非斜視性雙眼視覺(jué)異常視覺(jué)訓(xùn)練2018

天津職業(yè)大學(xué)眼視光工程學(xué)院陳麗萍非斜視性雙眼視異常的視覺(jué)訓(xùn)練

2018陳麗萍視視覺(jué)訓(xùn)練:介紹和基本概念Treatment非斜視性雙眼視覺(jué)異常的處理CorrectrefractiveerrorAddedlensesPrismVisiontherapy--------->WhytreatwithVT?Reviewstudiesofvisiontherapysuccessrates視覺(jué)訓(xùn)練的成功率相關(guān)研究Convergenceinsufficiency:90%(Grisham)Convergenceinsufficiency,adultssubjects:65%(Birnbaum)Convergenceexcess:84%(Gallaway,Scheiman)Accommodativeanomalies:80-90%(Rouse）Possiblynoglasses!VisionTherapyMostpatientswithA/BVproblemscannotbetreatedwithlensesorprismaloneOnly5ofthe12commonA/BVproblemscanbetreatedwithlensesorprismaloneBestTreatmentApproachbyDiagnosisAccommodativeinsufficiency Addedplus,VisionTherapyIll-sustainedAccommodationAddedplus,VisionTherapyAccommodativeExcess VisionTherapyAccommodativeInfacility VisionTherapyConvergenceInsufficiency VisionTherapy,PrismDivergenceInsufficiency Prism,VisionTherapyConvergenceExcess Addedlenses,VisionTherapyDivergenceExcess VisionTherapyBasicEsophoria VisionTherapy,Prism,AddedLensesBasicExophoria VisionTherapy,AddedLenses,PrismFusionalVergenceDysfunction VisionTherapyVerticalphoria Prism,VisionTherapyScheiman&Wick,2014VTisTreatmentofChoiceconvergenceinsufficiencydivergenceexcessfusionalvergencedysfunctionbasicexophoriabasicesophoriaaccommodativeexcessaccommodativeinfacilityVTCanBeUsedto:increaseamplitudeofaccommodationincreaseaccommodativefacilityeliminateaccommodativespasmincreasefusionalvergenceamplitudesincreasefusionalvergencefacilityeliminatesuppressionimprovestereopsisimprovetheaccuracyofsaccadesandpursuitsimprovestabilityoffixation診所vs家庭VT基于診所的標(biāo)準(zhǔn)治療集合不足訓(xùn)練研究（CITT）非斜視性雙眼視或調(diào)節(jié)問(wèn)題：12-16診所訓(xùn)練每天15分鐘家庭VT(HTS)單純的家庭VT次要的選擇經(jīng)濟(jì)上的考慮遠(yuǎn)距離9根據(jù)診斷確定的最佳治療方法調(diào)節(jié)不足 正鏡,視覺(jué)訓(xùn)練調(diào)節(jié)不持久 正鏡,視覺(jué)訓(xùn)練調(diào)節(jié)過(guò)度 視覺(jué)訓(xùn)練調(diào)節(jié)不靈活 視覺(jué)訓(xùn)練集合不足 視覺(jué)訓(xùn)練,棱鏡?發(fā)散不足棱鏡,視覺(jué)訓(xùn)練集合過(guò)度 正鏡,視覺(jué)訓(xùn)練發(fā)散過(guò)度 視覺(jué)訓(xùn)練,加負(fù)鏡基本內(nèi)斜 視覺(jué)訓(xùn)練,棱鏡,加鏡片基本外斜 視覺(jué)訓(xùn)練,加鏡片,棱鏡融像功能障礙 視覺(jué)訓(xùn)練垂直隱斜 棱鏡,視覺(jué)訓(xùn)練10VT集合不足發(fā)散過(guò)度融像功能障礙基本外斜基本內(nèi)斜調(diào)節(jié)過(guò)度調(diào)節(jié)不靈活11VT可以用來(lái):增加調(diào)節(jié)幅度增加調(diào)節(jié)靈敏度消除調(diào)節(jié)痙攣增加融像性集合幅度增加融像性集合靈敏度消除抑制改善立體視增加掃視和追隨的準(zhǔn)確性增加注視的穩(wěn)定性不能改變AC/A值1213基于診所的VTvs.家庭VT基于診所的視覺(jué)訓(xùn)練每周就診1-2次訓(xùn)練師訓(xùn)練每周5次，每次15分鐘家庭作業(yè)14家庭視覺(jué)訓(xùn)練所有的訓(xùn)練在家里計(jì)算機(jī)軟件非計(jì)算機(jī)設(shè)備30分鐘5X/周15VT中的反饋信號(hào)1.復(fù)視2.模糊3.抑制4.運(yùn)動(dòng)知覺(jué)5.SILO(近小,遠(yuǎn)大)16復(fù)視有力的線(xiàn)索易于向顧客解釋如果眼睛沒(méi)有平行有立即的反饋提供患者克服復(fù)視的方法17ApertureRule模糊解釋重要性代表低或過(guò)的聚焦顧客可以做出相應(yīng)調(diào)節(jié)的改變克服磨合18QuoitVectogram抑制易于解釋所有雙眼視的視覺(jué)訓(xùn)練過(guò)程包含一些用于監(jiān)測(cè)抑制的視標(biāo)例如,“R”和“L”其他的一些標(biāo)志點(diǎn)/十字垂直或水平線(xiàn)1920QuoitVectogramRL21Tranaglyph動(dòng)感知覺(jué)調(diào)節(jié)或集合的壓力意識(shí)顧客應(yīng)能感覺(jué)區(qū)別:刺激和放松調(diào)節(jié)集合或發(fā)散讓顧客解釋他的感覺(jué)感覺(jué)眼睛緊張或放松?感覺(jué)正在看近，交叉眼睛看遠(yuǎn)，放松眼睛？22SILO反應(yīng)SILO：近小遠(yuǎn)大23SILOBO-近小

BI-遠(yuǎn)大

24圖例BO25圖例BI26SILO的重要性反饋給病人的表現(xiàn)27SILO的重要性最佳的情景:集合集合的感覺(jué)覺(jué)得變小了感覺(jué)變近了28集合和調(diào)節(jié)的平面29使用鏡片改變需求(-)30使用鏡片改變需求(+)31使用棱鏡改變需求(BI)32使視覺(jué)訓(xùn)練容易BO:鏡片?棱鏡?BI鏡片?棱鏡?33調(diào)節(jié)集合調(diào)節(jié)集合使視覺(jué)訓(xùn)練容易BO技術(shù):34調(diào)節(jié)集合加負(fù)鏡片BIM使視覺(jué)訓(xùn)練容易BO技術(shù):35調(diào)節(jié)集合加BI棱鏡BIM使視覺(jué)訓(xùn)練容易BI技術(shù):36調(diào)節(jié)集合加plus鏡片BOP使視覺(jué)訓(xùn)練容易BI技術(shù):37調(diào)節(jié)集合加BO棱鏡BOP使視覺(jué)訓(xùn)練難BO:鏡片?棱鏡?BI鏡片?棱鏡?38調(diào)節(jié)集合調(diào)節(jié)集合使視覺(jué)訓(xùn)練難BO技術(shù):39調(diào)節(jié)集合加plus鏡片BOP使視覺(jué)訓(xùn)練難BO技術(shù):40調(diào)節(jié)集合加BO棱鏡BOP使視覺(jué)訓(xùn)練難BI技術(shù):41調(diào)節(jié)集合加負(fù)鏡片BIM使視覺(jué)訓(xùn)練難BI技術(shù):42調(diào)節(jié)集合加BI棱鏡BIM視覺(jué)訓(xùn)練中的鏡片與棱鏡BIM和BOPBI和Minus有同樣的效果BO和Plus有同樣的效果43雙眼視和調(diào)節(jié)訓(xùn)練的指南1.按照下列順序a.屈光不正的光學(xué)矯正b.加鏡片c.棱鏡d.遮蓋44分析數(shù)據(jù)集合不足發(fā)散過(guò)度融像功能障礙基本外斜基本內(nèi)斜調(diào)節(jié)過(guò)度調(diào)節(jié)不靈活眼球運(yùn)動(dòng)障礙45正鏡鏡片集合過(guò)度基本內(nèi)斜調(diào)節(jié)不足調(diào)節(jié)不持久加負(fù)鏡鏡片基本外斜發(fā)散過(guò)度46Pre-SchoolChildren治療方案47階段1與患者建立良好關(guān)系告知患者意識(shí)到各種反饋機(jī)制達(dá)到正常的正融像性集合（smooth）達(dá)到正常調(diào)節(jié)幅度、能刺激和放松調(diào)節(jié)訓(xùn)練自主性集合達(dá)到正常負(fù)融像性集合范圍（smooth）的能力達(dá)到正常的正融像性集合靈敏度（jump）達(dá)到正常的負(fù)融像性集合靈敏度（jump）訓(xùn)練從集合到散開(kāi)能力在改變調(diào)節(jié)需求的條件下訓(xùn)練集合在追隨和掃視雙眼共同運(yùn)動(dòng)下訓(xùn)練聚散階段2階段3階段1的訓(xùn)練項(xiàng)目48診所內(nèi):Brockstring技術(shù)sincludingsmoothbeadpush-up,beadjumps,和imaginarybugonastring.Lenssorting,Looselensrock,vectograms,focusonBOcomputerorthopticsr和omdotprogram,focusonBO.家庭訓(xùn)練BrockstringHTS集合和調(diào)節(jié)programsLooslensrockBrockStringComputer正位ptics階段2&3的活動(dòng)49VectogramsApertureRuleEccentricCirclesVectograms；Aperturerule；Eccentriccircles；Computerorthopticsjumpconvergenceprogram辦公室訓(xùn)練狀態(tài)訓(xùn)練次數(shù)雙眼視/調(diào)節(jié)問(wèn)題12-16次眼球運(yùn)動(dòng)問(wèn)題16-20次視覺(jué)處理問(wèn)題30-40次45分鐘辦公室，每周1-2次；15分鐘家庭訓(xùn)練，每周5次VTdecisionprocess步驟/程序DiagnosisPrognosisAge&intelligenceofchildMonetary/insuranceissuesSymptomsMotivationTreatmentdurationCaseJosh,a13yearold,iscomplainingofeyestrain&blurredvisionafter10minutesofreading.Heishealthyandisnottakingmedications.Henoticedtheproblemlastyearbutitseemsworsesincehehastoreadmorein8thgrade.ExamVA20/20OD,OSRefraction:+0.50+0.50Stereo:20sec;+grossformsColorvision:normal,OUPupils,motility,confrontationfieldsnormal,OUCovertest:Distance:orthoNear:8exophoria(XP)CTN:+1.0010XPExamNearpointofconvergence:Accommodative:2”/4”P(pán)enlight:5”/10”Redglass:5”/16”Canyoucrossyoureyes?ExamAmplitudeofaccommodation:13D,OD13D,OSBOnear:x/8/4BInear:10/20/10BinocularAccommodativeFacility:4cyclesperminute(CPM):failsPLUS2.00DMonocularAccommodativeFacility:12CPM,OD,OSMEM:+0.25OUAnalyzenormalsIsaccommodationOK?yesArebinoculartestsOK?Ifnot,isitPFVorNFVtests?Diagnosis?ConvergenceInsufficiencyTreatment?Lenses?Plus?FailsBAF+LowMEMLowAC/APrismVTSecrettosuccessinVT…EssentialTools….BasictoolsforthedoctortounderstandbeforepursuingtheartofvisiontherapyHowdoweknowifthepatientisseeingwhattheyaresupposedtobeseeingorobtainingfusionduringtheactivities?FeedbackmechanismsCuesforthedoctorCuesforthepatientFeedbackmechanismsDiplopiaBlurSuppressionLusterKinestheticawarenessSiloFloatLocalizationParallaxLusterPerceptionofcombinationofcolorsseenwhenpatientfusestwotargetsofdifferentcolorsShimmeringeffect---reflexlight(shinning)VT–RedandGreen65KinestheticawarenessThemeforallaccommodativeandbinocularvisiontechniquesSensationofaccommodatingorconvergingFeelingthedifferencebetweenstimulating&relaxingaccommodationFeelingthedifferencebetweenconverginganddivergingKinestheticawarenessAskthechildtoexplainwhatheisfeelingDoesitfeellikeyouarestrainingorrelaxingyoureyes?Doesitfeellikeyouarelookingcloseandcrossingyoureyesorlookingfarandrelaxingyoureyes?KinestheticawarenessTherapywillprogressfasterifpatientisabletodeveloptheawarenessSILOSmallInLargeOutPerceptualsizechangesintargetwhilemaintainingfusionduringconvergenceanddivergenceConvergence–TargetappearssmallerDivergence–TargetappearslargerWhySILO?SizeconstancyGeometricexplanationRetinalimagesizeisneveractuallychanging69FloatSILOphenomenon(distanceaspect)TargetisfloatingcloserorfartherawayasthedemandischangedFloatSILOphenomenonConvergenceFloatscloserDivergenceFloatsawayFloatIndividualusesvergenceasacuefortheperceptionofdistance.ThepersonperceivestheobjecttobemovingcloserbecauseheisconvergingandheknowsfrompreviousexperiencethewhenhedoessoitmeansheislookingatanobjectmovingcloserWhenconvergingpatientassumessincetheyareincreasinglyconvergingthetargetmustbecomingclosertothem.LocalizationFeedbackcueforvergencetherapyPatientpointstowherethetargetappearsinspaceIfthepointerandthepatient’svisualaxiscorrespond,boththepointerandthetargetwillbesingleConvergencevs.Divergencetherapy73ParallaxAppreciationofmovementofthefusedtargetasthepatientmovesDoesthetargetmoveinthesamedirectionasthepatientmovesortheoppositedirection?ParallaxConvergencedemandWithmotionThetargetmovesinthesamedirectionasthepatientPatientmovestotherightandthetargetmovesrightPatientmovesbackandthetargetmovesback.DivergencedemandAgainstmotionThetargetmovesintheoppositedirectionofthepatientWheredowestart?Whatisthemainissue?GeneralguidelinesforVTprogrammingLeveloftechniqueisbasedoninitialexaminationStartbelowexpectedperformanceAvoidfrustrationUsepositivereinforcement---givePatientencouragementWhatisthemainissue?CI?(ConvergenceInsufficiency)VoluntaryConvergenceTechniquesStartwithaccommodation--->STAGE1:FirstSessionLenssorting:distinguish+andminusLooseLensRockBrockStringTranaglyphsComputerOrthopticsTechniques-------------->LensSortingMonoculartechniqueHelpspatientdevelopawarenessofstimulationandrelaxationofaccommodationEquipmentLooselensesofvariouspowersAccommodativeRockcard82LensSorting-ProcedureHavepatientviewtextthroughvariouslensesAskpatienthowlensesaredifferentSizeoftextFeelingassociatedwithlookingthroughlenses–focusingorrelaxingfocusDoesthelensmakeyoulookcloseorfar?Askpatienttosortthelensesfrommostplustomostminus83LensSortingBeginwithlensesthatareverydifferent(1Ddifferences)Endpoint:Patientcansorteightlensesin0.5Dincrementsfrommostplustomostminus84ConvergenceNormalizeconvergenceEventuallydevelopvoluntaryconvergenceStartwith------------------>STAGE1:FirstSessionLenssorting:distinguish+andminusLooseLensRockBrockStringTranaglyphsComputerOrthopticsBrockStringGoalsAwarenessofdivergingandconvergingDevelopvoluntaryconvergenceNormalizenearpointofconvergenceEquipmentBrockstringLenses87BrockStringWhitestringwiththreecoloredbeadsTieoneendofthestringonadoorhandle,holdtheotheratthenose88BrockString-ConvergenceHavepatientfixatered(closest)beadatabout24inchesfromthepatient’snoseAskhowmanystringsarecomingin/outofbeadAskhowmanyyellow/greenbeadspatientseeswhenfixatingredbeadPhysiologicaldiplopia89BrockString-ConvergenceWorkonmovingthebeadclosertothepatient’snoseuntilthepatientcanconvergeto2.5cmandholdconvergencethereforatleast5secondsJumpbetween2.5cmbeadand60cmbead90BrockString–BugonaStringTrainingvoluntaryconvergenceHavethepatientfollowanimaginary“bug”upthestringVoluntaryconvergencewithoutstring91VariableTranaglyphsObjectives--->Normalizepositive&negativefusionalvergenceamplitudesDecreasethelatencyofthefusionalvergenceresponseIncreasethespeedofthefusionalvergenceresponseVariableTranaglyphsDescription------>Onered&onegreenslideCreateconvergence&divergencebyseparatingthe2slidesVariableTranaglyphsProcedure----->Patientwearsred/greenglassesRedlensoverrighteyeRighteyeseesgreenslideDistance=40cmPrismaticdemandisprintedatbottomofslide40cm=4mmseparation=1prismdiopter(pd)VariableTranaglyphs:IncreasingdemandProcedure----->Howdoweincreasetheconvergencedemand?BOPMovethegreenslidetotheleft&redslidetotheright=crosseddiplopiaAddpluslensesAddBOprismDecreasetheworkingdistanceVariableTranaglyphs:IncreasingdemandProcedure----->Howdoweincreasethedivergencedemand?BIMMovethegreenslidetotheright&redslidetotheleft=uncrosseddiplopiaAddminuslensesAddBIprismdecreasetheworkingdistanceprismaticdemandisdeterminedbytheworkingdistance.100cm/1cm=1pdwd/separationincm40cm,4mmseparation=1pd20cm,2mmseparation=1pdVariableTranaglyphsProgramming----->Step1:ObtainfusionEstablishpatientsabilitytofeeleyescrossing(BO)andrelaxing(BI)Step2IncreasedemandindirectionofdifficultyAssessfeedbackmechanisms–SILO,floatStep3Addlookaway/lookback;regainfusion10secondsAddopposinglensesandprism,decreaseworkingdistanceAddaccommodativebinocularflippersVariableTranaglyphsMotivators------>(Feedback)ConvergenceTrytokeepthetargetsingle&clearCanyouseethetargetfloating?Canyoufeelyoureyescrossing,lookingtowardyournoseorworkinghard?ImagineyoureyescrossinglikewhenyouweredoingthebrockstringVariableTranaglyphsMotivators------>(Feedback)DivergenceTrytokeepthetargetsingle&clearCanyoufeelyoureyesrelaxing,imagineyouarelookingfarawaythroughtheslideintothenextroomImagineyoureyesrelaxinglikewhenyouweredoingthebrockstringIncreaseworkingdistanceVariableTranaglyphsVariations----->(modifications)ConvergenceAllowthepatienttouseapointertoregainfusionBIMDivergenceAllowthepatienttouseaportableslideholder&lookthroughtheslideoutthewindowatafarawayobjectBOPIncreaseworkingdistanceVariableTranaglyphsGoal------------>33BOand10-15BICanachievefusionwith+/-2.00flippersCanalternatebetween25BOand10-15BIin15cycles/minuteComputerOrthopticsBaseoutHomeTherapyBrockstringSessionThree/FourHartChart(largeonthewalltenfeet,andpushtheneartargetclosercloser---usethelooselensbackandforth)BugonastringTranaglyphsComputerOrthopticsHartchartObjectives-------->Restore恢復(fù)accommodativeamplitudesRestoreaccommodativefacilityHartchartProcedure----->Smallchartat40cmFarchartat10feetReadstoplinenear;2ndlineoffarchart;alternatesHartchartProcedure----->Next,pushupatnearto1stblurthenpulloutuntilfirstclearsprint&readtopline;alternatewithdistanceHartchartGoal------------>“=inches‘=feetUpto20yearsold:alternate3”nearpointwith10’farpoint20+years:?accommodativeampnearpointwith10feetfarpointBrockstringProcedure----->BugonastringNobeadsFixatefarendofstringSlowlymoveeyesalongstringcloser&closerasiffollowingacrawlingbugto1inchinfrontofnoseThendivergefromnosetofarendofstringTranaglyphStep3–increasedemand!Addlookaway/lookback;regainfusion10secondsAddopposinglensesandprism,decreaseworkingdistanceAddaccommodativebinocularflippersComputerorthopticsBOHomeTherapyBrockStringHartChartStage3:SessionFive/SixTranaglyph/Vectogram:BO/BIEccentriccircles-BOAperatureRule-BOBinocularAccommodativeFacilitywithsuppressioncheckEccentriccirclesObjectives--->Normalizepositive&negativefusionalvergenceamplitudesDecreasethelatencyofthefusionalvergenceresponseIncreasethespeedofthefusionalvergenceresponseEccentricCircles:EC’sWhatdoweneedforEC’s?VoluntaryconvergenceEccentriccirclesDescription------>FreespaceChiastopic,orthopicfusionChildfusesbyconverginginfrontoftheplaneofaccommodationordivergingbehinditThirddegreefusion=stereopsisAntisuppressioncues&accommodativecontrolsNoglassesEccentriccirclesDescription------>“A”&“B”printedonthebottom:Helpmonitorchild’sresponses“A”stogetherBO=outerringfloatsBI=innerringfloats“B”stogetherOppositeEccentriccirclesDescription------>Stereopsis:EccentricityoftheinnercirclescreatesretinaldisparityEccentriccirclesDescription------>Prismaticdemand:NoscaleoncardMeasureseparationofsimilarpointsFormulafor40cm:.4cmseparation=4mmseparation=1pdEX:cards6cmapart.4cm/1pd=6cm/X=.4cmX=6cmX=6/.4=15pdEccentriccirclesProcedure----->UseopaquecardsforconvergenceandclearcardsfordivergenceEccentriccirclesProcedure----->Cardsareheldwith“A”stogetherat40cmShouldsee2cardsAskchildto“crosstheireyes”Shouldnowsee3setsofcirclesIgnore2sideimagesShouldseeouterringfloatingcloser“clear”shouldbeclear!EccentriccirclesGoal------------>Clearfusionwith:Convergence:12cmcardseparation（30）Divergence:6cmcardseparation=15PDAlternatebetweenconvergence&divergencewith:--voluntaryCards6cmapart20cycles/minuteMaintainfusionwhilemovingcards:Left,rightandinacircleCards6cmapartAperatureAnopeningorwindowthatseparatestheviewsofeacheyesothatoneeyeseesoneportionofthetargetwhiletheothereyeseesanotherpartAperatureruleObjectives-------->Normalizepositive&negativefusional

vergenceamplitudesDecreasethelatencyofthefusional

vergenceresponseIncreasethespeedofthefusional

vergenceresponseAperatureruleWhentoadminister-------->Aftergoalsoftranaglyph&vectrogrammetRequiresabilitytovoluntarilyconvergeanddivergeRequiresabilitytopreciselyaccommodate&convergeInitialsettingrepresentsaprismaticdemandCannotuseneutralizingdemandAperatureruleDescription------>Combinationofsecond-degreeorflatfusion&thirddegreeorstereopsisChiastopic&orthopicfusionasopposedtoanaglyphicorpolarizedfusionAperatureruleDescription------>AntisuppressioncuesEccentricstereoringsoneachcardAboveisacrossseenbyoneeyeBelowisasmalldotseenbytheothereyeAccommodativecontrolsDistancesetbyapparatusat40cmPrismaticdemand=card#X2.5AperatureruleDescription------>Chiastopic(BO)VisualaxisiscrossedrelativetothefixationdistanceatthetargetPlaneofaccommodation=planeofcardsPlaneofconvergence=singleaperatureAperatureruleDescription------>Orthopic(BI)fusionVisualaxisisuncrossedrelativetothefixationdistanceatthetargetPlaneofaccommodation=planeofcardsPlaneofvergence=behindthecardsAperatureruleProcedure----->ConvergenceSingleaperatureat#1/2markCardsat“placeAPcardshere”P(pán)laceendofstickatbridgeofnoseAperatureshouldbebetweenthenose&cardsAperatureruleProcedure----->divergenceDoubleaperatureat#1/2markCardsat“placeaperaturecardshere”P(pán)laceendofstickatbridgeofnoseAperatureshouldbebetweenthenose&cardsAperatureruleProcedure----->CovereacheyetoshowthateacheyeseesadifferenttargetObtainclear,singlevisionatcard1&2Aftertheattendingcardisclear&singlethenincreasetonextcard#&moveaperaturetocorresponding#AperatureruleGoal------------>ConvergenceClear,singlebinocularvisionCard#12DivergenceClear,singlebinocularvisionCard#6Binocularaccommodativefacility

ObjectivesDecreasethelatencyofaccommodativeresponseunderbinocularconditionsIncreasespeedofaccommodativeresponseunderbinocularconditionsBinocularaccommodativefacility

Procedure----->Selectlensesbasedoninitialexam:BAFPatientreadsprintthroughbothared&greenbar&thenlensesareflippedPatientshouldbeabletovoluntarilystimu