Clinical Orthoptics 2019

JOY INSTITUTE
COMPREHENSIVE CLINICAL VISION THERAPY
PRESENTED BY
CENTRE FOR EDUCATION

IN JOINT SPONSORSHIP WITH
FACULTY OF ORTHOPTICS
NIGERIAN POSTGRADUATE
COLLEGE OF
OPTOMETRISTS
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IMPORTANT NOTICE
ALL CURRICULUM MATERIAL PRESENTED IN THIS

BINDER/PACKET IS PROPRIETARY AND CANNOT BE USED
WITHOUT THE WRITTEN PERMISSION OF JOY INSTITUTE.
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YOUR GOAL IN TAKING THIS COURSE_________________

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NIGERIAN POST GRADUATE COLLEGE OF

OPTOMETRISTS
OFFICERS
 Dr. RONALD EYIME

President
 PROF. E. U. IKONNE
Registrar
FACULTY OF ORTHOPTICS/VISION THERAPY
 Dr. EFE ODJMOGHO

Chairman
 Dr. UDO UBANI

Secretary
 Dr. CHIDI EZETOHA

Member
 Dr. CECIL NWAFOR

Member
 Dr. AUGUSTINE .U. AKUNJOBI

Member
 Dr. UZOCHUKWU .C. ARODIOGBU

Member
 Dr. NGOZI J. EZE

Member
 Dr. CHINWENDU U. OGUEJIOFOR

Member
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COMPREHENSIVE CLINICAL ORTHOPTICS/VISION THERAPY
Nigerian Postgraduate College of Optometrists

Clinical Schedule for Residents
MAY 07-11, 2018
Schedule:
MONDAY, MAY 7, 2018
8:30 – 9.30am Welcome (Training Room)
9:30 – 11:00 am Tour of the Facility (Dr. CHINAZA ONWUAGBA )
11:00 – 12:00noon Module One
12:00 – 1:00 pm Lunch (on your own)
1:00 – 2:00 pm Module Two (Training Room)
TUESDAY, MAY 8, 2018

9:30 – 10:15 am Module Three (Training Room)
10:20 – 11:00am Module Three (Training Room)
11:00 – 12:00 noon Module Three (Training Room)
1:30 – 2:30 pm Module Four (Training Room)
2:30 – 4:00 pm Module Four (Training Room)
WEDNESDAY, MAY 9, 2018

8:30 – 9:30 am Module Four (Training Room)
9:30 – 11:00 am Module Four (Training Room)
11:00 – 12:00pm Module Five (Training Room)
THURSDAY, MAY 10, 2018

9:30 – 10:30 am Module Five (Training Room)
10:30 – 12: 00 noon Module Six (Training Room)
1:00 – 2:00 pm Module Six (Training Room)
2:00 – 3:00pm Module Six (Training Room)
3:00 – 4:00pm Module Six (Training Room)
FRIDAY, MAY 11, 2018

9:30 – 10:30 am Vision Therapy Summary Sheet (Training Room)
10:30 – 12:00pm Vision Therapy Summary Sheet (Training Room)
1:00 – 2:00 pm Hands-on (Training Room)
2:00 – 4:00 pm Hands-on (Training Room)
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 Orientation – Dr. CHINAZA ONWUAGBA
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LIST OF RESIDENTS
(1) Dr. ABU LATEEF
(2) Dr. IBHAZE-BAROR JULIET EGHONGHON
(3) Dr. EMUROTU DAFE OGHENEGANGAN
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MISSION STATEMENT
Vision. Joy Institute is a leading resource in Africa on vision

Rehabilitation.
Education. care (vision impairment and vision rehabilitation).
Research. Through its pioneering work in vision, rehabilitation,
Advocacy.
education, research and advocacy,
Joy Institute enables people of all ages who are blind
or partially sighted to lead independent, productive and
happy lives.
Founded in 1997 and headquartered in Port Harcourt,
Rivers State, Nigeria.
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Vision
Therapy
Module I
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MODULE ONE
ORTHOPTICS
1. Orthoptists helps detect and manage Amblyopia.

2. Orthoptists helps detect and manage Strabismus.
3. Orthoptists helps detect and manage Diplopia.
4. Orthoptists measures and improves Binocular Vision Disorders.
5. Orthoptists helps administer Orthoptic Exercises.
6. Orthoptics is a specialized health care profession in Optometry.
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Vision
Therapy
Module II
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MODULE TWO
WHAT IS VISION THERAPY?

Vision therapy is an individualised, supervised, treatment program
designed to correct visual-motor and/or perceptual-cognitive deficiencies.
Vision therapy sessions include procedures designed to enhance the brain’s
ability to control:
Eye Alignment
Eye tracking and Eye Teaming
Eye focusing abilities
Visual processing
Visual-Motor Skills and endurance are developed through the use of
specialized computer and optical devices including therapeutic lenses,
prisms, and filters.
During the final stages of therapy, the patient’s newly acquired visual
skills are reinforced and made automatic through repetition and by
integration with Motor and Cognitive skills.
WHO BENEFITS FROM VISION THERAPY?

Children
And
Adults with visual challenges, such as:
i. Learning – related vision problems
Vision therapy can help those individuals who lack the necessary visual
skills for effective reading, writing and learning (i.e. eye movement and
focusing skills, convergence, eye-hand activity, visual memory skills,
etc).
ii. Poor Binocular (2-eyed) Coordination
Vision therapy helps individuals develop normal coordination and team
work of the two eyes (Binocular vision). When the two eyes fail to work
together as an effective team, performance in many areas can suffer
(Reading, sports, Depth Perception, Eye contact, etc).
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iii. Convergence Insufficiency (Common near Vision disorder)

Recent scientific research- funded by the National Eye Institute and
conducted at Mayo Clinic – has proven that in- Office Vision Therapy
is the best treatment for convergence insufficiency.
iv. Amblyopia (Lazy Eye), Diplopia (Double Vision)and Strabismus
(Cross-Eyed, Wandering Eye, Eye turns, etc)
Vision Therapy programs offer much higher care rates for turned eyes
and for lazy eye when compared to eye surgery, glasses, and/or
patching, without therapy. The earlier the patient receives vision
therapy the better, however, our office successfully treats patients well
past 21 years of age. Recent scientific research has disproven the long
held belief that children with lazy eye, or amblyopia cannot be helped
after age 7.
v. Stress-Related Visual Problems – Blurred Vision, Vision Stress
from Reading and Competence, Eye Strained Stomachaches or
Motion Sickness.
21st century life demands more from our vision than ever before. Many
children and adults constantly use their near vision at school, works
and home. Environmental stresses on the visual system, (including
excessive computer use or close work) can induce blurred vision, eye
strain, headaches, etc.
vi. Visual Rehabilitation for Special Needs- Traumatic Brain Injury
(TBI), Stroke, Birth Injury, Brain Damage, Head Injury, Whiplash,
Cerebral Palsy, MS, etc.
Vision can be compromised as a result of neurological disorders or
trauma to the nervous system. Vision therapy can effectively treat the
visual consequences of brain trauma (including Double Vision).
vii. Visual Rehabilitation for Special Needs -Developmental Delays,
Visual Perceptual, Visual – Motor Deficits, Attention Deficit
Disorders, Autism Spectrum Disorders.
This is beyond this training
viii. Sports Vision Improvement

Strong visual skills are critical to sports success. Not much happens
in sports until your eyes instruct your hands and body as to what to
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do! We can measure and successfully improve Eye-Hand

Coordination, Visual Reaction Time, Peripheral Vision, Eye Focusing,
Eye Tracking and Teaming, Visualization Skills and more.
10 VISION THERAPY ACTIVITIES
1. BROCK STRING
a. White string with red, yellow, green and blue beads.
Patient holds one end at bridge of nose and therapist holds
other end.
b. Look at bead. 40cm away from nose, keep clear, notice the
strings form an “X” that cross at the bead (Physiological
Diplopia).
c. Good for: Eye Teaming, Binocular Awareness
2. VECTOGRAM
a. A transparent polarised stereogram placed in light box or in
free space.
b. Using polarized glasses, stand or sit up straight, notice 3-D
effect when the two transparent cards slide opposite each other
for convergence and divergence.
c. Good for: Eye Teaming, Binocular Awareness, SILO (small in
large out)
3. SPACE FIXATOR
a. A stand with a circular, transparent screen with circular targets
around the border and a central fixation target.
b. Stand in front of space fixator with hands to the side; look at
centre target while noticing the different targets in the
periphery.
c. Use eyes or fingers to touch the peripheral targets while fixating
centrally.
d. Good for: Central and Peripheral/Integration, Eye-Hand Co-
ordination, Body Awareness, Saccades.
4. MENTAL MINUS
a. Using a Minus lens, patch one eye and use the other eye to look
at a target and see if the image changes when the lens is in front
of the eye and when it is taken off.
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b. Good for: Flexibility of Accommodative System, Just Noticeable

Difference.
5. YOKED PRISMS
a. Use 5,10, or 15 prism Dioptre Yoked prisms
b. Put on yoked prism, walk around and describe what is seen,
what things look like around them, Notice Differences with BU,
BD, BL and BR
c. Good for: Just Noticeable Difference, Visual Discrimination,
Spatial Awareness.
6. JND WITH PRISMS AND LENSES
a. Lens sorting: using different powered lenses, ask if the patient
can put the lenses in a particular order, noticing difference each
lens has.
b. Loose Prisms push the image toward the apex-hold the prism
monocularly in front of the patient’s eye, and ask where the
image moves.
c. Good for: Just Noticeable Difference, Visual Discrimination.
7. ECCENTRIC O’S
a. Two circular O’s side by side on a transparent card with a
smaller circle in the middle of each O.
b. Voluntarily cross and relax eye to make a third 3-D image in the
middle.
c. Good for: Vergence Ranges, Spatial Localization.
8. PARQUETRY BLOCKS
a. A set of colourful blocks that helps develop matching and
discrimination abilities using 3-D figures in one-to-one
correspondence.
b. God for: Visual Discrimination, Matching, Spatial Rotations,
Tactile Feedback.
9. AFTER IMAGE
a. Flash an eye with an after image monocularly, have patient look
at an object and notice if the flash is exactly at the point in
which they are fixating.
b. Good for: Fixation, Spatial Awareness
10. NEAR/FAR ACTIVITIES
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a. This includes many activities in which the patient looks from a near
fixation target to a distance target. i.e. Bulls eye, Focus Flex.
b. Good for: Accommodation, Eye Teaming, Fixation.
Vision
Therapy
Module III
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MODULE THREE
FIXATIONS AND HEAD ROTATIONS
MATERIALS – A small hand mirror
PROCEDURE 1: To the Patient: Hold the small hand mirror in front of
you. Look at yourself (in the eyes) in the mirror. Hold this fixation steady for
5 to 10 seconds. Hold the mirror and your fixation steady and slowly move
your head back and forth (like shaking your head “No”), up and down (like
nodding your head “Yes”), circularly, diagonally, and in a random fashion.
The whole time be sure to hold fixation steady by staring your eyes in the
mirror.
PROCEDURE 2: To the assistant: Hold the hand mirror for the patient
and have him proceed as outlined above.
VARIATIONS – Hold your head still and move the mirror while
maintaining fixation by looking at the reflection of your eyes in the mirror.
Vary the speed of head movements while holding the mirror still, or vary the
speed of moving the mirror while holding the head still.
Time – Three to five minutes at least once daily.
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OCULAR PURSUITS
MATERIALS – A small target, e.g. pencil eraser or the tip of a pen.
PROCEDURE 1 – The assistant holds a small target (E.g. tip of pen or
pencil eraser) in front of the patient. The patient is directed to look at and
follow the object with their eyes and while holding their head still. The
assistant moves the object sideways, vertically, diagonally, circularly
(clockwise and counter clockwise), and randomly throughout the patients
field of view.
PROCEDURE 2 – To the patient: extend arm out in front of you with
your hand in a loose fist and your thumb extended up. Look at the smallest
detail you can see on your thumb nail. Now, while continuing to watch your
thumb nail, move your thumb around and follow it with just your eyes.
Move your thumb sideways, vertically, diagonally, circularly (clockwise and
counter clockwise), and randomly.
VARIATIONS – Try varying the speed.
TIME – Five minutes at least once daily.
FIXATIONS
MATERIAL – Circled number pattern sheet, Acetate cover, Crayon or
felt tip pen
PROCEDURE
1. Circled number pattern sheet is inserted in the acetate cover.

2. The patient is instructed to hold his arm with the hand pointing
upward. This is called the “Ready Position.” The patient holds the
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crayon or pen in his dominant hand. Upon the command of the home
assistant the patient looks for the number “one” and touches it with
the crayon. The patient attempts to place the mark directly in the
centre of the circle. After placing the dot, the arm is again positioned
upward in the “ready” position for location of the next number.

3. Continue until all sixteen numbers are located. Accuracy and fluid
movements are encouraged.
VARIATIONS
1. Time the activity and attempt to “beat your time.”

2. Numbers may be called out at random by the home assistant.
3. Repeat the procedure starting backward (from 16 to 1).
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SCANNING
MATERIALS – A table with miscellaneous objects on it and a chair to
sit in.
PROCEDURE:
1. The patient is to sit in the chair at the table

2. Various objects are to be randomly placed on the table in front of the
patient.
3. The assistant is to randomly call out the name of an object.
4. The patient scans with eye movements (minimize head movements)
until he visually locates the object that the assistant called.

5. Repeat for other objects.
VARIATIONS
1. Increase or decrease the number of objects on the table per the ability
level of the patient.

2. Place additional objects in other locations, e.g. on the floor, wall etc.
3. Do the exercise while standing.
TIME – Do at least ten minutes two or three times daily.
SCANNING WITH TACTILE REINFORCEMENT
MATERIALS – A table with miscellaneous objects on it and a chair to
sit in.
PROCEDURE
1. The patient is to sit in the chair at the table.
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2. Various objects are to be randomly placed on the table in front of the
patient.
3. The patient is to briefly scan the table to view the location of the
objects.
4. The assistant is to randomly call out the name of an object.
5. The patient either closes their eyes, or looks away and reaches out to
grasp the object that was called.

6. Once grasped, they are to identify the object by touch without looking
at the object.
7. The patient is then to look at the object and verify accuracy.
8. Repeat for other objects.
VARIATIONS
1. Increase or decrease the number of objects on the table per the ability
level of the patient.

2. Place additional objects in other locations, e.g. on the floor, wall etc.
3. Do the exercise while standing
TIME – Do at least ten minutes, two to three times daily.
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OCULAR SACCADES
MATERIALS – Two small fixation targets
PROCEDURE 1 – To the assistant: Hold two different small objects 16
to 18 inches in front of the patient and about twelve inches apart. Instruct
the patient to look first at one object and then the other. The patient is to
move just their eyes and hold their head still. Instruct them to continue
looking back and forth between the two objects. Do at least twenty times.
Repeat the exercise again except change the following:
1. Hold the objects vertically

2. Hold the objects diagonally
3. Vary the distance between the objects
4. Move the objects around to different position while the patient looks
back and forth between them.
PROCEDURE 2 – To the patient: Extend your arms in front of you
approximately twelve inches apart. Make a loose fist with each hand and
have your thumbs pointing upward.
Begin looking at the smallest detail you can see on one thumb nail. Out of
the corner of your eye, see your other thumb nail. Now look at your other
thumb nail (again at the smallest detail possible). Continue, look back and
forth between your thumbs. Do this at least twenty times.
Repeat the exercise again except change the following:
1. Hold the objects vertically

2. Hold the objects diagonally
3. Vary the distance between your thumbs
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4. Move the objects around to different positions while the patient looks
back and forth between them.
TIME: Five minutes at least once daily.
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MARBLE IN THE CUP
MATERIAL:
Marble and two small plastic cups. Best done on a hard floor.
PROCEDURE:
The patient and assistant sit on the floor at least six feet apart. A
marble is placed under the assistant’s cup and rolled with a flip of the cup
to the patient, who catches it by slamming his cup down over it. The patient
returns the marble to the assistants in the like manner and the game
continues for approximately 21/2 minutes. Then the cup is switched to the
other hand and the activity is repeated. There should be two more changes
in the ten minutes.
VARIATIONS
The exercise may be slow or fast, depending on the skill of the patient.
A ball maybe substituted for the marble to decrease the difficulty. The
distance may be increased or decreased to meet the patient’s ability.
PENCIL PUSH-UPS
MATERIALS – A Pencil, small fixation target, or pen light
PROCEDURE – Hold the fixation target at arm’s length. If using a
pencil, hold with the eraser end up. The patient is directed to look at the
eraser of the pencil, or at the tip of the fixation target. The target is slowly
moved closer in towards the patient, along the midline, while they maintain
fixation on it. Stop when the target begins to double, or the observer notes
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that one or both of the patient’s eyes have turned out and are no longer
tracking the target. If this happens, move the targets back a small amount
until it is clear and single again. Hold fixation and slowly move the target
back out to arm’s length. The goal is to be able to converge and hold fixation
on the target up to within one inch of the nose.
VARIATIONS – If the patient is unable to do the exercise as above,
they can try using a larger target, or touching or holding the fixation target.
When the above exercise is mastered, try moving the object a few inches off
the midline above, below and to the side.
NOTE – some degree of eye strain may be experienced during this exercise.
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POINTER IN THE STRAW
MATERIALS: A soda straw (with coloured stripes) and a pointer
PROCEDURE: The patient is to sit in front of the assistant and hold
the pointer in their dominant hand and then holds the straw in various
positions and orientations in front of the patient. The patient is instructed to
first carefully fixate the opening of the straw and then to place the pointer
into the opening of the straw. After each try, the patient should bring their
hand back to a resting position before repeating the task. After each attempt
by the patient to place the pointer in the straw, the assistant should move
the straw to a new location.
VARIATIONS: Have the patient use their non-dominant hand, or do
the exercise while standing.
TIME: Five minutes at least once daily.
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LETTER DOTTING
MATERIAL: Felt tip pen, sheet of newspaper.
PROCEDURE:
1. Sit comfortably and with good posture at a desk. Cover one eye with
the patch.
2. Dot and say out loud the first and last letter of every word.
VARIATIONS:
1. The doctor may recommend using an eye patch so that you can do
this exercise with one eye at a time.

2. Use your non-dominant hand to dot.
TIME: Three to four minutes per eye each day.
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VISUAL RECALL AND PROJECTION ACCURACY
MATERIALS: Bean Bags, 3”by 3”pieces of paper with numbers on
them.
PROCEDURE – Place the targets on a wall in a random fashion. The
patient is instructed to look at the targets. As soon as possible after viewing
and scanning the targets the patient should close their eyes. Now the
patient is instructed to try to visualize the location of the targets. The
assistant randomly calls out a target and the patient is to throw a bean bag
at the target. Immediately after the toss leaves the patient’s hand, have them
open their eyes to check accuracy.
GOAL – to increase the accuracy of your visualization skills.
VARIATIONS:
– Decrease your time to look at the targets before closing your eyes.
– Vary the location of the targets
– Instead of throwing, walk up and touch the targets (with your eyes
still closed).
– Point to all the targets keeping your eyes closed the entire time.
TIME – five minutes at least once daily.
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NEAR-FAR JUMP DUCTIONS
MATERIALS – Near and far letter or Harrison charts.
PROCEDURE – place the distance chart on a wall at eye level and
fifteen to twenty feet away from you. Hold the near chart below eye level and
sixteen inches away from you. Call out the whole first row of letters on the
distance chart. Now shift your gaze to the near chart and call out the second
row of letters on it. Continue in this manner through rows three, four etc
until you have completed the whole chart.
When you have mastered the above, repeat the exercise except with
the following changes:
1. Alternate letters instead of whole rows. Call out the first letter of the
far chart, then the first letter of the near chart, then the second letter
at far, then the second letter at near etc. Proceed in this manner
through all the rows of the charts.

2. Alternate letters within the rows. Call out the first letter at far, then
the second letter at near, then the third letter at far, then the fourth
letter at near etc. Continue in this fashion through all the rows of the
charts.
TIME – Do the charts at least once daily.
NOTE – If you begin to memorize the charts, turn them sideways or upside
down.
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Vision
Therapy
Module IV
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MODULE FOUR
HTS COMPUTERIZED HOME THERAPY SYSTEM
1. Pursuits
2. Saccadic
3. Accommodative Rock
4. Vergence (Base In)
5. Vergence (Base Out)
6. Vergence (Base up)
7. Autoslide Vergence
8. Jump Duction
9. Vergence (Base Down)
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PURSUITS
About pursuits
Pursuit exercise are designed to improve smooth eye movement or
tracking skills. These are the movements your eyes make, for example, when
following a ball in play or someone watching an object moving by you.
Improving your ability to accurately and comfortably follow an object
without being distracted can improve attention and eye-hand coordination.
It can also reduce eye stress, and of course, eye fatigue.
Instructions
i. Begin the procedure by clicking on “RUN” you will be required to
respond to the movement of a floating “E”. Its your task to use the
arrow keys on your keyboard to in dicate the direction the floating
“E” is facing. Respond as accurately and rapidly as possible.
Glasses
You should not wear the Red/Blue glasses unless assigned by your
Doctor.
Session
This is the number of times you have completed the procedure.
Duration
The amount of time in minutes the procedure will last. In manual
mode you may click on the left or right arrow to select the desired time. If
you re in Auto mode the time is preset.
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Target speed
This will change the speed of the floating “E”, four speed are available
if you are in the manual mode, clicking on the left or right arrow will
decrease or increase the speed.
Graph
Percentage correct – larger n umber indicate better performance, the
goal is 80% Average Response time – smaller numbers indicate better
performance, the goal is 95 sec or less.
Stars
If you are Auto mode, each time you meet the assigned criteria you
will receive a gold star. When all the stars are gold you have mastered the
procedure and it will no longer be presented in your daily assignment.
Viewing Distance
The distance from your eyes to the monitor screen should always be
the inches.
Display
Pressing the “D” key on the keyboard will toggle the on/off readout
results displayed at the bottom of the screen.
Pause/Resume
Press the “P” to pause the procedure. Press “P” again to Resume.
Quit
Pressing the “ESC” key will terminate the session and not record any
data from the session otherwise, this exercise will end when the preset
duration has elapsed.
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SACCADIC
About Saccadic
Saccadic functions are eye movements made between two points or
objects. These saccadic fixations are important while reading. Inaccurate
saccadic movements may inhibit reading efficiency or cause you to
frequently lose your place.
Instructions
Begin the procedure by clicking on “RUN” you will you will see an
arrow inside a box. Its your task to use the arrow keys on your keyboard,
tin indicate the direction the arrow on the screen is pointing. Respond as
accurately and rapidly as possible. After each response the arrow will
randomly move to a different location on the screen. The goal of this
procedure is to improve both speed and accurately.
Session
This is the number of times you have performed the procedure.
Duration
Graph/Goals
Percentage correct – larger n umber indicate better performance, the
goal is 80% Average Response time – smaller numbers indicate better
performance. The average response time goal is 95 sec or less.
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Stars
If you are Auto mode, each time you meet the assigned criteria you
Viewing Distance
the inches.
Glasses
Doctor.
Viewing distance
16 inches.
Display
Pause/Resume
Quit
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ACCOMMODATIVE ROCK
About Accommodative Rock
Accommodative Rock relates to how quickly you focus your eyes when
looking from something close to something in the distance. To accomplish
this, the muscles in the eyes change to the shape of the lens. However, this
muscles system was not designed to sustain focus on a set distance over
long periods of time as we do when working at a computer or reading. When
held in such sustained focus, the eye muscles frequently become tired and
irritated. Over a period of time, the ability to focus quickly from near to far
may become impaired. This leads to temporarily blurred vision when you
look up from reading or away from the computer. Other symptoms include
headaches, loss of concentration, and feeling sleepy a lot. This is why it is
always recommended, while reading or doing anything that requires you to
focus your eyes on something closed for long periods of time, to look up and
into the distance now and then. This allows your eyes to stretch their
muscles”.
Instructions
Begin this procedure by clicking on “RUN”. Be sure to wear the
Red/Blue glasses. You will also use special flipper lenses. Hold the flipper
horizontally, in your left hand and in front of your Red/Blue glasses with
the Flipper lever called for towards your face. The flipper level appears on
the lower left corner of the accommodations Rock preview screen and is
printed in the center of the flipper lenses are clean and free of fingerprints.
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You will see four Red squares. In each square there is a small letter
“C”. the “E” swill be facing either Left, Right, Up or Down. Using the arrow
keys on your keyboard, respond as quickly as you can, to match the
direction the letter “C” is facing to the Right press the Right arrow key. If the
letter “C” is facing up press the up arrow key. Always respond to the left –
hand first, just as when reading. After each response a box will disappear,
four blue boxes will appear. Again, respond to the direction, the letter “E” is
facing with the arrow keys on your keyboard.
Glasses
You should wear the Red/Blue glasses
Session
Duration
Flipper Level
The flipper level number for each step of the procedure will flash on
the lower left corners of the menu screen.
Graph/Goals
Percentage correct Left and Right – larger number indicate better
performance. The goal is 80%. Cycles per minute – larger numbers indicate
better performance. The goal is 13 CPM.
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Stars
If you are in Auto mode, each time you meet the assigned criteria you
Viewing distance
16 inches.
Glasses
Doctor.
Display
Pause/Resume
Quit
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VERGENCE (BASE IN)
About Vergence Base-In
Vergence relates to eye teaming skills, or the ability to turn your eyes
in and out together. Since you have two eyes, they both need to aim
accurately at what you are viewing. Otherwise you will have double vision.
When you are viewing an object close up, such as a book, your eyes turn
into converge on the words on the page. Sometimes due to poor eye muscle
coordination, the eyes may tend to aim to close (esophoeria), or two high
(hyperphoria). Improper or strained convergence is one of the most common
causes of eyestrain and headaches and is not correctable with glasses alone.
This procedure is designed to improve overall eye muscle coordination,
helping the eye muscles to work more efficiently together. It uses random
dot stereograms (RDSS). These are large squares, Made up of Red and Blue
dots, which contain a small stereo-square which appears to pop out of the
screen. The small square can be seen only when wearing the Red/Blue
glasses and when your eyes are properly aligned.
Instructions
Begin the procedure by clicking on “RUN” your eyes must turn out in
order to make correct responses.
 Mode: Classic/Spaceship/Clicker
 Classic Mode:
In Classic Mode, your task is to respond with the arrow keys on your
keyboard to the position of the small squares that is popping out from
the screen. It is located more to the top, bottom, left or right of the
letter inside the large square. Use the arrow keys to indicate the
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position of the small square relative to its position inside the large
square. (i.e., if the small square is above the letter, press the up arrow
key etc). Respond as rapidly as possible. After each response, the
small square moves inside the larger square to a new random location
if the response is correct the computer will “beep” and the Vergence
demand will decrease slightly. If the response is incorrect computer
will “boop” and the Vergence demand will decrease slightly. The
computer allows you eight seconds the respond. If no response is
Made the computer notes it is as an error and decreases the Vergence
demand. Relax your eyes, in order to keep the target single. The first
time you run this procedure, it would take up to a minute for your
eyes to discern the small squares popping out from the screen. This is
not unusual. Relax and let your eyes diverge and search the four
corners of the large square. Look for anything that appears different,
and even guess if necessary. Once you are finally able to see the
stereo square, the next time you begin the procedure you will be able
locate it easily. You may select either the large targets or the small
targets according to your doctor’s instructions.
 Spaceship Mode
Places the small stereo target in the upper half of the large stereogram
and requires you to “hit” the small stereo target before it reaches the
bottom of the large stereogram. Use the mouse to move the “space
ship” located below the stereogram. When the spaceship is in line with
the small stereo target, press the left mouse button to lunch a missile
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at the target. If the target is hit by the missiles, Vergence demand will
increase and a new stereo target will pop up.

 For spaceship mode, it is recommended that you should not
decrease the duration from the original minimum setting to
allow enough time to complete the level.

 Note: The small target is not available in spaceship mode.
 Clicker Mode
Places the small stereo target randomly within the stereogram. Use
the mouse to move the “swatter” over the target and click the left
mouse button to “swat” the target. Correctly swatting the target
increases Vergence demand and missing the target decreases
Vergence demand. If the target is not swatted after Eight Seconds, it
will be marked as missed and Vergence demand will decrease.

 Note: The small target is not available in clicker mode.
As you make responses, at some point, you will no longer be able to see the
small stereo square popping out of the screen. This is normal! When this
occurs, press the spacebar one time. Try for 2 or 3 seconds to see the
stereo square again. If you still cannot see the stereo square, press the
space bar again. Repeat this process until you are able to see the stereo
square again and then begin responding to its location.
Session
Duration
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Target Size
If in Manual Mode begin with a large target. When you achieve criteria
i.e. BI 13, switch to the small target by clicking on “Small”. In the Auto Mode
no adjustment is necessary.
Graph/Goals
Larger numbers indicate better performance. The goal is 13BI.
Stars
If you are using the program in the Auto mode you will notice a series
of empty stars on the menu for each procedure. You will receive a golden
star every time you accomplish your session goal. Collect all the golden stars
to advance to the next procedure.
Glasses
You should not wear the Red/Blue glasses.
Viewing Distance
16 inches.
Sound Sets
For spaceship and clicker Mode, there are four possible sound sets
that can be selected before staring the Vergence exercise.
Display
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Pause/Resume
Quit
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VERGENCE (BASE OUT)
About Vergence Base Out
Vergence relates to eye teaming skills, or the ability to turn your eyes
in and out together. Since you have two eyes, they both need to aim
accurately at what you are viewing, otherwise you will have double vision.
When you are viewing an object close up, such as book your eyes turn into
coverage on the words on the page. Sometimes due to poor eye muscle
coordination, the eyes may tend to aim too close (esophoria), too far apart
(exophoria), or too high (hyperphonia). Improper or strained convergence is
one of the most common causes of eyestrain and headaches, and is not
correctable with glasses alone.
The procedure is designed to improve over all eye muscle coordination
helping the eye muscles to work more efficiently together. It uses random
dot stereograms (RDSs). These are large squares made up of Red and Blue
Dots, which contain a small stereo square which appears to can be seen
only when wearing the Red/Blue glasses and when your eyes are properly
aligned.
Instruction
Begin the procedure by clicking on “RUN” your eyes must turn out in
order to make correct response.
Mode
Classic/Spaceship/Clicker
 Classic Mode
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In Classic Mode, your task is to respond with the arrow keys on your
keyboard to the position of the small squares that is popping out from
the screen. It is located more to the top, bottom, left or right of the
letter inside the large square. Use the arrow keys to indicate the
position of the small square relative to its position inside the large
square. (i.e., if the small square is above the letter, press the up arrow
key etc). Respond as rapidly as possible. After each response, the
small square moves inside the larger square to a new random
location, if the response ids correct the computer will “beep” and the
Vergence demand will increase slightly. If the response is incorrect
the computer will “boop” and the Vergence demand will decrease
slightly. The computer allows you eight seconds to respond. If no
response is made the computer notes it as an error and decreases the
Vergence demand.
Relax or converge your eyes, in order to keep the target single. Relax
and let your eyes converge and search four corners of the large
square.
 Spaceship Mode
Places the small stereo target in the upper half of the large stereogram
and requires you to “hit” the small stereo target before it reaches the
bottom of the large stereogram. Use the mouse to move the “space
ship” located below the stereogram. When the spaceship is in line with
the small stereo target, press the left mouse button to lunch a missile
at the target. If the target is hit by the missiles, Vergence demand will
increase and a new stereo target will pop up.
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 For spaceship mode, it is recommended that you should not
decrease the duration from the original minimum setting to
allow enough time to complete the level.

 Note: The small target is not available in spaceship mode.
 Clicker Mode
Places the small stereo target randomly within the stereogram. Use
the mouse to move the “swatter” over the target and click the left
mouse button to “swat” the target. Correctly swatting the target
increases Vergence demand and missing the target decreases
Vergence demand. If the target is not swatted after Eight Seconds, it
will be marked as missed and Vergence demand will decrease.

 Note: The small target is not available in clicker mode.
As you make responses, at some point, you will no longer be able to see the
small stereo square popping out of the screen. This is normal! When this
occurs, press the spacebar one time. Try for 2 or 3 seconds to see the
stereo square again. If you still cannot see the stereo square, press the
space bar again. Repeat this process until you are able to see the stereo
square again and then begin responding to its location.
Session
Duration
Target Size
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If in Manual Mode begin with a large target. When you achieve criteria
i.e. BO 13, switch to the small target by clicking on “Small”. In the Auto
Mode no adjustment is necessary.
Graph/Goals
Larger numbers indicate better performance. The goal is 35 BO.
Stars
If you are using the program in the Auto mode you will notice a series
of empty stars on the menu for each procedure. You will receive a golden
star everytime you accomplish your session goal. Collect all the golden stars
to advance to the next procedure.
Glasses
You should not wear the Red/Blue glasses.
Viewing distance
16 inches.
Sound Sets
For spaceship and clicker Mode, there are four possible sound sets
that can be selected before staring the Vergence exercise.
Display
Pause/Resume
Quit
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Vision
Therapy
Module V
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GROSS MOTOR SKILLS ACTIVITIES
BILATERAL WALKING
MAIN FOCUS: To enhance bilaterality and gross motor control. To provide

stimulation to both sides of the brain. In addition, to enhance body and
spatial awareness.
MATERIALS NEEDED: Patch, Lenses, Prisms, Filters, Letter/Symbol chart
BASIC PROCEDURE:
1. The patient is to walk on the floor using opposite arm and foot
combination one step uses right arm-left foot or left arm-right foot.
2. Patient should be standing on floor with feet lined up heel-toe (one foot iii
front of the other).
3. Have patient walk forward across room.
4. Once patient is able to handle walking forward, introduce him to walking
backwards — still using opposite foot and arm combination.
WHAT YOU SHOULD LOOK FOR: patient being able to walk across room
freely and with control with head up and eyes looking straight ahead
EARLY STAGES OF LOADING
1. Place patch on one of patient’s eyes and see if patient can read
letter/symbol chart while walking patient should say one letter/symbol
per step. This can be a good way of building an accommodative range
2. Can patient perform higher-level saccadic eye movements (specified
columns or rows) while walking?
3. Can patient spell a word or perform a math problem while walking?
GROSS MOTOR TRAINING (ADVANCED)
1. Place patient on balance beam (walking rail) while walking opposite foot
and arm.
2. While patient is walking, have him aim a flashlight at opposite foot and
name the foot at which he is aiming.
3. Have the patient touch the opposite toe with a, yardstick or dowel, while
walking. .
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VISUAL-AUDITORY INTEGRATION TRAINING
Add Metronome — have patient walk with one step per beat of the
metronone.
ANTISUPPRESSION TRAINING
1. Use an Anti-Suppression Letter/Symbol Chart (one printed in Red/Green

Anaglyphic colors) while the patient wears Red/Green Anaglyphic
glasses,
2. Use Disassociated prism while patient is walking towards a visually
stimulating object (a favorite toy, letter/symbol chart, etc.). Does patient
se more than just one object?
BINOCULAR VERGENCE TRAINING
1) Use prism in any orientation
a) Base-Out/Base-in - Does patient see size/spatial shift’? Can patient

maintain one image of each target? Does patient fatigue?
b) Bases-Up/Bases-Down- Does patient see size/spatial shift? Due
fatigue Can patient maintain balance? Does patient feel if he is
walking uphill or downhill uphill or downhill?
c) Bases-Right/Bases-Left – Does patient see size/spatial shift? Does
patient fatigue? Can patient maintain balance? Is patient
leaning/walking more to the right or left?
ACCOMMODATIVE TRAINING
Use plus/minus lenses – Does patient see size/spatial shift? Can patient
maintain clarity? Does patient fatigue?
VISUAL PERCEPTION/VISUALIZATION
1) Have patient estimate the number of evenly spaced steps it will take him
to cross room/reach end of walking rail, etc.
2) Can patient adjust his steps to cross room in a specified number of steps
you (the therapist) requests?
LATTER STAGES OF LOADING.
1) Combining the above loading demand levels. .
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a) For example, can the patient read an anti-suppression letter/symbol

change with Red/Green Anaglyphic glasses to the beat of the metronome
while walking on the balance beam and wearing Bases-Right/Left prisms.
UNLOADING
1) If starting at the basic procedure, does patient need a sticker on his

opposite hand/foot to help him organize the opposing, arm/foot pattern?
2) Perhaps it is best to work on walking forward for the time being.
3) Could you decrease the amount of time you have the patient walk’?
4) Could you try a larger size target for patient to read?
5) If performing activity with patient on a balance beam, would it be better
be allow patient to walk on a length of yarn/masking tape on the floor
first to build up to a balance beam?
6) Does the patient need his Rx?
7) Could more plus or minus help?
8) Could prism be helpful?
9) Decide if this is the right activity for your patient
WHAT THERAPIST SHOULD OBSERVE:
1) Can the patient maintain the opposite arm/foot organization?
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OCULAR MOTOR SKILLS ACTIVITIES
COLOR JUMPS
MAIN FOCUS: To develop saccadie eye movement control.
MATERIALS NEEDED: Two colored objects (markers, pencil topper, etc.),

and a tool (patch, lenses, and prisms).
BASIC PROCEDURE:
1) While patient is seated, have patient face you.

2) Place patch on patient’s eye.
3) Hold both markers at reading distance from patient — one in your left
hand, one in your right hand about lO”-12” apart. .
4) Instruct patient that he can only look at the color you say — he must
stay on that color until instructed otherwise.
5) Tell patient which color to look at.
6) Perform until you can evaluate performance of that eye.
7) Repeat procedure with other eye:
WHAT YOU SHOULD LOOK FOR:
An accurate, controlled eye movement to target. The ability to maintain

fixation on target until instructed to look elsewhere.
EARLY STAGES OF LOADING:
1) Rather than monocular — go to binocular (remove patch).

2) Vary speed of patient switching fixation — Have him maintain fixation for
longer periods of time.
3) Add cognition — see if patient can answer simple questions, spell or do a
math question while performing task.
4) Add movement to one or both targets — see if patient can resist
temptation to move eyes to the target in motion until instructed.
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GROSS MOTOR TRAINING
Add Balance — see if patient can perform the task while balancing on
balance board/beam, heel-toe or one-foot.
Add Metronome — have patient shift fixation to the beat of the metronome.
ANT-SUPPRESSION TRAINING
Use Vertical Disassociated prism — Does patient see four targets? Can
patient shift fixation between the four?
Use prism in any orientation
a. Base-Out/Base-in - Does patient see size/spatial shift? Can patient

maintain one image of each target? Does patient fatigue? Can patient
maintain balance?
b. Bases-Up/Bases Down - Does patient see size/spatial shift? Does
patient fatigue? Can patient maintain balance? Is patient more on his
heels or toes (leaning forward or backward)?
c. Bases-Right/Bases-Left — Does patient see size/spatial shift? Does
patient fatigue? Can patient maintain balance? Is patient leaning
more right or left?
1) Use plus/minus lenses — Does patient see size/spatial shift? Can
patient maintain clarity? Does patient fatigue?
LATTER STAGES OF LOADING:

1) Combining the above loading demand levels.
a. For example, can the patient maintain balance, shift fixation, with
cognition, to the beat of the metronome while wearing disassociated
vertical prisms?
b. See what you can dream up!
UNLOADING:
1) If starting at basic procedure, does patient need his Rx to help him?
2) Perhaps it is best to allow the patient to touch target with his finger.
3) Could you decrease the amount of time you wait before instructing
patient to move his eyes again (decrease the amount of time he has to
maintain fixation)?
4) Could you try a larger target?
5) Could you adjust the amount of space between the targets (place them
closer to each other)?
6) Could you adjust the amount of space between you and the patient
(get closer or further from patient)?
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1) Are the patient’s eyes accurate?
2) Does the patient show signs of stress or fatigue (i.e., watery eyes,
holding their breath or headaches)?
3) Is there excessive head/body movement?
4) Does the patient perform the activity with ease?
5) Can the patient feel what his eyes are doing?
6) Is the patient fusing/suppressing (if you are performing this activity
in a biocular or binocular fashion)?
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ACCOMMODATIVE SKILLS ACTIVITIES
ACCOMMODATIVE FLIPPER LENS ROCK
MAIN FOCUS: To build accommodative stamina and flexibility.
MATERIALS NEEDED: A chart with letters/symbols/numbers on it (either

a large chart for distance work or a small chart for near work), Lens
Flippers, prisms, filters, and a patch.
BASIC PROCEDURE:
1. Place patch on one of patient’s eyes.
2. Depending on chart you are using, place patient at appropriate
training distance for patient.
3. The doctor will prescribe the appropriate Lens Flipper power to use
with patient for the given chart.
4. Patient will hold Lens Flipper over eye(s) and look through lenses on
one side of flipper bar.
5. Have patient read a character/line through one lens, then the patient
will flip the flipper over and read the next character/line once patient
clears lens.
6. Continue until satisfied with performance.
7. Switch patch and perform with other eye.
WHAT YOU SHOULD LOOK FOR: The patient should be able to shift focus
between each lens quickly. Monitor patient’s stamina (length of time
he can perform activity before fatigue sets in). Patient should not
adjust body posture in order to clear the lens.

1) Remove patch and perform binocularly

1) Add Balance — see if patient can flip the flipper and read chart while
balancing on balance board/beam, heel-toe or one-foot
VISUAL-AUDITORY IINTEGRATION TRAINING
1) Add Metronome — have patient flip the flipper to the beat of the
metronome and read the characters.
ANTI-SUPPRESSION TRAINING
1) Use an Anti-Suppression Chart (one that cancels with Red/Green
Anaglyphic Filters). Place Red/Green Anaglyphic Filters over patient’s
eyes, then have patient read character/line with flipper then flip to
other side of flipper bar and clear that side. Continue flipping flipper
and reading chart until satisfied with performance.
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1) Take a Prism Flipper bar and place it so the Base-Out Prisms are
aligned with the Plus Lenses of the Lens Flipper Bar and the Base-In
Prisms are aligned with the Minus Lenses of the Lens Flipper Bar. Use
a rubber band or scotch tape to hold the two flippers together in this
fashion.
a. Have patient read a character/line of chart, then flip to the other side
of the flipper bar and clear that side. Continue flipping flipper and
reading chart until satisfied with performance.
2) Have patient wear prisms in ally orientation
a. Base-Out/Base-In - Does patient see size/spatial shift? Can patient
maintain balance?
b. Bases-Up/Bases-Down - Does patient see size/spatial shift? Does
patient fatigue? Can patient maintain balance? Is patient more on
his/her heels or toes (leaning forward or backward)?
c. Bass-Right/Bases-Left — Does patient see size/spatial shift? Does
more right or left?

a) For example, can the patient maintain balance; clear each side of the
flipper with a prism flipper attached to it, to the beat of the
metronome?
b) See what you can dream up!
UNLOADING:
1) If starting at basic procedure, does patient need his Rx to help him?
2) If the patient does not have the fine motor control to flip the flipper,
could you (therapist/parent) flip the flipper?
3) Could you decrease the amount of time you have the patient perform
this activity?
4) Could you try a larger target?
5) Could you try a lower lens power?
6) Could you adjust the amount of space between the patient and the
chart (get closer or further from patient)?
8) Could prism be helpful? For example, could you use a prism flipper
attached to the lens flipper in this fashion — Base-In Prism aligned
with the Plus Lenses of the Lens Flipper and Base-Out Prism aligned
with the Minus Lenses of the Lens Flipper?

holding his breath or headaches)?
3) Does the patient experience diplopia?
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7) Is the patient fusing/suppressing (if you are performing this activity in
a biocular or binocular fashion)?
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BINOCULAR VISION SKILLS ACTIVITIES
BROCKSTRING
(Beads and Sting)
MAIN FOCUS: To enhance binocular Vision skills.
MATERIALS NEEDED: A white colored string (any length that allows your
patient a range of focus is fine a 10’ length is usually standard) beads (or
put lots into your string at various intervals to be used as a focus target),
patches, lenses, prisms, and filters.
BASIC PROCEDURE:
1) Patient may be seated or standing without a patch over his eye.
2) Have patient hold one end of string to the tip of his nose. The other
end of the string can be tied to a doorknob Have the string taut
between the patient and the doorknob
3) Instruct patient to look a bead. Ask patient, “at do you see?”
4) Wait for feedback from the patient. If the feedback is satisfactory move
to a new focal target on the string and check for correct response.
Continue procedure until you are satisfied with patient performance

1) We Should Probably re-state this to “What you should hear.”
2) The patient should report seeing two strings which intersect at the
bead you asked him to observe. It should appear to be a giant “X” with
the intersection at the bead.
3) You should see both of the patient’s eyes pointing at the bead you
requested (this is tougher as the patient focuses further down the
string).
4) The patient’s head should be level (i.e., not tilted or turned).

1) Untie string from doorknob and hold it in your hand, then begin to
slowly move the string into different positions of gaze as patient shifts
focus from bead to bead.
2) Have patient spell a word or answer questions while shifting from
bead to bead.
3) Have patient “slide” eyes from far point to near point and back again
slowly and smoothly with control (almost like he is watching a lady-
bug walk up and down the string).
1) Add Balance — see if patient can shift focus from bead to bead while
balancing on balance board/beam, heel-toe or one-foot.
2) Have patient fully extend his free arm up overhead with index finger
pointing to the ceiling, while looking at near-point bead, can patient
quickly lower arm to touch bead accurately with index finger?
a. Try with arm extended to the side.
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b. Try with arm alongside patient’s body, have patient raise arm quickly
to touch the underside of the bead accurately.
c. For any bead beyond arm’s length, give patient a yardstick and have
him touch the bead with the tip of the corner of the yardstick.
VISUAL AUDITORY INTEGRATION TRAINING
1) Add Metronome — have patient shift focus from bead to bead to the
beat of the metronome.
BINOCULAR VERGENCE TRAINING (ADVANCED)

1) Place an appropriately sized letter on a bead(s) and have patient use a
prism flipper Base-Out/Base-in
a. Can patient see size/spatial shift?
b. Can patient shift intersection point of string to the bead?
c. Can patient achieve clarity of the letter?
d. Does patient fatigue?
1) Place an appropriately sized letter on a bead(s) and have patient use a
lens flipper plus/minus.
a. Does patient see size/spatial shift?
b. Can patient maintain clarity?
c. Can patient keep intersection of strings at the bead?
d. Does patient fatigue?
2) Put a distant letter chart on door, just above the doorknob the string
is tied to, have patient focus from a bead to the chart and read chart.
SPORTS VISION
1) Use two brockstrings.
2) Have patient stand in a batter’s stance.
3) Have patient hold both strings to his nose.
4) Extend one string that approximately follows the trajectory of patient’s
forward shoulder.
5) Extend the other string approximately 450 from that towards the
bat’s side of patient’s body.
a. For example, a right-hand batter will have a string going from his
nose toward an imaginary pitcher’s mound, and one toward the 18t
base line.
b. A left-handed batter will have a string going from his nose toward an
imaginary pitcher’s mound, and one toward the 3rd base line.
6) Adjust the beads on the strings to desired distances.
7) You may need to adjust angles of string because each patient will have
a different sized nose which may block part of the image, so have the
patient shift eyes from one brockstring to the other to ensure he can
achieve correct response at each bead.
8) Once strings are adjusted to your desired angles and heights (because
you could have one string higher and one lower if you wish), have
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patient shift focus from bead to bead, string to string, etc., as quickly
as possible.

a) For example, can the patient maintain balance, shift fixation, with
cognition, to the beat of the metronome while flipping a Prism Flipper?
UNLOADING:
1) If patient cannot maintain proper seated posture, have the patient lie
on his back on the floor. Hold the string above him, while he holds the
other end of the string to his nose. NOTE: Make knots in the string to
prevent the beads from sliding down the string to the patient face.
2) If starting at basic procedure, we need to know the feedback the patient
provided in order to know what is going on.
a. If Patient reports seeing only one string, you need to determine which eye
is suppressing (see the diagram).
i. If the patient is suppressing
1. Does patient need his Rx to help him?

2. If the patient blinks his eyes, does this help him?
3. Does tapping the corner of the suppressing eye help?
4. Does the introduction of plus/minus lenses help?
5. Does the introduction of prism help?
6. Does having the patient stand balanced on two feet help?
7. Does jiggling the string help?.
8. Does touching the string/bead help?
9. Put Red/Green Anaglyphic glasses on the patient, so one eye sees a
Red string and one eye a Green string, does this help the patient?
10. Decide if this is the right activity for this patient?
ii. If the patient reports seeing two strings which intersect in front (on
the patient’s side) of the string — this indicates over convergence.
1. Does the patient need his Rx to help?
2. Does the introduction of plus lenses help?
3. Have the patient focus on something past the bead (like your finger
touching the string a few inches beyond the bead), does this help
move the intersection point to the bead?
4. Do you need to use a shorter range (i.e., work in a range nearer to
him)?
5. Decide if this is the correct activity for this patient.
iii. If the patient reports seeing two strings which intersect behind (on the
doorknob’s side of the string) — this indicates under convergence.
2. Does the introduction of minus lenses help?
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3. Have the patient focus on something in front of the bead (like your
finger touching the string a few inches in front of the bead), does this
help move the intersection point to the bead?
4. Do you need to use a longer range (i.e., work in a range th is further
from him)?
5. Decides if this is the correct activity for this patient.
iv. If the patient reports seeing two strings which do not intersect
because one is higher than the other; this is an indication of a vertical
deviation of the two eyes’ alignment; however, try these steps just in
case it is something simple:
1. Is the patient’s head tilted or turned? If so, straighten it out. If the
patient needs more feedback to keep his head level, place a beanbag
on his head. if his head tilts, it will slide off.
3. If these do not help, notify the doctor as the doctor may need to make
some adjustments.

2) Does the patient show Signs of stress or fatigue (i.e., watery eyes,
6) Is the patient fusing/suppressible?
HISTORICAL PERSPECTIVE: Dr. Frederick Brock, a Long Island O.D.,

introduced the string in the early 1 94O’s.
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VISUAL PERCEPTION/VISUALIZATION SKILLS ACTIVITIES
CARDS OF TEN
MAIN FOCUS: To develop speed of visual scanning, visual memory and

visual recognition
MATERIALS NEEDED: Deck of 52 cards minus the Jokers, patch, lenses,

prisms, filters.
BASIC PROCEDURE:
Overview: This could be presented as a “magic” trick. One person will draw
three cards from the deck at random. The other person must discover what
the cards are, Without seeing the drawn cards.
1) Place patch on one of patient’s eyes.
2) Patient shuffles card (a form of fine motor development).
3) Fan cards and let the person (therapisparent) the trick is being play
on take out three cards Do not show cards to patient
4) With remaining cards, the patient will lay down one card at a time
face up.
a. When a combination of two cards which add up to “10” is showing,
the patient will cover each of the two cards with the next cards drawn.
The patient is only allowed to cover o cards that add up to 10, but you
should keep track of how many l0’s are covered The
combinations which add up to 10 are 7 and 3, 8 and 2, 5 and 5, 9 and
Ace, 4 and 6.
b. When the Jack, Queen, and King cards are played, they may only be
Covered if all three are present. If only a Jack and Queen are showing,
they cannot be covered until a King is placed on the table.
5) The patient will continue covering the 10 combinations until all cards
have been played.
6) He should try to go quickly to develop visual scanning visual memory
and rapid number recognition
7) When all cards have been played, the patient will look over the “piles”
of cards and search for piles that have top cards which when
combined sum 10. For example one pile may have a “2” on top and
another pile will have an “8”. The patient would pick up both of those
piles and set them aside. Continue picking up any piles that add up to
10.
8) Next, the patient picks up any number “l0’s” that remain.
9) Lastly, the patient will search for any Jack, Queen, King combinations
and pick up all three piles.
10) There should be some piles left over. These are left over because the
other person (therapist/ parent) has the necessary cards for those
piles to be removed.
11) Here’s the trick! The patient will look at the remaining piles. He
should subtract the number of the top card of a pile from 10. The
answer will be one of the 3 cards held in hand by other person For
example, if there are piles with the top cards of 7, 4 and Ace left on
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table. The other person is holding the 3, 6 and 9. Remember how

many 10’s have been played. If four cards are remaining the other
person will have the missing set of KQJ and a 10. If no cards remain
you will have either 3 10’s or a KQJ.
12) Switch the patch to the patient’s other eye and repeat.

1) The patient should have the ability to accurately scan, and recognize
the “10” combinations on his own without prompting.
2) Does the patient possess the necessary math skills required for this
game?
3) Does patient possess the ability to deduce the missing cards?

1) Remove patch and perform binocularly.
2) Can the patient carry on a conversation with you while playing?
3) Can patient perform other math operations or spell a word while
playing?

Have patient stand and add Balance — see if patient can play while
balancing on balance board/beam, heel-toe or one-foot near the table.

Add Metronome — have patient lay his cards out to the beat of the
metronome.
ANTI-SUPPRESSION TRAINING
1) Many playing cards demonstrate good cancellation of the heart and
diamond suits for Red/Green anaglyphic glasses, so you could
incorporate Red/Green Anaglyphic Glasses.
2) As stated above, you could use the Sherman or Bernell VT Playing
cards, which are printed for use with Red/Green anaglyphic glasses.

1) Use prism in any orientation
a) Base-Out/Base-In - Does patient see size/spatial shift? Can patient
maintain balance?
b) Bases-Up/Bases-Down - Does patient see size/spatial shift? Does
patient fatigue? Can patient maintain balance? Is patient more on his
heels or toes (leaning forward or backward)?
c) Bases-Right/Bases-Left — Does patient see size/spatial shift? Does
more right or left?
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1) Use plus/minus lenses — Does patient see size/spatial shift? Can
patient maintain clarity? Does patient fatigue?
LATTER STAGES OF LOADING

a) For example, can the patient maintain balance, play the game, to the
beat of the metronome while wearing Red/Green anaglyphic glasses
and Base-Out Prisms?
UNLOADING:
1) If starting at procedure does patient need his Rx to help him?
2) Therapist or parent shuffles cards for patient.
3) If patient is confused about when to cover the two cards which add up
to 10, try this:
i. The therapist will have the patient draw the three cards.
ii. With remaining cards, the therapist will lay them down in a
straight1jn pattern
iii. When two cards adding to 10 is revealed, the therapist will pick them
up and lay them aside in the “10” pile.
iv. A “10”, Jack, Queen, or King will be considered l0’s, so when they are
revealed, they will be placed on the table in a grid formation
v. Once all cards are played, there should be three or fewer cards.
Subtract each card from 10. That will tell the therapist what the
patient has.
vi. If there are only two cards left, check your grid and see if any cards
are missing. The patient may have the missing “10”, Jack, Queen or
King in his hand.
vii. If there is only one card left, the patient must have two cards which
total “10.” The therapist can check the “10” pile if figuring out which
specific combination he has is important
viii. If there are no cards left, then the patient must have two cards which
total “10” and he has a “10”, Jack, Queen or King in his hand check
your grid.
ix. Now that the therapist has done this for the patient, switch the patch
to his other eye,
x. Shuffle the cards
xi. Give him the deck so you (or his parent) can choose three cards
xii. Let him begin the play.
4) Take out the King, Queens and Jacks.
5) Take out the 10’s and play for combinations of 9
6) Take out the 9’s and play for combinations of 8.
7) Could you try large print cards?
10) Decide if this is the right activity for your patient.
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2) Does the patient exhibit good visual posture?
4) Is there excessive head/body moment?
7) Is the patient fusing/suppressing (if you are performing the activity in
a hi- ocular or binocular fashion)?
HISTORICAL PERSPECTIVE:
Cards of Ten was a favorite game of the late Trudy Adams, vision therapist,
presented at the Frazier Mountain Seminars, Frazier California.
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Vision
Therapy
Module VI
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MODULE SIX
INTRODUCTION
Visual field defects can be classified into two broad categories namely;
1. Hemianopic or sector defects:

Hemianopic defects are cerebral in origin and generally are acquired
after head trauma or stroke. Patients with this condition preferable
are seen early in the disease process so that they can begin
rehabilitation and avoid development of inappropriate adaptive
behaviors.
2. Overall Constriction: This is more likely caused by Tapetoretinal

degeneration or bilateral glaucoma and optic nerve disease. Patient living
with this condition are seen any time in the disease process.
The content is based on our experiences and includes our preferred
techniques. A more comprehensive overview of existing techniques has
previously been explored. (Cohen & Waiss 1993).
EFFECTS OF HEMIANOPIA
i. Large Scotoma Less remaining Field:

This will make the patient to seek rehabilitation early because of
significant field loss that will pose a great challenge
ii. Small Scotoma more remaining field:

This will not impact on the patient mobility and orientation, and daily
living skills. The patient will most likely not need enhancement of field
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JUSTIFICATION
1. Clinically there is increase in the number of patients with general visual

impairment and more specifically with visual impairment secondary to
compromised visual fields.
2. Improve survival rates of stroke/head Trauma patients
3. Practitioner’s first reaction to patients requiring field remediation is that
there are few successful treatment options available to them.
HEAD TRAUMA INDUCED FIELD LOSS
Early intervention is important. Head trauma patients need time to recover

whatever field they are going to recover naturally. Same apply to physical
and mental recovery readapting to their new status. Rehabilitative process
starts when patient is stable. This starts with evaluation of Oculomotor
skills and cognitive status because of the critical role of both eye and head
scanning behavior in compensating for visual field loss. Every patient
should be screened for neglect by functional observation and performance
tests.
TREATMENT OF HEMIFIELD OR SECTOR LOSS
Using element of vision training, optical and non optical techniques
i. Vision training: this develops smooth and efficient eye movement

,systematic head and eye scanning patterns and improved visual
spatial and body awareness
ii. Optical techniques utilize devices, primarily prisms and mirrors,
which shift incoming information from non functioning area of the
field to the seeing part (or take visual information present in the non-
seeing portion of the field and transfer it for processing by the
functioning area of the field)
iii. Non Optical technique: This includes cognitive training and
environmental modifications to help patients remain aware of their
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field limitations and to adjust for them appropriately providing

simultaneously large angle compensation for sector field defects.
MIRRORS
A mirror is mounted nasally on the spectacles on the same side as the

field defect. Information from the non-seen area is reflected onto the
functioning area of the retina. The larger the mirror, the larger the area
coverage. Information is provided via direct reflection into the eye and by the
mirror’s presence as a side view mirror into which a patient can gaze to scan
the field (analogous to the use of side view mirrors when driving).
Placement of the mirror provides the optometrist with a great deal of

control over the visual parameters. The more central the placement on the
carriers lens, the greater the area of simultaneous overlap of the fields; the
more nasal the placement, the greater is the dependency on the side view
scanning action. The smaller the angle between the mirror and the spectacle
plane, the more peripheral is the area of incoming information; the larger
the angle, the more forward is that area.
Figure 1: Schematic of Sector mirror. The shaded area represents the scotoma or non-
seen area and the clear area represents seen information. Although the area “seen”
by the mirror is physically on the right, it is precieved on the left, in the area 70
of
scotoma created by the mirror
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Theoretically when the mirror is perpendicular to the spectacle plane, the

patient should see the straight ahead central field. When the mirror is
parallel to the spectacle plane, the area behind the patient is seen. The angle
adjustment capability of a mirror is one of its major advantages, as it allows
the patient to choose which area of the missing field receives primary
compensation. One interesting patient, a percussionist by profession, was
required to alternate her attention between four widely spaced instruments.
A mirror provided her with the freedom to easily locate her instruments over
a large peripheral area.
Of course mirrors are no panacea for field defects. Mirrors occlude the
area of functioning retina of the eye over which they are placed, thereby
limiting their usefulness to binocular patients only. Semi-reflecting safety
mirrors for monocular patients solve this problem with faintly reflected
image as the only problem. (Goodlaw 1983) (Goodlaw 1982).
Figure 2: Schematic of a semireflecting/semisilvered full field mirror. The patient

sees the low contrast reflected image superimposed over the higher contrast real
world view.
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Patients with neglect are incapable of this reprojection and generally

are poor candidates for mirrors. Mirrors are not cosmetically appealing
causing rejection by most patients. The patient must sacrifice a large
portion of the field enhancement potential as compared to the standard
anteriorly placed mirror (Waiss B, Cohen JM 1992).
Any time a mirror is fitted behind the lens, one must take extreme
care to make sure that the mirror clears the cornea for safety and-clears the
eyelashes for patient comfort. One would have to caution the patient
regarding safety because the mirror could theoretically make contact with
the eye if there was a severe blow to that area.
Convex mirrors are devices whose potential is yet to be fully,

explored. They could conceivably decrease the required mirror size without
adversely affecting the size of the enhanced field. The disadvantage of convex
mirrors is that the image is located at a finite distance from the eye and the
patient must be capable of accommodating to maintain image clarity.
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Instructions for use of Mirrors
For clinical trials of mirrors, we prefer to use the clip-on mirror from
Jardon institute (Mintz et al 1979).
Figure 3: behind the lens mounted mirror is a cosmetic alternative to larger anterior
mounted mirrors.
Figure 4: Clip-on mirror placement for a homonymous field defect
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It consists of a small dental mirror soldered to a padded tie clip. It is

available in either a right or left orientation. It is inexpensive and provides
complete flexibility of placement on the lens and some limited flexibility as to
the angle of the mirror’s tilt. Patients also have the option of when they
choose to use the mirror since it is easily removed when desired.
Initially the patient sits comfortably in the exam chair viewing a

straight ahead distance target. The mirror is positioned over the lens until
the patient is aware of the reflected field. The patient is instructed in the
significance of the image and taught the techniques of locating objects in the
mirror and turning the eye when necessary to locate the objects in real
space. The mirror is then adjusted until the best subjective placement is
achieved. Finally the patient is permitted to walk around the room and
hallway wearing the mirror and the position is finely tuned to produce the
maximum beneficial effect. If the device is deemed safe and beneficial in the
hands of the patient, he should be shown how to position the mirror and it
should be loaned to the patient for a minimum one week home trial. At
follow-up, if the patient finds the mirror to be useful, it can be dispensed to
the patient. A permanently mounted mirror can be fabricated by some
custom optical shops but the cost is significantly higher and most of the
patient's control over the position adjustment is now lost.
PRISMS
Prisms are they second type of optical system used for enhancement
of visual fields in the cases of sector or hemifield loss-Prisms shift the visual
image toward the apex of the prism.
The linear displacement is dependent on the power of the prism and

the distance from the object. The intention is to shift objects within the non-
seen field toward and into the seeing area of field.
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Figure 1 – 4: Clip-on mirror placement for a homonymous field defect

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Figure 5: Schematic of overall prism relocation of a hemifield. The

image is shifted to the apex of the prism.
As one of the few ironclad clinical rules, the prism base is always placed
with the base toward the field defect.
CLINICAL STRATEGIES:
1. The prism base is always placed with the base toward the field defect.
Visual field defects and prism base placement correspond to the
patient's, and not the Optometrist’s, frame of reference. A Right
hemianopia with prism base-right refers to field loss on the patient's
right and to the left of the doctor facing the patient.
2. When writing prescription use base-in and base-out rather than base-
right or base-left. Thus base-right would-be written as base-out OD
and base-in OS, whereas base-left would be written as base-in OD
and base-out OS.
WAYS OF UTILIZING PRISM IN SPECTACLES OF HEMIANOPES
We have two ways namely: full field and partial prisms.
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Full Field Prism
Full field prism offers the most cosmetically acceptable means of

enhancing the visual fields for both distance and near tasks. The patient will
have an-uninterrupted field, which provides the most natural viewing
conditions. The prism is placed binocularly in the spectacle lenses which
shifts the entire field away from the scotoma.
Figure 6: Schematic of binocular overall prism. Depicts the amount of

visual field gained versus amount of visual field lost.
Use the prism binocularly to avoid inducing diplopia. Patient involvement is

passive and this technique works well in neglect and cognitive impairment.
This technique can favorably alter posture and reduce compensatory body
skews commonly seen after head trauma or stroke. (Padula, Shapiro & Jasin
1989).
Patient’s acceptance of device is influenced by Cosmesis and comfort.

Selection of appropriate frame is important for minimizing lens thickness
and weight. Factors for selecting appropriate frame
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1. Distance Between Centers (DBC) must be close to the patient

Pupillary Distance (PD)
2. Shape must be small and round as possible.
3. Plastic frames are generally better and able to conceal the thick lens
edge and hold the lenses more securely than Metal frames.
4. The weight and possible chromatic aberrations in the final
prescription.
CLINICAL STRATEGIES:
(1) Selection of high index lens material and antireflective coating can
also enhance the appearance of the finished product.
(2) The Bernell prism training goggle is cosmetically tolerable and makes
an ideal loaner and testing device and can be worn alone or over
glasses. It is available in a wide range of prism powers.
a. The ground-in prism has practical upper limit of usable power
15 to 20 prism diopters as compared to the 35 to 40 prism
diopters obtainable with Fresnel prisms. For most patients the
prescribed power is close to 10 prism diopters, so it is rarely
necessary to compromise power for optical quality.
Figure 7: Rotatable prism goggles available as a stock item. Courtesy of

Bernell
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INSTRUCTIONS FOR USE OF FULL FIELD PRISM
1. The patient fixates a distance target, 6 to 8 prism diopters of prism

with the bases yoked in the direction of the field loss, placed in front
of the patient's eyes.
2. The patient is asked to report on any subjective changes in the
appearance of the field and to quantify the amount of visual field shift
or increase.
3. The patient is also observed for any postural or behavioral changes.
4. Allow patients to become cognizant of the improved awareness with
prism by asking direct questions about the objects in the
environment.
5. Change power of the prism in 2 to 4 prism diopters steps in both
directions from the starting amount until the patient reaches the
preferred lens.
6. Use the prism power as the starting point for determining the best
lens for mobile conditions.
7. Observe the patient walk with the prism and reports on the
experience.
8. Modify the prism power is again modified until the best lens is found.
Some patients do well under stationary conditions but have difficulty
dealing with spatial distortion under dynamic use.
9. Determine best lens determined based on patient comfort and
performance.
10. Investigate the near point performance of the patient.
11. Ask the patient to seat and perform a series of activities such as
reading, locating objects, and pencil and paper tasks. Each task
should be done with and without varying amounts of prism until the
most appropriate power is found.
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12. Find the weakest power the patient will accept without
sacrificing performance.
13. Use multiple pairs of spectacles different amounts of prism for
stationery and non stationery tasks. Find out if patient requires a
different spectacle prescription for distance and near
Partial Field Prism
Its primary action is to reduce the amplitude of the scanning eye

movements into the blind field, rather than to increase awareness of the
field.
CLINICAL STRATEGY
1. A partial prism’s primary action is to reduce the amplitude of the

scanning eye movements into the blind field, rather than to increase
awareness of the field.
Place Prism with the base in the direction of the field loss over a portion of
the lens in the non-seeing field. The prism allows the object to meet the
place half way improving efficiency. Once the object is located, a head
rotation returns the eye to the regular portion of the lens for an unobscured
view. A Fresnel prism is usually acceptable to most patients for locating the
object. Specialty optical laboratories can fabricate cemented prism wafers if
the patient strongly objects to the visual quality of the Fresnel.
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Figure 8: Schematic of binocularly fitted partial sector prisms under

binocular viewing conditions. A prism jump scotoma characterizes the
transition from lens to prism.
As the eye enters the prism, a scotoma is created by the shift of the
optical image. The size of the scotoma depends on the strength of the prism
and the distance of the object from the prism. This result in a potential jack-
in-the-box phenomenon which many patients find disconcerting, especially
with cognitive deficits or slowed reaction time. This technique works only if
the patient scans into the scotomatous fields. Patient with neglect and/or
cognitive deficits may be unable to generate these scanning movements on
an intentional or regular enough basis to be effective. Extensive eye
scanning training is often a necessary adjunct therapy if the prism is to be
useful.
The placement of the prism edge determines the size of the excursion
the eye must make before it encounters the prism. The exact placement is
best left to customized trail fitting procedures.
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FITTING PROCEDURES
1. To keep the central lens clear for normal eye movement, and
2. To place the prism in a moderately peripheral position on the lens.
(Perlin & Dziadul 1991).
Placement close to the centre of the lens allows easier intentional
access to the prism, and since occasional random eye movements enter the
prism it also serves as a reminder to periodically scan the missing field even
without an immediate cause for it. Patients wearing the peripherally placed
prism rarely use it. Vision training exercise teaches patients to scan into the
hemianopic field to locate the prism.
Although some optometrists fit the prism monocularly, (Gottlieb,

Freeman & Williams 1992) (Smith, Weiner & Lucero 1982) prefer to fit them
binocularly. The monocular fit causes diplopia when the patient looks
through the prism, unless the target is peripheral enough to cause the
diplopic image to be occluded by the nose.
The overlapping diplopic fields actually permit a larger expanse of field

to be seen. In our experience the diplopia is confusing for most patients and
there is better comfort with binocular correction.
INSTRUCTIONS FOR USE OF PARTIAL PRISMS
The patient sits comfortably in a chair with one eye occluded and
fixates a straight ahead distance target. An index card is slowly moved from
the scotomatous area toward the
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Figure 9: Schematic of monocularly fit sector prism. This creates diplopia for
the patient
center of the lens until it is just seen. This position is marked on the lens.
The process is repeated until a consistent finding is obtained. The occluder
is switched to the other side and the sequence is duplicated on the second
eye. The occluder is then removed and the positioning is checked for
symmetry under binocular conditions.
A Fresnel prism with base toward the scotoma is then placed on each
lens about 1 to 2 mm before the demarcation points marked on the lens. We
generally start with a 15 prism diopter lens and modify the power after the
most comfortable position of the leis found. It is helpful to have precut prism
in a selection of powers for t ns rail purposes in order to prevent the waste of
unnecessarily cutting up prisms. The initial testing to determine the optimal
prism placement can also be done utilizing a strip of translucent or opaque
tape if necessary and gauging the patients’ reactions from that.
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After the prism is applied, the patient is asked to scan the

environment and report on his reaction. The prism is slowly moved back off
from the midlines as needed until the patient is comfortable and just barely
aware of the prism under these normal dynamic viewing conditions. This
position is now marked and represents what we believe to be the area of the
field covered by the patient’s normal head and eye scanning patterns. The
prism edge is this location.
The patient is instructed to scan into the prism to locate objects and
to rotate the head to reposition the object on the clear part of the lens when
necessary. The patient’s reaction and actual performance in successfully
locating objects in the room are important in deciding if this technique is
suitable. The power of the prism is then varied to find the preferred
strength.
The patient is then permitted to stand and try the prism while walking
around. The consequences of the prism edge jump are explained and the
patient is warned to be alert for them. Any final adjustment in the prism
position or power should be made at this time. The Fresnel prism is then cut
and applied to the lens according to the measured parameters and if all
satisfactory the patient is scheduled for appropriate follow-up.
Counseling and education about the visual characteristics of the

condition will help the patient and the family or caretaker understand why
the patient behaves the way he does. They will better understand why
merely placing the silverware and tableware on the same side as the seeing
field will improve the person’s mealtime function. For reading, the use of line
guides and margin markers, tilting the page and shifting the reading
material toward the seeing field, or reinforcing the use of the patient’s
thumb to mark the end of each line, will likewise improve performance.
CLINICAL STRATEGY
Simple environmental modifications and ergonomic adjustments can

make a world of difference in the patient’s quality of life.
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Patients must prove their proficiency based on a thorough driving

evaluation given by a neutral third party observer before approval can be
reluctantly given Hemianopic patients are strongly discouraged from
driving.
Every patient with constricted fields should be counseled and referred

for an evaluation by an orientation and mobility specialist, even when the
patient denies any problem with mobility.
TREATMENT OF OVERALL FIELD LOSS
Overall field loss generally develops slowly over time, most patients
develop compensatory scanning skills for extracting information for the
periphery. Head swings, rapid eye sweeps of the environment and
marginally slowed approach speed allow the patient to construct the gestalt
from the multiple discrete bits of input. The patient is usually unaware of
any problem until the visual field drops to a range of about 10 degrees or
less.
The treatment of overall field loss centers on increasing the amount of

visual information contained in the residual island of vision and improving
the efficiency and efficacy of visual scanning. This involves minification of
the image, and visual training and prism.
MINIFICATION
Treating overall field loss is inversely to the treatment for central field
loss. The optometrist attempts to transfer information from the scotoma by
magnifying it into the periphery by either decreasing the viewing distance or
optically enlarging the object in central field loss. In peripheral field loss the
opposite occurs. The Optometrist attempts to transfer information from the
periphery into the remaining central field via increased viewing distance and
optical minification of the object.
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Increased viewing distance remains the most natural and efficient

means of maximizing residual field function. It is impractical, to read at 30
inches and impossible to scan a room from behind the doorway.
Moving the working distance from 10 to 14 inches can afford some relief for
the patient’s problem. Patient education is also important so that he/she
will not be forced to hold the material closer so that “he see it better".
Optical minification, in theory, is effective in providing increased field

when increased working distance is not feasible but there are several
drawbacks in practical application.
Disadvantages of Minification
1. The inverse relationship between the amount of field expansion and

visual acuity. As minification increases, the visual acuity decreases in
direct proportion. A -5X device might increase a 10 degree field to 50
degrees, the 20/20 acuity would be reduced to 20/100 through it.
Figure 10: Schematic of overall optical minification to compact visual

information to fit into the remaining reduced visual field.
Figure 1 – 10: Schematic of overall optical minification to compact visual

85 information
to fit into the remaining reduced visual field.
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2. Purpose only (to gain a better perspective of the field), many patients
will reject the device because of the poor acuity it produces.
3. Even more significant than the acuity loss is the disruption of the
normal scanning pattern caused by the devices. The static viewing
conditions visual field enhancers offer an increased field relative to the
unenhanced eye, in the real world conditions are not static; patients
scan with eye and head movements which effectively expand the range
of their perceptual field to several times greater than their static visual
field. Thus a patient with a 10 degree static field might have a
functional field of 40 degrees while maintaining normal size
constancy.
4. Looking through a field expander cuts off the ability of the eye to freely
scan space and restricts scanning movement to the field of the device
itself. The static field through the device is offset by a loss in the
dynamic functional field.
5. The view through the field expander is a poorly resolved, minified
image compared to a normal image without the device.
Minification is achieved optically by two types of devices: reverse
telescopes and minus lenses. Reverse telescopes and minus lenses.
REVERSE TELESCOPES
Reverse telescopes utilize the same handheld monoculars and

spectacle mounted telescopes used in conventional low vision protocol.
There are low-powered minifiers, by Ocutech specifically for field
enhancement. Designs for Vision manufactures the New Horizon lens,
reverse telescopes which minify in the horizontal meridian only in an
attempt to preserve visual acuity (Hoeft, Feinbloom & Brilliant 1985).
Handheld telescopes are usually worn around the neck for easy
access. For patients with both decreased acuity and constricted visual fields,
a handheld telescope can be used in a conventional means for standard
magnification as well as reversed for orientation needs. Spectacle mounted
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reverse telescopes work best in bioptic form, although for stationary use, a
full field position can be utilized (Jose, Spitzberg & Kuether 1989).
Instruction for Use of Reverse Telescopes
The patient sits in the exam chair and views a distant target. The
patient is then given a 2.5 or 2.8X Galilean telescope and is instructed to
view the scene again while looking through what is normally the objective
lens of the telescope. These Galilean telescopes are lightweight, inexpensive,
and easy to use while producing a bright image. Patient response is gauged
regarding the overall impression of the scene viewed. If the response is
positive, then other powers of telescopes are tried until the preferred
telescope is chosen. The patient is coached in the concept of using the
reverse telescope to scan the environment to establish the location of
potential hazards and pertinent landmarks. The patient is observed for ease
of use of the telescope and for improved ability to locate objects in space.
The patient is also instructed that in place of eye scanning, the use of head
or body rotation while maintaining focus through the telescope is the most
productive way of exploring the environment through the device.
MINUS LENSES
Minus Lenses Minus lens minifiers are in principle essentially the

same as reverse telescopes. The minus lens serves as the objective and
patient accommodation as the ocular of a reverse telescope system. For
example, if a -5.00 diopter lens is held 30 cm from the eye to view an object
in the distance, the image of the minus lens would be at its focal point 20
cm in front of the lens or 50 cm from the eye (20 cm from image to lens + 30
cm from. lens to eye). The patient must therefore supply 2.00 diopters in
either lens form or accommodation to see this image clearly. This yields an
effective telescopic power of 2/5 or 0.4 magnification which is equivalent to
using the 2.5X telescope. The advantage of the minus lens is that by
tromboning the lens closer and further away, the patient changes the
minification effect. The closer the minus lens is to the eye, the lower the
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minification; the further the minus lens is from the eye, the greater the
minification. Looking at the example of the -5.00 diopter lens, we
determined that the patient obtains -2.5X when the lens is 30 cm from the
eye. If it were now moved closer to 20 cm, the effective ocular would be 2.50
diopters and the magnification 2.5/5 or .5X which is equivalent to a -2X
telescope. Conversely, if the lens were moved away to 47 cm, the effective
ocular becomes 1.50 diopters and the magnification of the system is 1.5/5
or .3X, equivalent to a -3.3X telescope. Minus lenses for field enhancement
are available in monocle form which can be worn around the neck, but any
minus lens can be used.
Uncut lens blanks with a predrilled hole to thread a neck cord are an
inexpensive and readily available option, as are uncut Fresnel lenses. Uncut
Fresnel lenses come in a plastic frame and are lightweight and flat and fit
easily into a shirt pocket. For in-office testing, trial lenses work reasonably
well despite their small diameter. For frequently viewed, large, fixed areas of
space such as doorway entrances or yards and porches, large Fresnel lenses
of the type used on rear van windows are extremely useful. They can be
mounted on storm doors or windows overlooking the area of interest. These
lenses are inexpensive and are readily available in science stores.
Figure 11: A minus lens creating overall optical minification

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Instruction for Use of Minus Lenses
Demonstration of minus lenses s similar to that of reverse telescopes.

The patient views a distance target and then brings a minus lens up in front
of the dominant sighting eye. The patient should be aware of the minified
image and be instructed in tromboning the lens in and out to vary the
minification. We prefer using a lens power somewhere between -5.00 to
-10.00 diopters as the initial selection. This power range provides a
manageable amount of minification at a reasonable lens-to-eye distance.
Once the patient is comfortable with the mechanics of using the lens, he is
taught to scan the field by rotating the arm and head as a unit in order to
maintain fixation through the optical axis of the lens. As the patient
experiments further with the lens, different powers are introduced until a
preference for power and viewing distance is demonstrated by the patient.
ENHANCEMENT OF VISUAL SCANNING SKILLS
Minification attempts to increase the amount of information

contained in the residual field. Increasing the efficiency of the information
gathering and input process. Improved eye movement strategy and optically
by use of prism to decrease the amplitude of the ocular excursions.
Increased patient awareness of the spatial area to be processed and plan for
a systematic and a complete search pattern team will work with
occupational therapists and orientation and mobility instructor.
PRISM
Partial prisms can bring unseen visual information closer to the area
of functioning field and decrease size of the scanning eye movements into
the area of scotoma. In overall field defects multiple prisms must be used to
cover different fields.
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Factors influencing the number of Prisms and Precise Location
1. Patients Binocular state

2. Life style
3. Needs
4. Response to the prism
Occasionally a patient will manage with a single base-out prism placed
temporally on one each eye, covering the right and left fields respectively,
two prisms placed nasally and temporally on each lens is usually the
minimum number of prisms used. The maximum number is four prisms per
eye, forming a ring around the central field.
Remember that the base is always toward the scotoma, thus, the nasal
prism is base-in, the temporal prism is base-out, the inferior prism is base-
down, and the superior prism is base-up.
Fresnel prisms are generally used for this technique although some
specialty laboratories will fabricate ground-in prism spectacle lenses within
limited parameters. At times, the Optometrist and patient can split the
pupil with prisms touching apex to apex to achieve best results (Weiss
1990).
Instruction for the Use of Prisms
The patient views a distance target with the preferred eye. An index
card is placed temporally on the lens and is moved in toward the lens center
until it is first perceived by the patient. The process is repeated from the
nasal direction and both points are marked on the lens. Two strips of 10 to
15 prism diopters of Fresnel prism are placed at those points with the bases
pointing away from the lens center. The patient is then permitted to scan
the room, and the position of the prism is adjusted until a comfortable
central corridor is established between the prisms. The process is repeated
inferiorly and, if desired, superiorly. The patient is instructed to appreciate
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the effect of the prism and to utilize the appropriate head rotation and
return the eye to the home base of the clear central corridor of the lens.
Figure 12: Circular placement of Fresnel prisms placed with the bases of the prism
toward the periphery of the lens to compensate for an overall reduced visual field.
Changes in the strength of the prism can be made based on patient

response. The entire process- is repeated on the second eye. Check the
prisms with both eyes open making the necessary adjustment to resolve any
binocular conflict. The patient stands and walk around with the prism. After
a short trial doing a variety of distance and near centered activities the
patient response is required. A weeklong home trial is recommended unless
the patient rejects the prisms outright. The prism can be refined in regard to
both power and positioning during the follow up visits.
ENHANCEMENT TECHNIQUES FOR OVERALL VISUAL FIELD LOSS

PATIENTS
1. Allow patient the option of accepting or refusing the interventions.

2. The do not respond well to optical enhancement because of major
disruption of their normal equilibrium
3. Minification and prisms have limited effectiveness and considerable
visual side effects
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4. The devices are primarily for general orientation, special consideration

must be given to reading. Patient should try to maintain the longest
working distance possible to maximize the field.
5. Weiss suggested using a low-powered minus lens but our experience
has not found great patient acceptance for it (Weiss 1991).
6. The inability to maintain one's place on the page while reading is more
important than the small field
7. Reading problem is best solved by use of a typoscope to keep attention
focused on a small and stable but manageable area of text and to help
reorient the patient, should fixation be lost.
8. When magnification is needed in order to read, the paperweight-type
stand magnifiers should be used to provide an exceptionally stable
image to patients with small fields.
9. Closed circuit televisions (CCTV) also provide a stable image for
patients and offer a wide range of magnification and contrast options
to the user.
10. Lighting and contrast enhancement are essential parameters to
be discussed with patients.
CONCLUSIONS
There are numerous approaches for the rehabilitation of visual field

defects and each technique has both inherent flaws and advantages. The
optometrist should be capable of offering a selection of treatments to the
patients so that they can choose the options that best fit their individual
needs. The Optometrist take cognizance of the vast network of
nonoptometric services available to help the patients deal with the complex
difficulties associated with whatever precipitative factor has caused the field
defect. It is unlikely the visual problems will be resolved unless the physical,
psychological, and social needs of the patient are being met.
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REFERENCES
Cohen JM, Waiss B: An overview of enhancement techniques for peripheral

field loss, J Am Optom Assoc 64(1):60-70, 1993.
Goodlaw E: Review of low vision management of visual field defects, Optom

Mon 74(7):363 -368, 1983.
Goodlavv E: Rehabilitating a patient with bitemporal hemianopia, Am J

Optom Physio Opt 59(7):617-619, 1982.
Gottlieb DD, Freeman P, Williams M: Clinical research and statistical

analysis of a visual field awareness system, j Am Optom Assoc 63:581-
588, 1992.
Hoeft WW, Feinbloom W, Brilliant R, et al: Amorphic lenses: A mobility aid

for patients with retinitis pig,mentosa, Am J Optom Physio1 Opt
62(2):142-148, 1985.
Jose RT, Spitzberg LS, Kuether CL: A behind the lens reversed (BTLR)
telescope, J Vision Rehabil 3(2):37-46, 1989.
Mintz MJ: A mirror for hemianopia, Am J Ophthalmol 88:768, 1979.
Padula W, Shapiro JB, Jasin P: Head injury causing post trauma vision
syndrome, New Eng J Opt 41(2):16-21, 1989.
Perlin RR, Dziadul J: Fresnel prisms for field enhancement of patients with
constricted or hemianopic visual fields, J Am 01710771 Assoc 62:58-
64, 1991.
Smith JL, Weiner IG, Lucero AJ: Hemianopic Fresnel prisms, J Clin Ncuro-
ophthalmol 2:149 -158, 1982.
Waiss B, Cohen JM: Utilization of a temporal mirror coating of the back

surface of the lens as a field enhancement device, J Am Optom Assoc
63:576-580, 1992.
Weiss NJ: An unusual application of prisms for field enhancement, J Am

Optom Assoc 61(4):291-293, 1990.
Weiss NJ: Low vision management of retinitis pigmentosa, J Am Optom

Assoc 62(1):42-52, 1991.
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Dr. ABU LATEEF

RESIDENT
NIGERIAN POSTGRADUATE COLLEGE OF
OPTOMETRISTS
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Dr. IBHAZE-BAROR
JULIET EGHONGHON
RESIDENT
OPTOMETRISTS
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JOY INSTITUTE
Dr. EMUROTU DAFE

OGHENEGANGAN
RESIDENT
OPTOMETRISTS
96
JOY INSTITUTE
Dr. UDO UBANI

CONSULTANT
OPTOMETRISTS
97

Clinical Orthoptics 2019

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JOY INSTITUTE

COMPREHENSIVE CLINICAL VISION THERAPY

CENTRE FOR EDUCATION

ALL CURRICULUM MATERIAL PRESENTED IN THIS

YOUR GOAL IN TAKING THIS COURSE_________________

NIGERIAN POST GRADUATE COLLEGE OF

 Dr. RONALD EYIME

FACULTY OF ORTHOPTICS/VISION THERAPY

 Dr. EFE ODJMOGHO

 Dr. UDO UBANI

 Dr. CHIDI EZETOHA

 Dr. CECIL NWAFOR

 Dr. AUGUSTINE .U. AKUNJOBI

 Dr. UZOCHUKWU .C. ARODIOGBU

 Dr. NGOZI J. EZE

 Dr. CHINWENDU U. OGUEJIOFOR

COMPREHENSIVE CLINICAL ORTHOPTICS/VISION THERAPY

Nigerian Postgraduate College of Optometrists

TUESDAY, MAY 8, 2018

WEDNESDAY, MAY 9, 2018

THURSDAY, MAY 10, 2018

FRIDAY, MAY 11, 2018

 Orientation – Dr. CHINAZA ONWUAGBA

Vision. Joy Institute is a leading resource in Africa on vision

1. Orthoptists helps detect and manage Amblyopia.

WHAT IS VISION THERAPY?

WHO BENEFITS FROM VISION THERAPY?

iii. Convergence Insufficiency (Common near Vision disorder)

viii. Sports Vision Improvement

do! We can measure and successfully improve Eye-Hand

10 VISION THERAPY ACTIVITIES

b. Good for: Flexibility of Accommodative System, Just Noticeable

10. NEAR/FAR ACTIVITIES

FIXATIONS AND HEAD ROTATIONS

MATERIALS – A small hand mirror

PROCEDURE 1: To the Patient: Hold the small hand mirror in front of

nodding your head “Yes”), circularly, diagonally, and in a random fashion.

and have him proceed as outlined above.

maintaining fixation by looking at the reflection of your eyes in the mirror.

speed of moving the mirror while holding the head still.

Time – Three to five minutes at least once daily.

MATERIALS – A small target, e.g. pencil eraser or the tip of a pen.

PROCEDURE 1 – The assistant holds a small target (E.g. tip of pen or

assistant moves the object sideways, vertically, diagonally, circularly

(clockwise and counter clockwise), and randomly throughout the patients

PROCEDURE 2 – To the patient: extend arm out in front of you with

Move your thumb sideways, vertically, diagonally, circularly (clockwise and

counter clockwise), and randomly.

VARIATIONS – Try varying the speed.

TIME – Five minutes at least once daily.

MATERIAL – Circled number pattern sheet, Acetate cover, Crayon or

felt tip pen

1. Circled number pattern sheet is inserted in the acetate cover.

upward in the “ready” position for location of the next number.

movements are encouraged.

1. Time the activity and attempt to “beat your time.”

MATERIALS – A table with miscellaneous objects on it and a chair to

1. The patient is to sit in the chair at the table

until he visually locates the object that the assistant called.

level of the patient.

TIME – Do at least ten minutes two or three times daily.

SCANNING WITH TACTILE REINFORCEMENT

MATERIALS – A table with miscellaneous objects on it and a chair to

1. The patient is to sit in the chair at the table.