Contrary to popular belief, 6/6 vision is not considered as perfect vision in ophthalmic domain. It, in fact, is a broad spectrum of visual functionalities including hyper acuity, good contrast sensitivity and contrast sensitivity function (CSF), normal colour vision, quick dark adaptation, broad field of view, etc. coupled with strain free straight lines of sight.
Vision therapy (VT), in simple terms, may be defined as “the science of achieving clear and comfortable vision”. VT is also called by other names such as, Visual Therapy, Visual Training, etc. The VT aims to enhance visual skills like, eye-tracking, focusing, and convergence, eye-hand co-ordination, visual processing speed. In fact, vision therapy is an eyecare-supervised program designed to improve the overall function of the visual system. Following are some of the conditions where vision therapy may be useful:
Amblyopia (lazy eye)
Eye teaming and tracking problems
Depth perception and 3D vision difficulties
Hand-eye coordination difficulties
Visual perception and processing issues
Therefore, it becomes prudent for an optometrist to be familiar with various vision therapy instruments. Following is the list of some of the most commonly used vision therapy tools:
A. HART CHARTS
The chart is used to treat conditions affecting accommodation, saccades, and visual attention. There is a set of two charts. In order to treat accommodative disorder, the patient holds the smaller chart at his/her arm’s length and gradually slows down the speed of the chart movement toward the eye, while reading. The patient continues to reads the text from the large chart placed at 10 feet and the chart at the arm’s length alternatively.
B. BROCK STRING
The Brock String is often used as initial vision therapy technique. This is used to improve the ability of the eyes to work together, especially for nearby. One end of the string is tied to the door knob (or similar arrangement is made) and the patient holds the other end in his/her hand next to his/her nose. Place the nearest bead to the position where it is seen clear and single. Other beads are spread out with equal spacing. Patient jumps the fixation from bead to bead. Patient will be able to see “V”, “X”, and “A” patterns while moving from nearest to center to the farthest bead. Gradually the speed of movement from bead-to-bead is increased.
The Vectogram is used to improve the positive and negative fusional amplitudes. The patient wears the polaroid glasses and looks at the Quoits Vectogram targets in the Dual Polachrome illuminated trainer with the targets set at zero prismatic demand. Patient also sees the boxes with “R” aligned over “L”. The patient is instructed to ignore “R” and “L” initially and try to focus on the picture. Then the two sheets are slowly separated in induce small amount of convergence and divergence demands, patient is asked to keep the picture clear as well as single and keep describing the state of the picture. Patients would notice that the target is gradually becoming smaller and closer to converge and larger and farther apart during divergence demand.
D. BALANCE BOARD
The balance board is comprised of a square board with a base. The patient stands on the board and tries to shift his/her hips from side-to-side. The idea of using balance board concept is that eyes are the parts of the body and they must move independently of the head and body. Eye movements are believed ineffective when accompanied by the movement of the body or head.
It is used to improve the patient’s ability to gain control over the patient’s eye movements. The patient places the golf tees in a rotating board. As the patient’s performance improves, the speed of the rotating pegboard is increased. During this procedure the patient wears a patch on one eye so that a strong monocular skill is developed before subjecting the patient to achieve binocular skills.
F. LENSES and PRISMS
In this method of vision therapy, the prism bar is used to measure the convergence and divergence amplitudes while patient fixates at a near or distance target depending upon for which distance you want to measure the amplitudes. Base-out (BO) orientation is used in gradual increasing prismatic power in order to measure the amplitude of convergence and the base-in (BI) orientation is used to measure the amplitude of divergence.
In order to detect abnormal retinal correspondence (ARC), a thin strip of glass on top of a prism is used. If the patient has ARC, he/she will complain of paradoxical diplopia on the red glass test after prism neutralisation. An isotropic patient will notice a crossed diplopia, while an exotropia patient will notice an uncrossed diplopia with prism neutralisation with red glass test if there is an ARC.
G. COMPUTER SOFTWARE-BASED PROGRAMS
In order to augment office therapy there are computer-based programs with many added advantages. Depending upon the program chosen, activities can focus on vergence, accommodation, ocular movements, and processing of visual information. Computer software programs are used to improve eye monitoring skills, visual thinking, processing skills as well as binocular skills. Exercises improve the eye co-ordination and also strengthen the muscle control.
H. WOLFF WANDS
The Wolff Wands are a pair of metallic chopsticks of one foot length with the ball at the end. These wands are used for the activities related to tracking and convergence. The patient understands where their eyes are pointing in relation to his/her body. The eye monitoring is done at the beginning of the treatment.
One pair of plus lenses attached to another pair of minus lenses makes a flippers device. In order to gain enhanced facility and control over the focusing system, flippers are alternated from plus pair to minus while the patient is reading a print, thereby increasing or relaxing the accommodative effort. The power of the lenses is increased gradually.
Cheiroscope is a haploscopic diagnostic as well as training vision therapy device which is used to assess binocular stability (intermittent heterotropia and heterophoria) and alignment and also to detect the presence and extent of suppression. The fixating eye is used to see the picture in the mirror and the fellow eye is used to draw the picture on a sheet of paper.
K. RAF RULER
Royal Air Force (RAF) ruler also known as RAF Near Point Rule (RNPR) is used to measure, near point of convergence (NPC), near point of accommodation (NPA) as a diagnostic use and, giving home exercises as a therapeutic use.
It has a 4-sided rotating cubic drum held on a slider. The slider is attached to a square steel ruler. Each of the 4 sides of the cubic drum has different accommodative targets with black-on-white prints. Slide 1, 2, and 3 are used in the measurement of NPA and the slide 4 is used in the measurement of NPC.
Most commonly used Synoptophore is basically a major amblyoscope. This instrument with a wide range of diagnostic and therapeutic functionalities is based on the haploscopic principle.
Diagnostic uses include: grades of binocular vision, objective and subjective angle of deviation, measurement of deviation in all cardinal direction of gazes, inter-pupillary distance (IPD) measurement, retinal correspondence, measurement of primary and secondary deviations, suppression, fusional vergence, angle kappa, and AC/A ratio, etc. The therapeutic used include: treatment of suppression, abnormal retinal correspondence (ARC), ambloyopia with eccentric fixation, accommodative esotropia, and heterophorias and intermittent heterotropias.
M. SACCADIC FIXATOR
The saccadic fixator is an instrument that involves eye movement, follow-up, visual memory, peripheral awareness and motor visual integration. It helps patients set goals as they continuously strive to improve their latest performance. Apart from patients with oculomotor dysfunction, this machine is especially good for young athletes; it improves eye-hand-body coordination and response time. Overall, he is a great trainer for visual stamina and efficacy.
N. APERTURE RULE
An aperture rule is a haploscopic fusional device. In this technique the patient is made to look through an aperture towards a series of targets that are positioned at the end of the instrument. Each eye sees a different part of the target, and the patient learns to merge the two images from his left and right eyes into a single image. The role of the optometrist is to coach the patient on how to adjust his visual system to achieve the goal of a clear and single vision.
Last, but not the least, before starting vision therapy clinic, a good theoretical knowledge and application skills of vision therapy tools is all that is required.
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