little four eyes

Yes, we buy every cute glasses-themed T-shirt we see. Busted farmer's hat? Not a typical accessory.

Last night, my daughter experienced double vision. But panic soon gave way to reassurance. It was not a bad thing. Surprisingly, I haven’t lost my mind. (Though if I did, would I know it? Anywho.) Please allow me to explain.

Stella, whose vision I’ve covered here at Little Four Eyes before, just turned three. When she was 18 months old, her accommodative esotropia and anisometropia were discovered and addressed with glasses. Her stylish specs keep her eyes straight–HOORAY! We still patch a little bit, because her left eye is more farsighted than the right and so has slightly lower acuity (really, less than one line difference at last check). We’re finishing up vision therapy. Stella can catch a ball, now without using her chest to corral it. She can snag falling feathers with the grace of a major league outfielder, and hit a birdie with a racket, not so much with grace (yet) but with real and consistent contact. Her peripheral vision was opened up by the vision therapy, and her toe-walking reduced. She’s doing very well, and even asks to do our daily at-home vision therapy activities. Amazing progress all around.

Last night, when I heard her crying out from bed, I blamed the cold she’s been battling. I went in to comfort her and help blow her nose. As I leaned over her, I saw a dazed smile on her face. That’s when she said, “I see two mommies.” I looked more closely, and sure enough, her left eye was turned in. I so rarely see her eyes cross–because she almost always wears her glasses. The sight is still a punch in the gut, but I quickly put the pieces together and saw a big positive.

First off, she has a cold–the stress of illness is what brought out her strabismus out in the first place.

Secondly, she wasn’t wearing her glasses. Spec-free, all bets are off, particularly when she’s studying something up close. At least until age 11 to 13 or so, she’ll need glasses to keep her eyes aligned. The vision therapy helped re-wire her brain to always use her eyes, aligned by glasses, together. If her glasses were on and I saw crossing, only then would I have real reason for concern.

Lastly, and this felt like a big and helpful realization to me: She wasn’t suppressing the weaker eye. She saw double because she was trying to use both eyes as usual. If her weaker eye was being tuned out, she wouldn’t experience double vision. Typically, again thanks to her glasses, her eyes are aligned and work together, enabling great stereoscopy as recently measured by both her new ophthalmologist (who is wonderful) and her developmental optometrist (also super fantastic). It’s no wonder Stella found the double vision amusing and unusual. She’s used to two eyes in concert, not in conflict.

Upon further obsession (err, reflection), I was pleased with how she quickly articulated what was going on. Back when she got her glasses, half a lifetime ago for this three-year-old, she had a relatively good vocab for her age but obviously couldn’t describe her vision to me. She also refused to even look at the feather I held in my hand above her head, nevermind catch one. She’s come a long way!

All that said, last night was a good reminder about how crucial it is for Stella to wear her glasses at all times (sleep, bath, and swimming excluded). I’ll confess that sometimes, upon waking, she comes to our still-darkened room and hangs out in our bed for a bit, usually without her glasses. About time we made “glasses on!” the very first step in our day.

Now, if only she could effectively clean her glasses on her own. This cold is resulting in permanently smeared lenses! (Ew.)

The COVD (College of Optometrists in Vision Development) is looking for videos that tell of success stories with vision therapy.  They’re holding a video contest, “Visions of Hope” on their facebook page.  The deadline for submitting videos is August 10, and winners will be selected by vote on Facebook.  You can read more here:   Announcing the COVD Visions of Hope Vision Therapy Video Contest!

Let me know if you do submit a video, and I’ll keep a running list so that others can see who from Little Four Eyes has submitted a video.

I’ve come across a pretty random assortment of links recently, on topics of vision therapy, cataracts, and a do-it-yourself iPhone app for vision testing.

• Questions for doctors – Stewart Snippets recently learned that her 2 year old son has lamellar cataracts.  She wrote a wonderful list of questions for her son’s doctors.  The questions are worth checking out and keeping in mind for doctor’s appointments, no matter what your child’s diagnosis.
• Red Eye Reflex – Jack’s Journey has a great post – with lots of pictures – about red eye reflex in photos, which can be a sign of cataracts (it can also be a sign of a really good camera with red eye reduction).

• Vision Therapy Video – This is a short video giving a concise explanation of vision therapy, with particularly good explanation of how visual problems can lead to difficulties with reading.  If you’re looking for a quick introduction to VT, this is a good place to start.  Via Bright Eyes News.

• Vision Testing App, iSight Test – There’s a new app available for the iPhone/iPad that allows you to assess visual acuity at home.  The app was developed by ophthalmologists and a pediatric orthoptist.  The app gives parents the ability to track their child’s visual acuity during amblyopia treatment in between  eye doctor visits.  Obviously, this app would not take the place of vision exams, but rather give parents a tool to use in between visits.  Quick note, the app uses and was created by Kay pictures, which were developed in part by Hazel Kay, author of Hoppity Frog has Two Clever Eyes, and a pediatric orthoptist.  Watch for a more detailed review of the app.

If your child has amblyopia and/or strabismus, you’re going to want to check this out: ”Do You See With Your Eyes Or With Your Brain and … What Difference Does It Make?” on The VisionHelp Blog.

I know about it thanks to Stella’s developmental optometrist, who emails relevant vision-related news and helpful educational opportunities and resources to her patients and colleagues. Tonight she shared a link to an engaging discussion between Dr. Press, a developmental optometrist and Board Certified Fellow of the College of Optometrists in Vision Development (COVD) who contributes to The VisionHelp Blog, and Dr. Granet, a prominent ophthalmologist. Really! They communicated with each other! And did a wonderful job of it, too. Though some of their chat is very expert-level, and therefore hard to follow, I was able to glean interesting points and find references to studies worth checking out. Hope it’s helpful to someone out there!

Dr. Press’ review (on The VisionHelp Blog) of Dr. Granet’s appearance on TV’s “The Doctors“ sparked this online dialog. Dr. Granet should be applauded for taking the time to respond to the (relatively mild) critique of his comments on amblyopia treatment, along with the optometrists who continued to engage him diplomatically yet honestly. You may’ve seen the video segment from the show, in which Dr. Granet tests a young toddler  for vision problems due to a family history of amblyopia. I really felt for the mom and dad, who found out in front of a live audience that their child likely does struggle with her vision. I remember that moment hitting me hard in the privacy of a small exam room. But as pointed out by “The Doctors,” early detection is something to be thankful for, and they’ve got it on their side.

In the comment section you’ll find an interesting conversation in which the disconnect between ophthalmologists and optometrists is taken on directly and in a very civil fashion. I couldn’t help but chime in (possibly coming across like a hysterical idiot parent, but hey, I tried!) and I hope you will, too. After all, it’s been talked about here on Little Four Eyes frequently. The lack of clarity many of us face in making decisions about our children’s care would be alleviated greatly if the two fields could find a way to collaborate or at least communicate. This comment section interaction seems like a step in the right direction. Stella’s doctor thought it was great and I agree.

One last time, here’s the link to the post and ensuing discussion:

Do You See With Your Eyes Or With Your Brain and … What Difference Does It Make?

(P.S. The video seems worth sharing, if only to convince other parents that eye exams are a great idea for all little ones and to show them how accurate testing can be even on babies as young as six months.)

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!

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I’ve recently learned about, and subsequently added some new links on the resources for parents page, and wanted to bring them to your attention.  Thanks to everyone that has suggested sites, and please, keep them coming!  If there’s a helpful website or great community out there, I want to list it.

Reference resource

• Eye Resources on the Internet – this is an extremely thorough list of Internet resources about vision compiled by the Association of Vision Science Librarians. (Thanks to Dr. Maino for posting this)

Communities for specific vision issues

• Congenital Glaucoma Network - a network for all people affected by childhood glaucoma come to share their story.  (Thanks to commenter Amy for pointing me to this network).
• Magic Foundation: Septo Optic Dysplasia (SOD)/Optic Nerve Hypoplasia – information and links to other families with children with Septo Optic Dysplasia.  (Thanks to commenter Denise for pointing me to the Magic Foundation).

Blogs by eye care professionals

• Dr Lea & Children’s Visions – Dr. Lea Hyvärinen is a Finnish pediatric ophthalmologist.  She may be most well-known by people here as the developer of the LEA symbols (the pictures of a house, an apple, a circle and a square that are commonly used as an eye chart for children).  Her blog managed by her daughter, and is so far, a way of making available her writings about children’s vision development.
• The VisionHelp Blog – VisionHelp is a blog written by a group of leading optometric vision specialists in the U.S.  They seek to increase awareness and understanding of vision treatment and vision therapy.

Kamerin Moore competing in Japan in 2009. (Image copyright 2009 L. Smith)

Stella and I recently started attending the open gym at a local gymnastics academy. It’s only $6, she loves it, and it’s so strenuous that she tires herself out and sleeps well. I casually mentioned this fact to her vision therapist, whose recent recommendations have included movement exercises like crab and other animal walks. The therapist lit up at the mention of Stella’s gym time. She said that parents often ask what sports are best for kids with binocular and other vision issues, a question that has been asked here at Little Four Eyes, too. Their immediate answer is always “gymnastics.”

Stella’s vision therapist then told me about another young girl in vision therapy who started gymnastics classes. At first, the girl’s vision actually seemed to be getting worse. But that wasn’t really the case–it was initial fatigue, as gymnastics can heavily engage the visual system. After three weeks or so, the girl adjusted and a new rate of visual improvement unfolded. So, in many ways, gymnastics is vision therapy. Stella and I will be signing up for a “parent and tot” class post haste!

Being the research junkie that I am, I started digging around online to find out about the connection between gymnastics and vision. I quickly found some inspiration, or perhaps reassurance, for parents of kids in glasses. Her name is Kamerin Moore, now 15 years old, and she reached the highest level of competition in gymnastics: international elite. In 2008, she made the U.S. Junior National Team. She’s wracked up some incredible achievements–all while wearing glasses.

Kamerin clearly doesn’t let anything stop her. She had two shoulder surgeries last year to correct bone issues that had been present since birth but had worsened as her growth sped up. So she hasn’t been competing, but is slated to make a triumphant return very soon. This time around, she’ll be wearing contacts. But again, she paved the way to greatness in glasses!

Head to kamerinmoore.com to learn more about Kamerin and her impressive gymnastics career. You’ll find many fabulous pictures of a bespectacled Kamerin competing and wearing hard-earned medals.

(Stay tuned–I will contact her in an attempt to find out what type/brand of glasses she wore. She’s been quoted as saying they’ve never fallen off or gotten in her way. Clearly!)

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.

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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?

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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 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.

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