ABC Clinic

Can all problems of the eye be solved with glasses alone?

The Answer is NO. The treatment of several problems in the eye is not as simple as glasses or surgery.

Just the way you hit a gym to strengthen your physique when its weak, the function of the eye and its muscles too can be enhanced with exercises when they are weak.

ABC clinic comprising of Amblyopia clinic, Binocular vision clinic and cortical visual impairment clinic deals with just these intricate issues of the eye.

Amblyopic clinic

Imagine 2 brothers Ram and Shyam who belong to the same farmer’s family. As long as Ram is active and doing all the work that needs to be done in the farm, Shyam is just going to lie around lazily. Its only when Ram is asked not to work, that Shyam gets rid of his laziness, and becomes active at work.

Similarly, when one of our eyes is affected by any eye disease like squint, spectacle power, corneal scars, cataract etc during childhood, the affected eye becomes lazy as the normal or better eye is the one working continuously. This would mean that even if the disease is treated, vision may not recover completely. This is especially true when the child’s eye is affected in the early years.

Remember the story of Ram and Shyam!

So the only way to get the eye to see better is to give it more work. This is done by patching the better eye for a while everyday or by selectively giving more work to the affected or the lazy eye

It is very important to treat lazy eye during the early years while the connections between the eye and the brain are more malleable and hence respond to lazy eye treatment easily. Therefore it is very important that lazy eye be detected at an early age and treated promptly. As once the connections ar fully formed, treatment may only be partially effective

Treatment of Amblyopia: Conventional treatment of amblyopia involves closing the better eye with sticky patches or specially designed occluders for glasses and making the child see through the worse eye. This is advised for a few hours everyday depending on the severity of the lazy eye.

Blurring the vision in the normal eye temporarily by means of medications or spectacle lenses is another way of treating lazy eye

 

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FAQ

Frequently Asked Questions

What is amblyopia or lazy eye?

Amblyopia is when the vision in one or both eyes is reduced due to decreased stimulation of the eye.

What causes amblyopia?
  • High uncorrected spectacle power
  • Difference in spectacle power between the 2 eyes
  • Decreased stimulation of the eye due to cataract or drooping of the eyelid or a scar on the central part of the eye
  • Squint – when one of the eyes turns and looks in a different direction
  • Retinal disease – Thoough the vision is reduced mainly due to the disease per se, there may be a small component of amblyopia too.
Is the vision loss due to amblyopia reversible?

Yes vision loss in amblyopia is  reversible provided the cause for decreased stimulation of the eye is corrected early and amblyopia treatment is initiated immediately

The cause that deprives the eye of vision must be  corrected at the earliest – Starting the use of spectacles, correcting squint, removal of cataract, etc

Treatment of lazy eye must also be initiated early, preferably before the age of 8 years when the connection between the eye and the brain are not fully formed

Can the vision loss due to amblyopia become permanent?

Yes, If the cause for the decreased vision is not treated at the early years, the vision loss may become permanent.

For example – if a child has dense cataract and the removal of cataract is not done in the early years, and instead the surgery is delayed until his teens, child may regain only partial vision ( poor vision)

How is lazy eye treated?

Patching or occluding the better eye is the gold standard of treatment for lazy eye. This is advised for a fewr per day ranging from 1 to 6hrs for a few months and then  the duration is gradually decreased depending on the response to treatment.

Other means of treating the lazy eye are by using atropine eyedrops in the better eye or blurring the vision in the better eye by changing the spectacle power in the better eye.

Computerized amblyopia therapy is gaining popularity these days due to several reasons, stated below.

Why do a lot of children dislike patching?

Imagine you have one weak hand and another strong hand, you will obviously prefer using the string hand to do all your work. And if forced to work with your defective and weak hand, not only do you find it tougher to do the work but you also get tired easily which may annoy you.

In a similar way, no child would prefer to have the better eye closed and do all their activities using the lazy eye but it our responsibility to make sure they do so.

My child does not use patches regularly. What do I do?

There are several ways one can ensure your child uses the patches.

If the child is old enough to understand, explain the child in simple words how wearing the patches makes his/her eye stronger

If the child is too young, then try to encourage patching. This can be done by using fun stickers on the patch and playing a game everyday or by making the child play his/ her favourite game during patching or by giving the child his/ her favourite snack. This will ensure positive reinforcement of patching

If despite several attempts, child does not allow patching then other methods of treatment msentioned above may be used

Computerized vision therapy is a good option here since children usually love  playing  games on the computer and the exercises that are given are in the form of games and children have fun doing them

Computerised vision therapy also has ways in which exercises can be done with both eyes open, but only the weaker eye gets more stimulation. This is made possible by the use of special glasses.

How do I know when my child is responding to amblyopia treatment?

Good response to treatment results in improvement in visual acuity, this means your child can read more letters or lines on the vision chart. Amblyopia is said to be fully corrected when the vision in the lazy eye reaches that of the better eye. This is when treatment or patching is gradually reduced – This prevents lazy eye form recurring.

Sometimes improvement visual acuity ( ability to read letters from the vision chart)  may not improve but other faculties of vision like contrast sensitivity, ability to use both eyes simultaneously, 3D vision may improve.

I have crossed 18 years and I have amblyopia that was not treated during my childhood. Is there any hope now?

Amblyopia best treated in the early years – especially  before 8 years is when the vision may be regained completely

Studies have shown that vision cane be regained partially even until 18 years but as mentioned the visual recovery may only be partial and may need treatment for a long duration.

Recent studies on adults have also demonstrated partial visual recovery in a few but it strongly depends on the cause for the lazy eye  ( for example lazy eye due to small difference in spectacle power may respond but that due to cataract in childhood does not)

KIDROP & NN

Narayana Nethralaya started the Karnataka Internet Assisted Diagnosis for Retinopathy of Prematurity (KIDROP) program in 2008. Since babies were born in several neonatal intensive care units (NICUs) where there are no ROP specialists to screen and treat on time, KIDROP created a tele-medicine platform on which images taken by mobile teams of trained imagers using specialized ROP cameras, were uploaded and graded by NN’s ROP team.

KIDROP was India’s first tele-ROP program and currently is one of the largest single center ROP programs in the world. In all, 127 NICUs across the state of Karnataka (Government and Private) are covered each week. Over 150,000 screening sessions have been completed and over 2500 babies treated thus far. This program is a public private partnership with the Government of Karnataka and has mentored other ROP programs across the country. KIDROP has received several awards nationally and internationally for its innovations, including Public Private Partnership of the Year, 2012, National Award for Excellence in HealthCare 2016, K R Datta Award for Community Outreach, 2017 and BIRAC Innovator Award for HealthCare in 2018.

Binocular vision clinic:

Why did we develop two eyes during evolution. Wasn’t one eye enough to satisfy all our visual needs.

The advantages that the presence of two eyes offers us are several – Wider field of vision, better judgement of distance and depth ( 3D or stereovision) etc

But in order enjoy these advantages to the fullest, the two eyes must work in perfect unison. Any disturbance to this delicate balance, affects our binocular vision.

Binocular vision problems may manifest as eyestrain, easy fatiguing of the eyes, intermittent double vision, blurring of vision, headache etc.

With the advent of technology and increasing use of gadgets, the demand for sustained near activity or focus is getting higher. When the eyes work hard to meet this demand, they may get tired and over time as this fatigue builds up, they develop issues with the binocular vision (binocular vision anomaly)

 

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FAQ

Frequently Asked Questions

How do I know I have binocular vision anomaly?

Problems related to binocular vision may manifest in widely different ways. In some people it may  cause obvious symptoms and directly point to an eye related issue. Some of the common symptoms are

  • doubling of letters
  • blurring of letters
  • letters appearing jumbled
  • distance appearing blur after prolonged reading
  • eye strain
  • eye pain

In other cases it may  be very subtle and hence may not really hint the person to visit an eye doctor. For example difficulty on concentrating for long, feeling sleepy after just reading a few lines.

How is binocular vision anomaly treated?

If you are into photography, you may understand how camera’s focus needs to be changed to enable capture images at different distances. Well, sometimes even the entire lens needs to be changed to focus something.

But imagine how fascinating it is that our eyes are far more advanced than any of these cameras that it makes these switches automatically and within a split second

Our eyes have several muscles which help in switching focus between various distances and also help in sustaining this focus, once the switch is made. But sometimes there may be a glitch in this perfects functioning. Ans that is when they need to be treated

Treatment of binocular vision problems may involve:

Following good practices while reading or working on computers

Prescribing glasses

Prescribing prisms

Training the eye muscles using some special instruments like flippers, brock string

Training the eye muscles using computer based softwares.

I have a busy schedule and cannot come for office-based therapy. What are my options for treatment?

Binocular vision issued are often best treated with office-based exercises. This is because not only are certain instruments only available in a specialized clinic but this also enables regular monitoring by our orthoptist to ensure you do the exercises correctly and also do not miss your appointments.

 But you may be a person who lives in another city or a busy mother who cant spare time in the hospital working hours. Well If that’s the case then do not worry. We can offer you home based exercises with instrumenst that can be purchased from us or avail softwares that can enable you to perform these exercises at home while we monitor these exercises sessions from where we are.

What measures should I take to ensure that my binocular vision problem does not recur after it is fully treated?

Being regular with the exercises recommended by your orthoptist is an important measure in preventing recurrence. Also exercises need to be slowly tapered off. This will ensure that your binocular vision problem does not recur in future.

You must also continue to follow visual hygiene practices like

  • maintaining correct distance while reading  (14-16 inches for a book, 16-20 inches for Visual display devices
  • maintaining good posture (sit erect on a comfortable chair)
  • Comfortable overhead lighting
  • Intermittent viewinf of distance every 20-30 mins ( 20-20-20 rule – Look at something 20 feet and beyond every 20 mins for 20 secs)

 

CVI clinic

CVI or Cortical Visual Impairment might sound like a disorder of the eyes but it actually has very little to do with the eye and has everything to do the brain.

Imagine you look at a red ball coming towards you. Your brain immediately processes the colour, shape, texture, size, direction and speed of the ball so that, in a split second you can put up your hands to catch it. This happens because of the “Tree of Vision” – different parts of your brain work together as a team to prevent you from getting a bump on your head (to help coordinate vision, recognition and eye-hand coordination) The occipital cortex ‘sees’ while the temporal cortex tells you ‘what’ you’re seeing and the parietal cortex tells you ‘where’ you’re seeing the object.

This complex processing of vision starts from birth but takes a while to develop and mature. The development happens in stages as the child grows. That is why a child takes upto 3 months to recognise it’s mother’s face and upto two years to throw or catch a ball.

Now, while this is fascinating there are unfortunately a lot of children whose visual processing is impaired which means their quality of vision will be poor though their eyes may look perfectly fine and that is Cortical Visual Impairment.

 

 

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Common causes for CVI:

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Complicated birth history – reduced oxygen or glucose levels

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Serious infections in infancy

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Trauma

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Seizures

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Cerebral palsy

Problems a kid with CVI can face:

  1. Difficulty walking downstairs but climbs up well
  2. Doesn’t notice fast moving objects (cars, rats)
  3. Doesn’t see when pointed to far off objects (moon, bird)
  4. Difficulty in locating an item amongst a pile (toy, clothes, at the supermarket)
  5. Difficulty in copying words or writing but identifies when pointed out.
  6. Difficulty in writing within lines on a notebook
  7. Difficulty in reaching out for an object accurately

 

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Assessment of CVI:

A multidisciplinary approach is necessary to diagnose CVI. By this, we mean a detailed evaluation of not just the eye but the functional assessment of everything the child can do. At Narayana Nethralaya we have the Buds to Blossom clinic dedicated for that. Our Paediatric ophthalmologists and optometrists examine the eyes thoroughly for any refractive errors, squints, retinal issues, some of which if corrected, can give better results during therapy. The child also undergoes a functional assessment by our experts at the CVI clinic to determine what kind of therapy the child might require. The assessment will include (insert flowchart)

A pediatric neurologist will also examine the child and if needed, imaging of the brain (MRI) is advised to help streamline the therapy according to specific areas of the brain affected.
Treatment of CVI begins with correction of eye issues that may additionally deteriorate the vision of the child like correction of refractive error with glasses or correction of squint to improve binocularity. The child will be subjected to targetted visual therapy to improve the quality of vision using various modalities such as Computer based exercises on Senate vision integrator, vision therapy system 4, Marsden ball, Marsden with balance board,
The child will also be given physiotherapy, occupational and speech therapy because we believe that, only through an integrated approach we can help the child as a whole and not limit it only to vision. We have a special educator and a  child psychologist in our team to help the children with any issues they may be facing with academics . Parents too are counselled periodically so they can understand their child better and provide for them. Regular follow-up, adherence and consistency in therapy are factors that will influence the response to treatment and inturn the life a child with CVI would lead.

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FAQ

Frequently Asked Questions

How much vision will a child with CVI have?

In CVI a child’s vision is impaired and in some children, the grade of vision maybe be normal too! It is the quality of vision that is mostly affected. Even in a child whose vision is extremely poor,the child will be able to perceive movement and can be taught  exercises to improve the existing faculties of vision and to enable to child to use this vision in daily activities of life.

Can CVI therapy be done at home?

Yes, some simple forms of therapy can be done at home. But others would require a special software to deliver the therapy which will be available only at a specialized clinic. Most of the times, a combination of home and clinic-based therapy is offered. Because though compliance with therapy improves with office based therapy, child spends most of his day at home. So incorporating the exercises with daily activities at home is very important.

Will my child need glasses?

A child with CVI will need glasses if there is a refractive power or a squint. Sometimes, plus power spectacles are given that will help see things at near distance better.

Will my child ever be "normal"?

CVI is a rainbow of abilities and every child is different. Even if there are physical and morphological challenges, with the right kind of therapy, functionality can be enhanced so that a child will be able to reach his/ her best potential despite the morphological changes.

Can my child go to regular school?

We have seen a lot of children with CVI who go to regular school. Children who do not have gross developmental delay and if the factor causing CVI isn’t severe, your child can attend regular school but may need help with their scholastic performance. That’s why, we have a special educator who can help you with regards to your child’s education.

How long should we continue therapy?

The duration of therapy will depend on factors such as overall development of milestones, the cause of CVI, the age of the child, response and compliance to therapy The key is to be consistent, have faith and be hopeful!

Is CVI a disability?

Sadly, the government of India does not recognise CVI specifically as a disability. Hence children with near normal visual acuity but with difficulties with specific faculties of visual function may not be considered disabled. This is may be frustrating for parents. However, CVI can come under the criteria of low vision or Visual disability and if the child has motor developmental issues too, it can be classified as a disability.

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