VISION THERAPY

IN A
YOUNG PEDIATRIC
POPULATION

Marie I. Bodack, O.D.1 INTRODUCTION fixation testing, retinal correspondence

Marilyn Vricella, O.D.2
1. Cincinnati Childrens Hospital Medical Center,
Cincinnati, Ohio
2. State University of New York, State College of
T here are a limited number of stud-
ies in the optometric literature re-
garding vision therapy (VT) for patients
testing, and more specialized ocular mo-
tility evaluations (e.g. DEM or Visagraph)
if they were appropriate. When the evalu-
ations indicated that VT was an appropri-
Optometry, New York, New York under the age of 6.1-4 The majority of these ate intervention, the clinician discussed
are case reports.1-3 To our knowledge, there the particulars with the parent/caregiver
have been no reports of the characteristics of the patient. If it was agreed, a schedule
of these patients that could be used as a was developed, according to the particular
Abstract profile for planning purposes in either pri- case, including the number of visits to be
We conducted a retrospective chart re- vate or institutional VT clinical settings. conducted on a weekly or other appropri-
view of pediatric patients under the age The purpose of this study was to provide ate basis. This therapy was performed in
of 6 who had at least one vision therapy data regarding infant and pre-school pa- a group setting generally with three pa-
(VT) session. The VT was conducted in tients who were treated in the Vision tients receiving therapy at the same time.
the Vision Therapy Service, the Preschool Therapy, or the Pre-School Therapy Unit In virtually all instances, the patient was
Vision Therapy Service or the Infant Vi- (PST), or the Infant Vision Clinic of the under the care of the same staff doctor or
sion Clinic of the State University of New State University of New York (SUNY) resident. In some instances these optom-
York State College of Optometry from over a three year period. etrists provided direct care, but in other
September 2001 to September 2004. The BACKGROUND instances these doctors supervised care
yield was 35 charts that met the criteria Patients five and older are evaluated and given by interns.
and were available for review. The aver- treated in the VT clinic after referral from The infant vision clinic examines patients
age age of these patients was 4.4 years. within SUNY or by a direct referral from under the age of 5 and is not the same as
Among the data recorded for each patient an outside professional. In the former in- the pediatric clinic. If the comprehensive
were: initial reason for exam, referral stance the record of the last comprehen- examination indicates the need for vision
source, symptoms, ocular and medical sive optometric evaluation is provided. therapy, therapy is conducted in the PST
histories, number of vision therapy ses- When the patient is referred from a source clinic. Before initiating therapy a com-
sions completed and reasons for cessation external to SUNY, a copy of the individ- plete history including: ocular, medical,
of therapy. Almost 60% of patients seen uals most recent eye examination must pre/peri/post natal, developmental and
for evaluation and later for VT were diag- be received prior to the initial VT evalu- family history is conducted. This history
nosed as strabismic. The average number ation. After a review of that record, a VT is vital in the understanding of the devel-
of therapy visits per patient was 10. staff optometrist decides whether a further opment of binocularity, or lack of it. Bin-
comprehensive optometric evaluation, ocular development is thought to closely
Key Words performed at SUNY, is required before the parallel the history of the child from con-
amblyopia, orthoptics, pediatrics, pre- VT evaluation. ception through birth and after.5
school, strabismus, vision therapy At the initial VT visit all patients receive Unlike the primary VT clinic, where ther-
evaluations that include: visual acu- apy sessions are scheduled for 45 minutes,
ity, cover testing, external examination, in the PST, therapy sessions are scheduled
ocular motor status, phorometric testing for 30 minute sessions. Another differ-
including distance and near phorias, ver- ence between the two clinics is that the
gence ranges and accommodative test- therapy is conducted one-on-one with the
ing. Additional or supplemental testing patient and doctor. If a patient is too im-
Bodak MI, Vricella M. Vision Therapy in a Young mature for in-office PST, the therapy is
Pediatric Population. J Behav Optom 2010;21:59- can include ophthalmoscopy, refraction,
61 cheiroscopic tracing, vectogram ranges, scheduled primarily on a home basis, with

Journal of Behavioral Optometry Volume 21/2010/Number 3/Page 59

frequent follow ups conducted until he/ Four patients, (11%), report-
she is mature enough for office PST. The ed prior strabismus surgery.
case is the same with infant patients seen More specific information as
in the Infant Vision Clinic: therapy is ac- to the type of surgery that was
complished on a home basis with frequent performed was not available.
follow ups. Two patients, (5.7%), reported
METHODS a history of retinopathy of pre-
We conducted a retrospective review of maturity (ROP).
charts for patients under the age of 6 who Medical History
had at least one therapy visit (CPT code Two patients (5.7%) were hos-
92065) in the VT, preschool or infant vi- pitalized in a neonatal inten-
sion clinic at SUNY between September sive care unit. These patients
2001 and 2004. There was no lower age were distinct from the two
limit, but the upper age limit was 5 years whose history included ROP. Figure 1.
11 months. For those charts that met the Another patient did report a
criteria, we recorded: patient ages, reason history of prematurity with-
for exam, referral sources, entering symp- out a history of ROP. Two pa-
toms, ocular and medical histories, visual tients, (5.7%), were diagnosed
diagnoses, the number of therapy sessions as developmentally delayed.
and the reasons for cessation of therapy. One patient was diagnosed
RESULTS with craniosynostosis.
Subjects Visual Diagnoses
Thirty-five charts met the study criteria. The visual diagnoses were
All charts were available for review. The determined by ICD-9 codes
average patient age was 4.4 years (range 5 recorded in the examination
months to 5 years 11 months). Fifty one record. Most patients had
percent (18 patients) were male, 49% (17 multiple diagnostic codes.
patients) were female. We used the first three listed
codes although we did not
Referral Sources differentiate by primary, sec- Figure 2.
Ten patients (28.6%) were referred from ondary or tertiary diagnosis. of VT. Nine patients (26%) successfully
outside of SUNY. Of these, 5 (14.29%) The most frequently diagnosed condition completed the program, as deemed by the
patients were referred from occupational was an oculomotor dysfunction, reported attending staff. Three patients, or slightly
therapists, four (11.43%) patients were in 20% of patients. This diagnosis was over 8%, were referred for surgery. It is
referred by outside optometrists and one followed by constant monocular esotro- possible in these cases that therapy was
patient (2.86%) self-referred specifically pia, in 14.29% of patients and intermit- resumed after surgery was completed, but
for VT. The remaining 25 patients were tent alternating exotropia in 11.43% of any future therapy occurred outside the
referred for VT after having a comprehen- patients. Refractive amblyopia and al- time frame of the study. Two patients (6%)
sive eye examination within the Infant Vi- ternating esotropia were each reported in
were dismissed for behavioral issues. One
sion or Pediatric Clinic at SUNY. 8.57% of the sample. Almost six percent
patient in each category was dismissed
of patients were diagnosed with one of
Entering Symptoms
the following: accommodative esotro- because of insurance issues, scheduling
These were determined by a review of the
pia, intermittent esotropia and constant conflicts, vacation or self-dismissal.
following: a history form completed by alternating exotropia. (Figure 2) The fol- DISCUSSION
the parent/caregiver of the patients who lowing diagnoses were each reported in Gruning notes that most practitioners do
received a comprehensive examination at only one patient: accommodative spasm, not think of VT for young patients, he
SUNY, clinic correspondence and exami- strabismic amblyopia, unspecified eso- presents six arguments why practitioners
nation notes for patients referred by out- tropia, convergence excess and binocular should incorporate it into a VT practice.6
side providers, and/or symptoms reported vision disorder unspecified. In looking These reasons include: it is challenging,
during the initial VT evaluation. The at the diagnoses by category, 20 patients, outcomes are generally very good, early
most common sign/symptom reported (57.14%), were diagnosed as strabismic. intervention may be easier and less costly,
was an eye turn (60%). Tracking problems
Number of Therapy Sessions early application of lenses, prisms or oc-
(11.42%), visual perceptual/motor prob- clusion can be successful, the therapy can
The average number of therapy visits per
lems, distance vision blur and binocular be performed by a therapist and that these
patient was 10 (range 1-36). The patient
problems were each reported in 5.7% of services will be filled by other profes-
who had 36 visits was the patient with the
patients. A complaint of blurry vision and sionals if not done by optometry. He also
craniosynostosis.
reading too close were each reported by notes that the conditions most commonly
one patient (2.86%). Two patients (5.7%) Reasons for Cessation of
Therapy treated include strabismus, amblyopia,
reported no symptoms. (Figure 1) oculomotor and/or visuomotor dysfunc-
Upon ceasing VT, the staff noted the rea-
Ocular History son for stopping. Seventeen patients (49%) tion.6 Early guidance for amblyopic/stra-
did not report a reason for the cessation bismic patients can be an important and

Volume 21/2010/Number3/Page 60 Journal of Behavioral Optometry

valuable component of the total therapeu- Strabismus and amblyopia are problems total sample is because this study was ret-
tic regimen.5 that are found in patients of any age and rospective. Additionally, the sample size
Unfortunately, studies on the efficacy of are often treated more aggressively in of patients was small, with only 35 pa-
VT for this population are lacking. A lit- younger children than older children. De- tients. Future studies should be prospec-
erature search did not reveal prior studies termining the prevalence of amblyopia in tive so that more complete data can be ob-
dealing with the efficacy of VT in young infants, toddlers and preschool children tained and improvement in alignment or
children. There are, however, case reports presents special difficulties because of the visual acuity can be documented.
on this topic.1-3 To our knowledge this re- uncertainty in establishing precise visual Acknowledgement
port is the first to specifically look at pre- acuity measurements in many children of Thanks to Tina Perez at the Harold Kohn
school VT. A prior retrospective study by this age group.7 Prior studies have found a Vision Science Library at SUNY Optom-
Krumholtz and FitzGerald on outcomes in prevalence of 2-3% for amblyopia and 3- etry for her help in obtaining articles.
strabismic patients treated with VT found 4% for strabismus in preschool children.8
a success rate of 36% in patients ages 2 In the current clinical study, almost 60% References
1. FitzGerald DE, Gruning CF. Vision therapy for
to 6.4 The authors defined success as a of patients had a diagnosis of strabismus, a preschool child with acquired accommodative
reduction in the magnitude of the strabis- and 8.75% had a diagnosis of amblyo- esotropia. J Behav Optom 1997;8:59-63.
mus to 8 prism diopters or less. When pia. Certainly the higher percentages of 2. Yang JC, Fitzgerald DE, Gruning CF. Reduction
of anisometropia and amblyopia in a non-fixat-
looking at specific classifications of stra- patients with strabismus and amblyopia ing eye following esotropia surgery and vision
bismus in the 2 to 6 age group, they found reflect the fact that patients were seen in therapy. J Behav Optom 2005;16:125-29.
a success rate of 100% for intermittent a VT clinic, and not as a random sample. 3. Maples WC, Bither M. Treating the trinity of
exotropia patients (N=2), 50% for patients Therefore, this sample cannot be com- infantile vision development: Infantile esotro-
pia, amblyopia, anisometropia. Optom Vis Dev
with accommodative intermittent esotro- pared to prevalence factors of the general 2006;37:123-30.
pia (N=2), and 43% for patients with con- population. The fact that many patients 4. Krumholtz I, Fitzgerald DE. Outcome indicators
stant accommodative esotropia (N=7). It with strabismus were not amblyopic can in a strabismic sample treated by vision therapy.
J Behav Optom 1999;10:143-46.
is important to note that this study looked be attributed to the percentage of patients 5. Sanet LZ. Vision therapy with toddlers: The chal-
at outcomes for all pediatric patients with who were diagnosed with intermittent or lenge and the rewards. Behav Aspects Vis Care
strabismus and was not specific for pre- alternating strabismus. In this study 11 2000;41:28-34.
school children. patients, or 31% of the strabismic patients, 6. Gruning C, FitzGerald DE, Duckman, RH. Vi-
sion therapy for the very young patient. In: Visual
While our study did not specifically look had alternating, intermittent, or intermit- Development, Diagnosis, and Treatment of the
at outcomes of success based on diagno- tent alternating strabismus. Pediatric Patient. Duckman RH, ed. Philadelphia:
sis, sixty percent of the patients in this In the past few years, much has been writ- Lippincott, Williams & Wilkins 2006;393-420.
7. Garzia R. Management of amblyopia in infants,
study initially presented with a complaint ten about the treatment of amblyopia, spe- toddlers and preschool children. Prob Optom
of an eye turn. This percentage corre- cifically with the Ambylopia Treatment 1990;2:438-58.
sponds well with the primary diagnosis Studies.9-12 Although these studies did in- 8. Ciner EB, Schmidt PP, Ore-Bixler D, Dobson
of strabismus in 57 %, or 14 patients who clude patients as young as age 3, they dealt V, et al. Vision screening of preschool children:
Evaluating the past, looking toward the future.
underwent preschool VT. with patching or topical atropine as treat- Optom Vis Sci 1998;75:571-84.
Case reports discussing the optometric ment options. These studies compared the 9. Pediatric Eye Disease Investigator Group. A ran-
treatment of esotropia in preschool chil- efficacy of patching versus atropine, the domized trial of atropine vs. patching regimens
dren can be found in the optometric lit- frequency of patching regimens and the for treatment of moderate amblyopia in children.
Arch Ophthalmol 2002;120:268-78.
erature.1-3 Maples and Bither report on frequency of atropine instillation. They 10. Pediatric Eye Disease Investigator Group. A ran-
the successful treatment of an infantile did not use traditional active in-clinic VT domized trial of patching regimens for treatment
esotrope treated with corrective lenses, as was used in this study. of severe amblyopia in children. Ophthalmol
2003;110:2075-87.
patching, bi-nasal occlusion and 14 weeks In this study, the average number of VT 11. Pediatric Eye Disease Investigator Group. A ran-
of VT.3 After treatment, the patient had a sessions was 10. This is similar to the av- domized trial of atropine regimens for treatment
visual acuity of 20/20 in each eye with- erage number of VT sessions reported in of moderate amblyopia in children. Ophthalmol
out a strabismus. Similarly, FitzGerald studies on adult patients.13,14 2004;111:2076-85.
12. Pediatric Eye Disease Investigator Group. A ran-
and Gruning report on the treatment of a Thus, the present study adds evidence to domized trial of patching regimens for treatment
3 year 3 month old male with accommo- the previously discussed case reports that of moderate amblyopia in children. Arch Oph-
dative esotropia and bilateral amblyopia young children with binocular problems, thalmol 2003;121:603-11.
13. Cohen AH, Soden R. Effectiveness of visual ther-
treated with lenses and occlusion and later especially strabismus, can be enrolled and apy for convergence insufficiencies for an adult
with 10 sessions of preschool VT.1 After can benefit in an in-clinic VT program, population. J Am Optom Assoc 1984;55:491-94.
the completion of therapy, the patient had based upon the clinical opinions of the at- 14. Bodack MI, Vricella M. Vision therapy in an
20/20 vision in each eye and no strabis- tending staff. adult sample. J Behav Optom 2007;18:100-05.
mus. Yang et al reported on the treat- CONCLUSION
ment of esotropia and amblyopia in a 2 The present study about young pediatric Corresponding author:
year old child using lenses, occlusion and Marie I. Bodack, O.D.
VT patients is unique in that it presents
surgery.2 After surgery, the patient had a Cincinnati Childrens Hospital Medical
data that are not previously reported.
consecutive exotropia and amblyopia that Center, MLC 4008, 3333 Burnet Avenue,
Our study can serve as a template for fu- Cincinnati, OH 45229-3039
was treated with in-office VT. After treat- ture investigations of the characteristics of
ment, the visual acuity was 20/25 in each marie_bodack@cchmc.org
pediatric VT patients. However, the in- Date accepted for publication:
eye and the patient was orthophoric in all ability to obtain data in some cases on the
positions of gaze. April 23, 2010

Journal of Behavioral Optometry Volume 21/2010/Number 3/Page 61