vision therapy

[chris83]

Hi, could you offer some advice about vision therapy helping to correct strabismus. I am in my early twenties and have strabismus (my right eye turns out). I will be having surgery to get the eyes in alignment, which will be my second strabismus surgery in 12 months. If you dont mind i have some questions about vision therapy, my questions are;

1. Does vision therapy help with strabissmus?

2. Does vision therapy work best when it is done alongsidde surgery, or should vision therapy be done on its own?

3. Should i start vision therapy before i have the second surgery?

4. Should i start vision therapy after i have had the second seurgery?



Thannks in advance.

[Michael J Kutryb, MD]

I'm going to defer to your strabismus surgeon on this one.  It's not my place to jump in an suggest changes in your regime.  I try to keep an open mind about these type of treatments which are not mainstream.  My best answer is this:  the thing that is going to help you the most is proper surgery to get the eyes in alignment.  If that can be physically accomplished then that's going to make a big differnce.  Talk to your surgeon about vision therapy - I'm assuming he/she is a board-certified pediatric ophthalmologist.  If not, consider a second opinion.  There are previous posts on this site regarding vision therapy - you may be able to use search feature to find them.

MJK MD

[JodieJ]

I developed strabismus and double vision as an adult.  (Apparently, I had a mild phoria that decompensated as a result of monovision contact lens wear.)  Due to over-scheduling, my strab surgeon could only see me briefly at my initial appointment, and he sent me home with a computerized vision therapy program to "try out" before I could be rescheduled.  I worked on the vision program for many very frustrating hours during the 6 weeks before my strab surgery, and I actually made measurable progress at reducing my esotropia.  (My strab surgeon was truly shocked by my progress.)  My strab surgery completely eliminated my problem in about 40 minutes, with no effort on my part.  The optometrist I saw subsequently attributed my excellent surgical outcome at least in part to the vision therapy I had done beforehand.  (Frankly, I'm not at all convinced of this.)

The issues you've raised are controversial, and opinions vary depending on whom you ask.  The research I've done suggests that vision therapy works best for problems involving convergence (near vision) and exotropia (outward eye turn).  (My problems involved divergence and esotropia.)  My best advice to you would be to consult an experienced strab surgeon and ask his/her advice about the value of vision therapy for you  I certainly wouldn't advise anyone to spend hundreds (or thousands) of dollars on a controversial treatment.  On the other hand, with your surgeon's permission, it wouldn't hurt to spend some time with a computerized program or similar exercises, either before surgery or afterward to "fine tune" the outcome.  
  

[chris83]

Thanks for your input Jodie.

I do have a extropia so maybe vision therapy might help me, but like you say vision therapy does cost a lot of money so I will ask my surgeon (when i find the right one).

[chris83]

If you dont mind me asking you Jodie, how many dp was yor eye out before you had surgery? How many dp was it out after the Vision therapy? And did the results hold for long or just a short while after a vision therapy session?

Sorry for so many questions, hope you can help.

Thanks

[JodieJ]

I had strab surgery in August 2005, and I honestly can't remember my pd numbers.  The program I used was the 2004 version of Jeffrey Cooper's "Computerized Vergence System."  My double vision was really driving me crazy, and my super-heavy prism glasses didn't totally eliminate it.  So I was willing to do just about anything that might help.  My strab surgeon estimated that there was about a 75% chance that my surgery would be successful, so I viewed vision therapy as my "Plan B."  I wanted desperately to succeed at it.  As I recall, I easily passed all the convergence (near vision) tasks but failed some of the divergence (distance vision) tasks more than 100 times!  It was definitely an exercise in frustration.  But I managed to pass all the tasks (by a hair) and complete the program just a few hours before surgery.  (I still view this as a major life accomplishment.)  Because I worked on the program every day, there wasn't time for regression between sessions.

If you'd like more information about the CVS program, the support number I have is: 888-810-3937.  The phone support people were really excellent.  Post-surgery, I did ask one of them if I might have eliminated my esotropia with vision therapy alone, and he didn't think I could have.  I was quite impressed by his apparent honesty.

Vision therapy works best for convergence problems (near vision) and exotropia.  I've read that it can be especially helpful at "fine tuning" surgical results if you end up with slight exotropia.  But there's very little research about when/how well it works.  And I suspect that most vision therapy is done with children, who may be less than highly motivated.

Be sure that the surgeon(s) you consult is/are board-certified and experienced .  With his/her approval, working with a computerized program is a good way, IMO, to do vision therapy without spending $100+ per session out-of-pocket.  Best wishes for a successful outcome.  

      

[chris83]

Thanks Jodie that is some really helpful information. I would be interested in getting more information about the CVS program you mentioned, but i am from England so i dont think that the support number will be much help. Do you know if they have a website with the informaton about their CVS program?

Thanks

[JodieJ]

Apparently, they have a new version of their CVS program, although the support person I checked with told me that it is essentially the same program that I have.  However, it is now being marketed for "eye strain" related to binocular vision problems/"computer vision syndrome".  I was told previously that it is an appropriate program for someone with strabismus (either exotropia or esotropia).  Their website is at www.homevisiontherapy.com, and there is an email address for questions/additional information.

Here in the US treating strabismus with vision therapy can be very expensive--about $100 (or more) for a 1-hour weekly session over a period of about a year--and most American health insurance won't pay for it.  Personally, I think that at least some cases of strabismus would benefit (which ones?), especially if the patient were highly motivated.  Maybe in England this treatment modality is provided at no charge by your national health care.

Best of luck.    

[JodieJ]

There is a better description of the "computerized binocular home vision therapy program" at www.visiontherapysolutions.net/hts.html.  (You can also get there by following the link from the above website.)

Jodie

[chris83]

Thanks again Jodie you have been very helpful. Unfortunately the National Health System (NHS) does not provide vision therapy, so i would have to see a optometrist privately. In fact after a bit of research i can only find three places in the country where you can do vision therapy, it appears that vision therapy is not very common here (which could be why my opthamologist never mentioned it to me).

[JodieJ]

The computerized binocular home vision therapy program probably costs less than a single session with a vision therapist.  It contains 100 computerized vision therapy sessions.  If you use them up and want more, the support staff will give you a code to enter to get 100 more sessions at no charge.  You can do this as many times as you'd like, making the program very cost effective.  You can also customize the program to suit your needs.  I found the support staff to be very knowledgeable about strabismus.  You could probably communicate with them by email, but I don't think that a trans-Atlantic call would cost that much.  The 800 number is free in the US.

It's easy to measure your progress (or lack thereof) using the program.  If you do decide to try it, don't get discouraged.  The divergence tasks initially seemed impossible to me, but with persistence I slowly progressed to an acceptable level.  I had (barely) passed all the tasks before surgery, which immediately restored my eye alignment and eliminated my double vision.  I continued working on the program post-surgery and easily made rapid progress.  I still use the program occasionally--it's sort of like playing a video game.  The support people are always willing to give me more sessions at no charge.  

[chris83]

Thanks Jodie, once again you have been very helpful.

I have looked on the websites you suggested. Unfortunately to get the computerised binocular home vision therapy program you need a doctor to order it for you, and worse still it appears on their website that they only supply the program through international doctos from Australia, New Zealand, South Africa and Canada. I have sent them an email asking if it is possible for me to aquire their program, if that is a no go then i will try phoneing their support number once i figure out how to make a trans-atlantic call.

Thanks.

[JodieJ]

The website lists the doctors who already sell (or have sold) the program.  But I suspect that any eye care provider (ophthalmologist, optometrist) or probably even a family practice M.D. could obtain it for you.  (My cataract surgeon's name is on their list, and his practice involves mostly cataract/refractive surgery.  He definitely doesn't do strabismus surgery or vision therapy.  I assume that his name is listed because he was willing to help out a patient who wanted the program.)  I'm sure you can find a sympathetic doctor in your area who would order the program for you.  I think the www.visiontherapysolutions.net/hts.html website has instructions for the doctor about ordering.  Unfortunately, I don't think they'd sell you a program directly.  Good luck--and let me know what you think about the program.    

[chris83]

Cheers Jodie for all your advice, if i can get a doctor to order the program for me i will definately try it out and let you know what i think (and any results).

Due to the facts that my was eye were initially in alignment for the first couple of months after surgery before my eye turned out, my eyes were in alignmnet for about 18 years before my eye first turned out, i do see with both my eyes at the same time (although the weaker one has turned out),  and i have a exotropia which as you mentioned tends to react better to vision therapy, i do believe that this program can give me better chances with my next surgery (fine tuning i think you called it earlier).

Thanks

[JodieJ]

Most of the very limited research on vision therapy is over 25 years old and involves only a few subjects.  And I suspect that most vision therapy is done with children who are not highly motivated.  (I never did benefit from those piano lessons my parents made me take as a kid, but this doesn't negate the value of music lessons.)  It's anybody's guess who will benefit from vision therapy and how much.  But you certainly sound like an excellent candidate to me.  I'll be eager to hear about your results.  Best wishes.

[John C Hagan III, MD, FACS]

Objective studies done by ophthalmologists and orthoptists have failed to document benefit of visual therapy except for convergence insufficiency. This is a reference from 2005. There is a newer one that was published in 2007. I am still looking for it, if I find it I'll post it. The conclusions are much the same. While I no longer do strabismus surgery when I did a lot of it there were many many parents that came in having spent $5000-$10000 US on worthless "visual training" by optometrists.

http://www.ophsource.org/periodicals/ajopht/article/PIIS0002939405006872/fulltext

JCH III MD

[JodieJ]

Thank you very much for this citation.  Unfortunately, all I could get for free was the abstract, which is not terribly enlightening.  I'll try to find a medical library that will allow me access, so that I read the entire article--or treat myself to the $30 online version.  From what I already know, much of "vision therapy" consists of misguided (IMO) attempts to correct myopia, learning disabilities, hyperactivity, and other conditions for which visual training is undoubtedly inappropriate.  (In other words, much of what passes for vision therapy is probably quackery.)

Because I was interested in the topic, I read the postings in a vision therapy newsgroup for awhile.  Some of them were from an optometrist-in-training, who worked mainly with children at the outpatient clinic of the optometry school here in Chicago.  He wrote about his disappointing results working with children who did not do homework between sessions or even attend the sessions regularly.  (It reminded me of my failure with the piano lessons that my parents' dragged me to when I was a kid.)  It's interesting that the (very few) people posting on this site who claim to have had a positive experience with vision therapy for strabismus have been highly-motivated adults.

In any case, the computerized program mentioned above costs less than a single session with a vision therapist.  I did make demonstrable progress at reducing my esotropia at distance, but it's unknown whether the gains I made would have disappeared without surgery or ongoing practice.  The experience of working with the computerized program was extremely frustrating for me--far too frustrating to inflict on a child.  But my personal experience suggests that vision therapy may be beneficial for more than just convergence insufficiency.  I'm very interested in learning about chris83's experience with vision therapy, if he tries it.  

[chris83]

Hi Jodie,

I am definately going to give vision therapy a go, even if i cant get the above computerised program then i will pay for vision therapy privately with an optometrist. I am highly motivated about trying that can help improve my eye alignment and vision, so i believe i will fall into the highly motivated adult with strabismus category you mentioned. I will keep you informed of my progress in both undertaking vision therapy and any results achieved.

Thanks

[John C Hagan III, MD, FACS]

I would not spend $30 for a reprint. Maybe a library can get it for free or maybe your FP or GP will request a copy from the hospital medical library.

I have not had time to search the reference from 2007. The eye journals I read that would have published it are american journal of ophthalmology, archives of ophthalmology, ophthalmology. I thought it was Archives and I thought it came from the Indiana medical school but when I searched last night I couldn't find it. Make me mad because it was just what you are looking for. Hopefully things will lighten up and I'll be able to locate it.

JCH III MD

[JodieJ]

Dr. Hagan, thank you for your time in researching this.  It's still my belief that no one should spend hundreds (or worse yet, thousands) of dollars on vision therapy.  But I also think this modality might be a useful adjunct to strabismus surgery, and perhaps it would work well alone in cases involving small deviations.  As I stated previously, the support person for the vision therapy computer program thought my angle of deviation (maybe 14 PD at the time of surgery--I'm not sure) was still too large to be eliminated with vision therapy alone.  (However, he didn't know how hard I was willing to work to be rid of that double vision.)

Chris83, I'm sure that you'll be able to find a doctor who will order the program for you.  Good luck.

[John C Hagan]

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