saw an improvement.’
- ‘After the two-year point, I had a review with the consultant at Moorfields, who told me that the vision therapy wouldn’t work (despite being led down that path for over two years) and that there was nothing more they could do for me. Of course, I got upset at the thought of having to deal with this problem for the rest of my life; I believed that if Moorfields couldn’t help me then there was no one else that could. Due to how upset I was, the consultant offered me a second opinion by a different consultant ophthalmologist.’
- ‘When I went for the second opinion, three years into the problem, the orthoptist spoke to the consultant and they read through my notes together. The consultant didn’t see or examine me, or give me the time to explain my symptoms to her; she just told the orthoptist that they couldn’t say they had tried everything as they hadn’t personally tried a prism in a pair of glasses. So, from this, they tried me with a few different strength prisms. I had a temporary one stuck on my glasses for a while but because of how they look I didn’t like wearing it in public. I felt that I needed to give the prism a fair chance so I had it incorporated into a pair of glasses (even though I knew the prism strength may need to be altered) and I went through a stage of wearing them all the time. The strength was a 12 dioptre prism split over the lenses which gave me 6 in each’ (base direction not stated). ‘When I first started wearing the glasses I thought I felt an improvement but the glasses did not remove the pulling sensation as much as I would have hoped. My eye still wanted to wander with them on. They did help a bit, but my sight wasn’t as clear with them on, things seemed a bit blurry and I got extreme three-dimensional vision with certain things like the dials on the car and books/images which was very strange and somewhat unsafe driving-wise.’
- ‘I decided to pay privately for an appointment with a different consultant at Leicester Royal Infirmary which was closer to me who said he believed surgery would be the only way my problem could be sorted out so he referred me to a squint specialist in Nottingham (four years into the problem). I had a cycloplegic eye test and it picked up a +4.75DS refraction in my left eye.’
- A decision was made that binocular status would not benefit from surgery and instead prisms be tried again with a weekly review. Botox was rejected due to a risk of permanent diplopia, and permanent prisms advised which would ‘over time encourage my eye to turn in when what we want is to encourage it to stay straight.’
- The patient found out about behavioural optometrists on the internet – ‘I spoke on the phone and then went to see one in York who had a better understanding of my problem than anyone I had spoken to that point. She was very pleased that I hadn’t had any surgery and believed she could help me through bi-nasal occlusion and vision therapy. We started on a course of eye exercises and corrected my sight with a contact lens. Time to complete the exercises on a daily basis was still a big challenge in such a busy life and I didn’t really see much improvement over the six months.’
- ‘I eventually stumbled across an American behavioural optometrist that recommended Syntonics to me. I hadn’t come across this before so I soon found out where in the UK I could have the treatment after hearing some great things about it. It turned out that my behavioural optometrist actually knew Geoff (Shayler) so she was able to follow up my call to him with some facts and figures of my eye condition in medical terms.’
Symptoms
On first presentation at our practice, Laura described her symptoms as follows:
- Cannot fixate on anything small and keep in focus. Left eye does strange things, eyes burn, objects go blurry, drifting in and out of focus, then I have to look away or close my eyes.
- When adjusting from near to far, the left eye turns out slower than right, so gets strange sensation and a delay in refocusing.
- Painful eyes, eyebrows hurt, pain in and around sockets, particularly near ‘pressure points’.
- If I relax my eyes, everything goes blurry. If I continue to relax my eyes, they turn in, and I have severe double vision.
- Extreme tiredness.
- Motion sickness, even when not moving.
- Anxiety caused by the sensation my eyes give me.
- Struggle to concentrate on what I am saying or what people are saying to me, because I am so ‘busy’ trying to keep my eyes straight and in focus.
- Poor memory.
- Eyes always feel under tension and unable to relax my eyes, whether open or shut.
- With left eye shut, if I relax my right eye, everything goes blurry.
Initial assessment
- Motility full R&L.
- Pursuits smooth R&L.
- Saccades monocularly accurate.
- Convergence normal but problems with divergence.
- Cover test DV while putting in effort looks fairly straight but when relaxes her eyes, significant L esophoria, which breaks down to esotropia.
- Cover test NV increased esophoria but similar in all angles of gaze.
- Maddox rod DV 10 esophoria, no vertical phoria.
- Howell DV 2 - 4 esophoria while straining to keep numbers on chart clear.
- Howell NV 5 esophoria while straining to keep numbers on chart clear.
- Bi-hemispheric Dissonance test (Merrill Bowan) similar to overlay ‘visual stress chart’ – very uncomfortable feeling in both horizontal and vertical directions. Feeling of eye wanting to turn in.
- Accommodative flexibility (range of clear near vision) 16-56cm.
- Eye tracking measured with Okimo software.
- Static (form) coherence threshold - binocular 19.21% (within normal limits).
- Motion coherence threshold RE 16.31%, LE 14.58% (within normal limits).
- Refraction; R -0.25DS (6/4) L +3.00DS (unstable 6/18 to 6/24, worsened during testing).
Conclusion of assessment results
Laura had anisometropic amblyopia. Previous optical providers had tried her with spectacles and contact lenses, none of which she found beneficial. I thought it likely that the accident had broken down her ‘normal’ amblyopic suppression systems resulting in her unstable esotropia and an inability to maintain stable binocular vision, so causing her myriad of symptoms
Recommendation
Due to the magnification effects of her anisometropia, Laura was advised to resume contact lens wear (following a check by her current optometrist) as it would be essential for them to be worn during optometric vision therapy
A two-week, 20 session programme of ‘fast track’ optometric vision therapy was recommended, where Laura would attend for a one-hour therapy session twice a day, five days a week for two weeks, with a three-hour gap between appointments (as recommended by the late Dr Wayne Pharr).
Each one hour session comprised the use of the following:
- Translid binocular interactor (TBI – as developed by Merrill Allen, Atlanta University) to break down suppression patterns.
- Two 10-minute sessions of Syntonic Optometric Phototherapy (syntonics) to relax the autonomic nervous system and stimulate the visual system.
In addition, we undertook six-minute sessions to treat each of the following:
- Fields (peripheral awareness)
- Fixations (eye movements, convergence)
- Focus (speed, flexibility and automaticity of focus change)
- Fusion (building fusional reserves and depth perception)
- Flexibility (integration of the above with gross and fine motor activities)
We use a variety of activities under each heading in the above list to avoid teaching a splinter skill. In our practice, it is considered that optometric vision therapy is about providing the brain with visual problems that it has to solve. In this way, OVT can be considered as not simply ‘muscle’ training (like ‘pencil to nose’ exercises, because there is nothing wrong with her muscular function), but updating and developing improved neurological control of the various visual processes.
Results
The pre/post results of optometric vision therapy for Laura are summarised in table 1.
Table 1: Results before and after vision therapy interventions
In just two weeks of therapy, her eyes straightened, her esophoria reduced and fusional reserves normalised, with significant improvement in all areas of visual performance, in particular her eye tracking and co-ordination. Of some surprise to me was the improvement in the acuity of the amblyopic eye – from a variable 6/18 down to 6/7.5. In particular, her symptoms were relieved and she experienced a significant change in her quality of life.
I was also interested to see the difference in her writing before and after therapy (figure 1).
Laura stated after treatment, ‘After nine of the 20 one-hour sessions, the pulling sensation in my left eye had completely gone, along with all the double vision. Over the course of the second week my visual skills continued to improve and my lazy eye was almost functioning as normal by the end of the therapy.’
Table 2: Okimo eye tracking software results
The eye tracking results of pursuits before and after therapy, using Okimo eye tracking software, are shown in table 2. This computer based program (using an eye tacking ‘gaming bar’) assesses the ability to:
- Follow a ball that is moving back and forth in a lateral direction, and recorded over time as a sine wave pattern, and,
- Monitor eye movements whilst the patient is reading some text.
The campimetry field plots pre-therapy are shown in figure 2, and post therapy in figure 3. The functional visual field were now nearly normalised.
Figure 2: Campimetry pre-therapy
Figure 3: Campimetry post-therapy
Van Orden Stars assessment indicated a substantial improvement in spatial and hemispherical organisation (figure 4).
Figure 4: Van Orden Stars assessment showing improvement on three successive occasions
Syntonic phototherapy
The College of Syntonic Phototherapy was founded in 1933, following years of research by Dr Harry Riley Spitler. There are only a few university-based studies on the benefits of syntonics, but its increasing use by optometrists around the world is suggesting improvement in some aspects of visual performance with its use. Within our practice, we have found significant improvements in the functional visual field, improved eye tacking, convergence, fusional reserves, accommodative facility and flexibility associated with improved magnocellular processing (as identified by assessment of global motion coherence thresholds).
We have additionally shown that the provision of low plus lenses on some children with vision related educational difficulties can impact on global motion coherence thresholds.
Clinical research
Three controlled studies by optometrists have examined syntonic phototherapy’s impact on children’s learning and vision.1,2,3 These studies provide evidence that relatively short-term syntonic treatment can significantly improve visual skills, peripheral vision, memory, behaviour, mood, general performance and academic achievement. They also confirm that children with learning problems have a reduction in the sensitivity of their peripheral vision. During and after phototherapy they demonstrated improvement of peripheral vision and visual skills.
Table 3: Change in other measured parameters
All three studies show improvements in the children who used syntonic phototherapy compared with subjects matched for age and academic success who did not. The non-syntonics students either looked at white light (Kaplan), had optometric vision therapy (Liberman) or had optometric vision therapy and academic tutoring (Ingersol).
The control students showed no or significantly less improvement in their peripheral vision, symptoms or performance than the phototherapy treated children. Ingersol found the experimental group receiving academic tutoring, vision therapy and syntonics had significantly superior outcomes than students given tutoring and vision therapy but no syntonics.
Conclusion
Almost every day, some new development is published whether to do with myopia control, new treatments for ARMD, etc, and the training of optometrists in understanding the complexities of binocular vision is not moving forward as our understanding of pathology. For me, personally, syntonics is not a ‘stand alone treatment’ but another tool for me to select and integrate with the many others in my vision therapy work box.4
References
1 Kaplan R.M. Changes in Form Visual Fields in Reading Disabled Children Produced by Syntonic Stimulation. International Journal of Biosocial Research 1983; 5(1):20-33.
2 Liberman J. The Effects of Syntonic Colored Light Stimulation in Certain Visual and Cognitive Functions.. Journal of Optometric Vision Development 1986; 17[June].
3 Ingersol S. Syntonics as Reading Enhancement Techniques at the Livingston Developmental Academy (presented at 66th Annual Conference Light and Vision, Vancouver, Canada, 1998). Journal of Optometric Phototherapy [1999]
4 Shayler G, The association of Static (form) and motion coherence thresholds with various measures of visual and scholastic performance. Optometry and Visual Performance, Vol 4, Issue 16, 2016.
Geoff Shayler is a behavioural optometrist based in Dorset.
More information about optometric vision therapy available at www.babo.co.uk, www.nora.cc, www.covd.com, www.boaf-eu.org, www.collegeofsyntonicoptometry.com and www.syntonicoptometry.mobi
If you have a view on this case study, or on behavioural optometry, please let us know – bill.harvey@markallengroup.com.