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Beyond patching: Stella’s vision therapy now includes MFBF
The Treat Game: Stella's baby helps find matches during vision therapy at home
Stella’s developmental optometrist views patching as a first step in amblyopia treatment. Patching (in our case, Magic tape over the lens of the stronger eye) boosts the acuity of the weaker eye. Stella’s lazy eye is growing stronger, and vision therapy is more and more focused on training her eyes to work together for strong binocular fusion, in an effort to encourage stereoscopy, prevent or minimize regression and provide a lasting fix.
Stella’s daily patching time now feels pretty turn-key, even though (as is my nature) I do it on the fly. She does a solid hour, at least, first thing in the morning, kicked off by some video watching. Sometimes it says on and patching is done by late morning. Sometimes patching is completed in two or three chunks. I seize opportunities strategically. If she’s engrossed with a toy that demands a ton of hand-eye coordination, I’ll throw on her patch to give her amblyopic eye a workout. We’ve got patching down! Vision therapy? Or more accurately, getting 20 to 30 solid minutes of vision therapy done at home? Still a challenge. But as her weaker eye improves, the nature of her vision therapy is changing. The latest exercises seeming to provide more improvement bang for our frustration buck. So we’re trying harder than ever.
Ever since Stella’s vision therapy progress evaluation which showed great gains, we’ve been doing a bit of what Susan Barry discusses on page 150 of Fixing My Gaze: monocular fixation in a binocular field (MFBF). This means that instead of being completely excluded via the patch, the stronger eye is merely put at a disadvantage. Her dominant eye is still able to receive and contribute visual input, allowing the eyes to work together, but the amblyopic eye is forced to do the heavy lifting. Several doctors/researchers, over several decades, have endorsed the effectiveness of this approach (Brock, Cohen and Hess for starters). Our experience with MFBF is limited but growing.
Almost every day, Stella dons a green-tinted patch over her strong eye and watches a video on our TV, the center of which is covered by a transparent red sheet. Her strong eye can’t see what’s in the red area thanks to the green tint, but it can still see what’s going on the periphery. In order to take in all the action and view the complete picture, her un-patched amblyopic eye has to pick up the slack and garner what is usually the most important part of the scene (whatever is centered, like close-ups of facial expressions, etc.). Her eyes are working together but her weaker eye has to perform at a higher level, setting the stage for binocular fusion. This work counts as patching time, so hooray for that!
Your stories: intermittent exotropia and conflicting treatment options
This story was sent in by Sheetal. She’d love to hear from anyone else dealing with intermittent exotropia. – Ann Z
My daughter has intermittent extropia. Her eye drifts outwards intermittently. We discovered it when she was about 7 months, but doctor said not to do anything about it then. We started patching when she was about 1 1\2 years; we patched only one eye (right eye) to make the left eye stronger. We did it for about four months. We went for a follow up in November 2010; she was 2 years by then. Doctor said, he sees the drift and he says he will have to do surgery soon. He also told us that her vision is fine in both the eyes. (20\20)
I really panicked, because though I see the drift in her eyes, I don’t see it all the time and I see it occasionally, maybe 5-10 times a day and it is different on different days. Whenever the drift is there, it stays for few seconds and she corrects it. Drift usually comes when she is looking at certain angle, I don’t see it when she is looking straight at things. So I was completely shaken when doctor said surgery is the only option.
I subsequently took appointment from 2 other doctors.
The second doctor told me that the drift is about 20-25 prism units, but he suggested not to do anything, he is very experienced and he told me to wait, according to him 1\3 of the cases stays the same, 1\3 gets better on their own and 1\3 gets worse. So he told us to keep a watch and I have appointment with him in April. (He also advised is against patching because he of the binocular vision). He also mentioned an interesting fact, that small kids have to look up at everything because their height is small, but as they grow everything is at an eye level and that helps in getting the drift better.
We went to the third doctor and he also mentioned that the drift is about 20 prism units.
He knew my first doctor and he said, he didn’t agree with him as far as the surgery goes, he said surgery is the last option and he recommended to continue patching and suggested pencil pushup exercise.
Now, I am a little relieved that surgery is off for now but am confused that there are different statements from different doctors. Am not sure if whatever I am doing is right, fear of something going wrong is always there.
Now I am patching the right eye for 1 1\2 hours and left eye for 1\2 hour alternate days.
We also try doing the Pencil Pushup exercise with her, we got 100 sticks from dollar store and we stick stickers on the tip and move it from back to front, she does it or few minutes and then looses attention.
A warning about Nintendo’s upcoming 3D device
Nintendo 3DS, expected to hit stores in March, comes with a vision-related warning
Jessica Gottlieb is a prominent blogger known for sharing strong opinions on motherhood, social media, and other assorted and engaging topics. Her son happens to have strabismus and amblyopia. He visited regularly with a pediatric ophthalmologist from age four months until earlier this month. Now nine years old, his vision has come a long way. He continues to wear an eye patch for a couple hours each day.
I thought the Little Four Eyes community would be interested Jessica’s recent thoughts on a piece of tech news: Nintendo’s 3D Gaming Device Comes with a Warning for Children Under Six. The soon-to-be-released gadget will come with a warning about potential injury to the eyes of children under age six, whose vision is still developing. Jessica has a valid concern about the device and its warning. The reason her son still wears a patch is because, at age nine, his eyes are still growing and changing (per the renowned doctors charged with caring for his vision). So why does Nintendo set the cut-off age at six when we know that eye development continues beyond then? What is the real risk?
This area of concern seems likely to grow as gaming systems evolve without much regard to their impact on young eyes. As if we didn’t have enough on our parental minds, ay? Extra caution certainly seems warranted, especially when it comes our children with visual issues such as strabismus and amblyopia. Thanks for the heads up, Jessica.
Parents/experts, what do you think? How much do you worry (or not) about the effects of video games and emerging forms of 3D entertainment, and screen time in general?
My daughter is only two and her screen time is generally limited to 30-60 minutes of TV (age-appropriate videos) a day, only while wearing her patch as it helps with compliance to our regimen, but I know this will get trickier as time goes on. What guidelines do you have in place for your child? How have viewing/gaming habits and limits changed or become harder as they’ve gotten older? What have optometrists, vision therapists, or ophthalmologists told you about the impact of TV, computers and video games on your child’s vision?
Vision therapy update: Stella’s first progress evaluation
Vision therapy: Skills and porcupine quills! Stella's first time wearing therapeutic prism lenses.
Last night and this morning, there was a nerve-wracking build-up to Stella’s check-up, wherein her developmental optometrist would gauge how patching and vision therapy have helped Stella, or not. I’ve worked very hard (okay, harder on some days than others) during Stella’s first three months of vision therapy, sometimes pulling my hair out, often swallowing pesky doubts, and occasionally guzzling wine. She’s 27 months old now, and has been such a trooper through glasses, patching and vision therapy. She asks to do certain “eye games” and requests her patch in the morning so she can watch a video (it’s her routine, plus there’s no TV watching without a patch). But she can also be impossibly resistant in that flippant, in-your-face way common to two-year-olds. And Stella’s not the only one with a short attention span! What was I talking about? Oh yeah–this isn’t easy, folks!
I’m proud of Stella regardless, but has all our effort paid off? As we headed out to the doctor’s office, part of me was absolutely certain that yes, her progress has been hit-you-over-the-head obvious and will be decisive and documented for posterity in the history books (or at least Stella’s patient records). But, I’ll be honest. Another part floundered and secretly wondered if we’d been throwing away hundreds of dollars each month.
The verdict: Stella has made solid improvement! Stella’s amblyopic eye is getting stronger and her eyes are working together more effectively. In August, when Stella was 24 months old and had been patching for maybe three weeks, her left eye was judged to be 20/40 [edit: found out at vision therapy that it was 20/80 before patching began]. Her right, 20/20. Since then, her left eye ramped up to 20/30, and her right is still 20/20. Other positive signs: During the exam, Stella’s eyes didn’t cross like last time. She showed much clearer evidence of 3D vision and binocular vision while wearing red/green glasses. These areas still need a lot of work, but Stella’s doctor and I see her first three months of patching and vision therapy as a success.
Reader question: kids with very low power presciption glasses
This question just came in from Jen. Anyone out there in a similar situation? -Ann Z
My daughter was diagnosed at 20 months old and we have been patching since. She was also prescribed glasses a month ago, her prescription is +1.5 ONLY but our doctor says we should give it a shot to see if that will help straighten her eye. So it turns out that the prescription is so low that it does not help her “see” better at all so it’s been a struggle to get her to wear it. I’m just getting frustrated that nothing is helping her yet. She has been a trooper in patching and we just had another baby so there are so much changes in her world. I want to see if there are anyone here with a child in similar prescription and has seen a difference in straightening out the eyes or successful in keep the glasses on?
The eyes are looking good
The chunky funky frames are a slightly higher prescription that we are trying to see if filling her whole script will help reduce the squinting. Her left eye is looking straighter without having the muscles moved and her right eye is still healing! The new muscle position is also helping with her academics. The progress she has made with reading and writing in the last 3 weeks is amazing!!!!
Another look at full occlusion, and why we patch with tape instead.
Our early days of "tape patching." On vacation, sans napkins, apparently.
They’re not easy to spot, but if you look closely, you’ll find little ovals of Magic Tape jutting out from just about every surface in our home. Like an infestation of ghostly flat beetles, they peek out from door jams, edges of dressers and bookcases, and the side of our bathroom mirror. You’ll even discover them slapped to the dashboard of our car–because we take our occlusion to go!
For three to four hours a day, the right lens of Stella’s glasses is covered in a little patch of tape. I’ve been wondering if anyone else in the Little Four Eyes community is patching this way. I’ve never seen it mentioned, and have read here many times that doctors insist on the importance of full occlusion. At the risk of sounding controversial, I’d like to propose that 100% full occlusion, provided by the standard adhesive patches, is not necessary or “right” for every child with amblyopia. Stella’s story (so far, anyway) and solid research back up this premise.
Quite simply, translucent tape on the glasses lens over her stronger eye works for Stella. Her reaction to the adhesive-on-skin-style patch was so over-the-top. To me, it was heartbreaking and scary. She’d had an NG tube as a baby, a feeding tube that is taped to the face and goes into the stomach through the nose, so maybe old trauma was involved. Regardless, we all know that patching can be very trying for some kids and parents (though for some it seems to go quite smoothly), even without negative past experiences with adhesive! That said, I’m relieved to point out that Stella’s intense resistance is not why we patch with tape.
Vision therapy progress: Maybe little efforts are a big deal after all
Stella's newly repaired glasses were a perfect complement to her owl costume.
So, my 26-month-old Stella has been patching for three months, and doing vision therapy for almost two months now. We do 20 minutes (30 or even more if we’re really, really lucky, 10 to 15 if we’re not) of vision therapy exercises at home five days a week, and we go into the office for a 45-minute session with Stella’s vision therapist once a week.
Stella has made obvious strides. Many fine motor tasks, like puzzles, are simply much, much easier for her, even when just using her ambylopic eye. She has more patience and confidence with such challenges–a wonderful side benefit to vision therapy and/or the product of more reliable vision. She’s taken to completely filling up a pipe cleaner with foam beads (they’re about a half inch wide with a tiny hole in the center). But when we first tried this exercise a little over a month ago, she couldn’t thread a single bead without tossing it in frustration. Catching a balloon is now pretty darn easy for her, whereas not long ago she avoided it completely. One of our current efforts is catching feathers, which she really enjoys and is mastering despite the added challenge of the smaller, more erratic targets. Some of the progress may be due to the daily practice, and some to the natural advancements in skill that come with each additional month in age, but the smoothness and confidence of her motions tell me that her eyes have become better guides, too.
Those bits of improvement were clear. But then, during last week’s office session, her progress was illuminated. Our vision therapist brought out the quoits vectogram, used to encourage stereopsis, and discussed in Fixing My Gaze by Susan Barry. Stella donned polarized glasses, comically large and round, over her own specs. I did the same with my sunglasses, perhaps helping to secure her cooperation–especially after we smiled at ourselves in a hand mirror. (One of many subtle but clever tactics employed our vision therapist.) A good explanation of this exercise can be found on page 115 of Fixing My Gaze: “A vectogram consists of two clear polarized sheets, each containing a similar image… When the viewer is wearing polarized 3D glasses, each eye sees the image on only one of the sheets. To see just one image of the rope circle, he or she must fuse the right- and left-eye views.” The moment felt large. Would Stella see the rope circle in 3D?
Vision therapy for toddlers… an exercise in patience.
Stella, back in May, on her first day with glasses. (She was 20 months old.)
Hello! I’m Amber. Ann recently posted about Stella, my little “fashion visionary.” She honestly does love wearing that “pirate girl” onesie! Stella very recently turned two and, in addition to wearing glasses and patching three hours a day, is two weeks into vision therapy. I’d love to share our vision therapy stories and hear about your experiences, especially with vision therapy for very young kids as it seems to present unique challenges.
First, let me explain how our path led to vision therapy. Treatment for her vision issues (first, accommodative esotropia and now ambylopia) began in April in the ER at Seattle Children’s Hospital. She’d been sick with a bad cold and had lost about a pound, and that morning I thought she’d bumped her head (saw it out of the corner of my eye–I wasn’t sure about anything but the screaming). That’s when both of her eyes suddenly started crossing–severely. Her pediatrician was visibly alarmed and sent us to the ER where they ruled out serious lie-threatening problems via head CT scan and tentatively diagnosed her with “convergence spasms.” A couple weeks later, we were routed to one of Children’s Hospital’s ophthalmologists. We now realize that the illness and stress must be what brought out Stella’s latent or, at the very least, hard to detect intermittent esotropia. I wish the ER had been aware that this was actually a rather common presentation, so Stella could’ve avoided all that radiation. Hindsight is 20/20. Unlike Stella’s left eye. Ahem.
After a very thorough exam, the ophthalmologist prescribed glasses, which have helped a lot in keeping her eyes straight. Then, at the follow-up appointment, they told us to start patching as visual acuity was decreasing in her weaker eye (her left eye has a stronger prescription which, from what I gather, means she has anisometropia). They said she may need to patch for years, but never mentioned vision therapy, I suppose because most ophthalmologists not only don’t offer it but aren’t very familiar with or approving of it. After reading Fixing My Gaze, I became dissatisfied with this approach for Stella and was excited to explore the possibility of vision therapy. Our second opinion came from a developmental optometrist who told me that Stella was too young for vision therapy. Luckily, we sought out a third opinion from a developmental optometrist who, among other seemingly innovative suggestions that differed from what we’d heard elsewhere, said Stella could begin vision therapy at this age! We now go every Wednesday morning to play “eye games.” The vision therapy guidelines they gave us initially say that most courses of vision therapy span nine to 12 months. Our journey is just beginning.
Web interview with Susan Barry- “School Crossings: A Neurobiologist’s View of How Our System Fails Children With Vision Problems”
Dr. Nate (of Bright Eyes News) and reader Amber both just let me know that COVD (that’s the College of Optometrists in Vision Development) is sponsoring a 30 minute web interview with neurobiologist Dr. Susan Barry entitled “School Crossings: A Neurobiologist’s View of How Our System Fails Children With Vision Problems.” The free web interview is targeted at parents and educators and will be Thursday, August 26, at 9 pm EDT. The interview will be recorded, but I don’t yet know whether or how it will be made available for people who are unable to attend the actual interview. As soon as I know more, I’ll update.
From the facebook event:
Hear Dr. Susan Barry answer questions about difficult school experiences that resulted from her vision problems; how, for example, she was mislabeled as a low aptitude student and assigned to a special problems class, and what her mother did to help her child succeed. And more….. including what you can do to help your child succeed!”
Dr. Barry is the author of the book, “Fixing My Gaze” which talks about her experience growing up with strabismus, and never achieving stereoscopic vision until she started vision therapy as an adult. The book is fascinating and her background as a neurobiologist is clear, as she explains the vision system in a very engaging and understandable matter (you can read my full review of her book). I’m certain that the web interview will be very interesting as well.
More details: “seating is limited to the first 1,000 people to respond. To register for this free event, go to: www.joinawebinar.com and enter the webinar ID number, which is 547-423-251, your email address, etc. Just follow the instructions from there.” Again, as soon as I know more about the availability of a recorded session, I’ll let people know.
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