Wednesday, October 31, 2012

Dry eye syndrome hurts work productivity

Study of dry eye disease and work productivity

A study published in the October 2012 issue of ClinicoEconomics and Outcomes Research found that dry eye disease causes workers to loose productivity and costs their employers big bucks.

The study, by Japanese researchers, looked at a total of 396 individuals aged 20 years or older (258 men and 138 women).  Study subjects were classified into the  following four groups according to the diagnostic status and subjective symptoms of dry eye: a definite dry eye group; a marginal dry eye group; a self-reported dry eye group; and a control group. The impact of dry eye on work productivity was evaluated using the Japanese version of the Work Limitations Questionnaire. The cost of work productivity loss associated with dry eye and the economic benefits of providing treatment for dry eye were also assessed.

The study found that degree of work performance loss was 5.65% in the definite dry eye group, 4.37% in the marginal dry eye group, 6.06% in the self-reported dry eye group, and 4.27% in the control group. Productivity in the self-reported dry eye group was significantly lower than that in the control group. The researchers estimated that employers loose $741 per year for every dry eye sufferer that they employ.

The study shows that dry eye impairs work performance among office workers, which may lead to a substantial loss to industry. Management of symptoms of dry eye by providing treatment may contribute to improvement in work productivity.

Dry eye and quality of life

The prevalence of dry eye varies among the reports with some studies putting the number as high as 30% of the population.  Dry eye disease is a chronic eye disorder in North America. The risk of going blind or suffering permanent vision loss due to dry eye is low.  Nevertheless, it has a significant impact on the daily and social lives of affected patients.  In our Vancouver dry ey clinic, we have seen patients whose dry eye disease was so debilitating that they could not hold down a job and were permanently disabled.   One study foudn that patients with dry eye syndrome had more difficulty reading, carrying out professional work, using a computer, watching television, and driving compared with those without dry eye.  (see Miljanovic B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007; 143(3):409–415.). 

For more information on dry eye disease and visit
For the basic facts about dry eye disease and for dry eye downloads, visit our Vancouver clinic website here.

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Sunday, October 28, 2012

Alternatives to strabismus surgery - vision therapy is 87% effective

Vancouver's children's optometrist -Vision therapy for strabismus is an alternative to surgery

Under optimal clinical conditions the success rate for vision therapy treatment of strabismus is 87%

Vision therapy/orthoptics has been used to successfully treat the various forms of strabismus for over 100 years. Numerous studies have found it to have a 75% success rate in achieving normal cosmetic alignment of the eyes as well as functional binocular vision.  Under optimal clinical conditions such as those in a private practice optometric clinic where each patients receives individualized, one-on-one care, the success rate can be as high as 87%.

The Ludlam Study on Vision therapy for strabismus

Dr. William Ludlam conducted a landmark study, but not the first such study, of 149 strabismus patients who came for treatment at the Optometric Centre of New York.  Ludlam summarized the results as follows: 

"combining the functional and almost cured groups and adding four patients whose eyes ware straight ... but are listed as 'moderately improved' because of the the technical requirements of the 'cured' categories (2 subnormal ranges of motor fusion, 1 with a 7" N.P.C. rather than the required 4", and 1 with frequent asthenopia, headaches and accomodative spasm), we may state that a total of 113 (76%) of the patients in the sample had binocular vision with straight eyes 95% of the time or more at dismissal from teh regular clinic training sessions. The other 36 patients had residual deviations occurring more often than 5% of the time, and were classified as orthoptic failures. Of these, 8 of the "moderate improvement" group dropped out when quite near the "almost cured" category, i.e. with their eyes straight well over half the time and possessing all of the technical factors necessary for a cure with several moths of additional stabilization work."

Even though the Ludlam study produced outstanding results, Ludlam pointed out that the patients treated at the Optometric Centre were treated in poor clinical conditions. For example, they received group therapy, control and management of each case was relatively poor, and they were treated by different clinicians who had diferent personalities and treatment approaches.  He expected that under the optimal conditions of a private practice optometric office, the results would be even better.  Indeed, subsequent studies shown this to be the case.   Click here to read more about the Ludlam study.

The Hoffman & Allen Study on vision therapy for strabismus

Another significant study addressed Ludlam's expectation that optimal clinical conditions would produce better results.  The study, by Hoffman, Cohen, et al., found that the vision therapy treatment fo strabismus had an 87% success rate in clinical circumstances that were "near optimal" such as those conditions that obtain at a private practice optometric clinic.  The researchers also found that younger patients were easier to treat than older ones and that exotropes (patients whose eye turns outwards towards the wall) were easier to treat than esotropes (patients whose eye turns inwards towards to nose) .  Even so, the vision therapy treatment of esotropes achieved a very impressive success rate of 74.5%.  Moreover, the maximum success rate of 100% was obtained in treating intermittent and periodic eye turns whereas constant eye turns were treated at a still-impressive success rate of 76%.

Case Reports on vision therapy for strabismus

Numerous case reports have been published documenting the treatment of strabismus patients with vision therapy.  The most recent was published in August 2011 in the journal Optometry by Peddle and Steiner who discussed two cases of adults with moderate sized intermittent exotropia (eyes turned outward to the wall). Both patients also had asthenopia (eye fatigue and discomfort), headaches, and/or diplopia (double vision). Twenty to 30 in-office VT sessions were recommended to reduce the magnitude and frequency of the deviation as well as improve their binocularity and decrease their symptoms. After completing VT, both patients became phoric for all distances, had normal vergence ability, and had normal near points of convergence.

The most famous case of vision therapy treatment for strabismus

In an inspirational book called Fixing My Gaze, neuroscientist, Susan Barry, who was born with strabismus and had lived all her life without depth perception as a consequence, meaning that she could not see in three dimensions.  The book was's number 4 science book of 2009.

She had three surgeries to "correct" the eye turn cosmetically but she still could not see properly and the eye was still turned, although less than before. She had lived this way for over 40 years until she met optometrist Dr. Theresa Ruggiero.

Dr. Ruggiero treated Susan with vision therapy and corrected the eye turn and allowed her see in three dimensions for the first time in her life. Can you imaging how her world was transformed? I've heard rumors of a "Fixing My Gaze" movie but have not been able to confirm them.

Doctor Barry has received much attention for her book and her experience with vision therapy.  She has been interviewed for numerous publications and her story was the subject of a feature article in the New Yorker.  

You can visit Susan Barry's website here.  Here are some videos of Susan Barry talking about vision therapy and strabismus:

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Saturday, October 27, 2012

Poison in eye drops puts some kids in a coma - FDA issues a safety warning

The United States Food and Drug Administration (FDA) has issued a warning about over-the-counter eye drops.

The danger is that children may accidentally swallow the eye drops.  The drops in question are used to relieve redness in the eyes and they include the popular Visine brand of drops.  

Keep in mind that there are safer and more effective alternatives available on the advice of your optometrist.  In fact, at our Vancouver clinic, we almost never recommend these drops because of their danger and because they only "get the red out" of your eyes by narrowing blood vessels, which does not treat the cause of the redness and ignores the fact that there is a biological reason why  blood vessels are so visible in your eyes in the first place and it is that reason that needs to be addressed if the condition is to be properly treated.  

The eye drops can be dangerous because they contain the active ingredients tetrahydrozoline, oxymetazoline, or naphazoline. These same ingredients are also found in some nasal sprays.  These products are sold under various brand names, as generics, and as store brands (see List of Products created by the FDA below).

The FDA reviewed 96 cases of accidental swallowing in  children 5 years of age and younger. There were no deaths but swallowing had serious consequences requiring hospitalization such as:
  • coma,
  • decreased heart rate, 
  • decreased breathing, and 
  • sedation (sleepiness) 

These serious conditions have occurred on the swallowing of  only a small amount (1-2 mL; for reference, there are 5 mL in a teaspoon) of the eye drops. Most of these redness-relief eye drops  do not currently come packaged with child-resistant closures, so children can accidentally ingest the drug if the bottles are within easy reach.

Consumers should store these products out of reach of children at all times. If a child accidentally swallows these eye drops  and seek emergency medical care immediately.

List of Products*
Products containing tetrahydrozoline
Products containing naphazoline
Products containing oxymetazoline
Visine Original
Visine A
Visine L.R.
Visine A.C.
Ak-Con Ophthalmic Solution
12 Hour Nasal Decongestant Nasal Spray
Visine Advanced Relief
Napha Forte Ophthalmic Solution
Afrin Extra Moisturizing Nasal Spray
Visine Totality
Naphazoline HCl Ophthalmic Solution
Afrin No Drip Severe Congestion Nasal Spray
Visine Maximum Redness Relief Formula
All Clear Ophthalmic Solution
Afrin No Drip Sinus Nasal Spray
Walgreens Redness Reliever Advanced Eye Ophthalmic Solution
All Clear AR Maximum Strength Ophthalmic Solution
Afrin No Drip Sinus Extra Moisturizing Nasal Spray
Tyzine Nasal Spray
Opcon-A Ophthalmic Solution
Afrin Original Nasal Spray
GNP Original Eye Drops
Naphcon A Ophthalmic Solution
Afrin Severe Congestion Nasal Spray
Opti-clear Ophthalmic Solution
Walgreens Eye Allergy Relief Drops
Dristan 12 Hour Nasal Spray
Tetrahydrozoline HCl Ophthalmic Solution

Equaline 12 Hour Nasal Spray
Today’s Health Original Eye Drops

Equaline 12 Hour Extra Moisturizing Nasal Spray
Leader Eye Drops Regular Formula Ophthalmic Solution

Equate Nasal Spray

GNP 12 Hour Nasal Spray

GNP 12 Hour No Drip Nasal Spray

GoodSense 12 Hour Nasal Spray

Leader 12 Hour Nasal Spray

Maximum Strength Nasal Decongestant Nasal Spray

Mucinex Full Force Nasal Spray

Mucinex Moisture Nasal Spray

Nasal Relief Spray

Neo-Synephrine 12 Hour Nasal Spray

Publix Nasal Spray

Select Brand Nasal Spray

Sinex Nasal Spray

Sudafed OM Nasal Spray

Today’s Health Nasal Relief Nasal Spray

Tope Care 12 Hour Nasal Spray

Walgreens Anefrin Nasal Spray
*List may not be all-inclusive. Check the Drug Facts label on the package to determine the active ingredients of any over-the-counter product.
  1. Spiller HA, Rogers J, Sawyer TS. Drug facilitated sexual assault using an over-the-counter ocular solution containing tetrahydrozoline (Visine®). Legal Medicine 2007;9:192-5.
  2. Katar S, Taskesen M, Okur N. Naloxone use in a newborn with apnea due to tetrahydrozoline intoxication. Pediatr Int 2010;52:488-9.
  3. Tobias JD. Central nervous system depression following accidental ingestion of Visine eye drops. Clin Pediatr (Phila). 1996;35:539-40.

Friday, October 26, 2012

What MDs say about vision therapy

Vancouver's children's optometrist on vision therapy for kids
As a member of the College of Optometrists in Vision Development, I read the COVD blog which often has excellent and up to date information of developmental vision disorders and vision therapy.  Today, there was an excellent post on that blog on what MDs say about optometric vision therapy.  

That is an interesting topic because vision therapy is not taught in medical schools but is taught in every optometry school on the continent.  This fact is often at the root of a misunderstanding between some MDs and optometrists about what vision therapy is, what diseases it treats and why it works.  

The topic is a timely one for COVD to discuss because one of the most famous (and one of the only) developmental vision MDs - developmental ophthalmologist, Dr. Lea Hyvarinen, addressed the COVD at last weekend's annual meeting.  We wrote about her and her new book in a previous post.

Here is the COVD's collection of statements from MDs about vision therapy:
Pediatrician and Parent Advocate for the National Center for Learning Disabilities

Dr. Debra Walhof is a Pediatrician who specializes in Integrative Medicine.  During the past 20 years, she has practiced in hospital, academic and community-based clinical settings.  Her work has focused primarily on multi-cultural and under served populations who present as "at risk" across many developmental and behavioral domains.  According to Dr. Walhof:

“It is important to remember that normal sight may not necessarily be synonymous with normal vision... That being said, if there is a vision problem, it could be preventing the best tutoring and learning methods from working. Now that certainly doesn't mean every dyslexic child needs vision therapy, however in my opinion, skills such as focusing, tracking and others are essential foundational tools for reading. In general, if your child has trouble with reading or learning to read, getting a vision evaluation to assess these skills from a qualified Developmental Optometrist would be a smart move.”

Psychiatrist & Physician

Dr. Katherine Donovan, a Psychiatrist from Charleston, S.C., was one of those parents who didn’t give up, “It wasn’t until my own child had problems with reading that I discovered that my medical training was missing a very valuable piece of information which turned out to be the key to helping my daughter, Lily. While I had taken Lily to many ophthalmologists and learning specialists, desperate to understand why this very bright child still could not read well, or write legibly at age 12, I always got the same answers:  ‘her vision’s fine’ and ‘she’s dyslexic.’”

“As a physician, I had been taught that vision therapy was controversial and could not treat learning disabilities. However, my personal experience with my daughter proved to me that vision therapy worked, when nothing else did,” Dr. Donovan shares. “While vision therapy cannot treat learning disabilities, per se, it absolutely corrected a vision problem which was blocking Lily from being able to learn. After a visit with a developmental optometrist who tested over 15 visual skills critical to reading and learning, I was shocked to learn that Lily was seeing double out to three FEET—which meant that when she tried to read, the words were double. No wonder she hated to read!” Following optometric vision therapy, “Lily now reads 300 pages a day, in her free time; she puts down ‘reading’ as her favorite hobby; and she has a 95-average at Buist Academy with NO help from me on her homework! Prior to this, I’d been spending three to four hours each night, for many years, tutoring Lily,” Dr. Donovan shares with delight. 

 Physician and Medical Expert Witness for Medico-Legal Cases

Even though there is a wealth of optometric research which proves vision therapy works, as Dr. Donovan mentioned, there is false information in the medical community about vision therapy.  This can be confusing for parents, especially when it comes from their child’s pediatrician.  

Dr. Joseph Manley, a physician and medical expert witness for medico-legal cases, states, “The conclusions (particularly the failure to recommend vision therapy for children likely to benefit from it) of the American Academy of Pediatrics report on Learning Disabilities, Dyslexia and Vision are based on exclusion of the most relevant data and inconsistent application of the Academy's stated criteria for selecting evidence.  They fail to acknowledge abundant published and anecdotal evidence supporting the use of vision therapy.  This overlooked evidence includes controlled trials, observational studies, case reports and consensus of experts - the same kinds of data that underpin the daily practice of medical professionals.”
Neurologists & Leading Clinicians on Learning Disabilities

Brock Eide, M.D., M.A. and Fernette Eide, M.D., leading clinicians and writers on learning disabilities, state, “In spite of the very positive research findings validating the role vision plays in learning, some are still claiming visual dysfunction plays little or no role in the reading challenges that dyslexics face. This is a shame. When we look specifically at the results of studies performed to address specific visual issues, the evidence supporting visual therapy is quite strong.”

The Eides run the Eide Neurolearning Clinic in Edmonds, Washington, are authors of the popular book, The Mislabeled Child:  How Understanding Your Child’s Unique Learning Style Can Open the Door to Success, and lecture throughout the U.S. and Canada to parents, educators, therapists, and doctors. Drs.  Eides have published extensively in the fields of gifted education, learning disabilities, and twice exceptionalities such as giftedness and dyslexia, and served as consultants to the President's Council on Bioethics.
 “While not all children or adults with dyslexia have visual processing problems, many --at least two-thirds in some studies-- do. This makes sense from a neurological standpoint, because several of the structural neurological features associated with dyslexia appear to predispose to visual difficulties,” Dr. Brock Eide adds.

“Not surprisingly, several types of visual difficulties are more common in dyslexic than non-dyslexic children. In one study of dyslexic children, just one type of visual problem, near-point convergence insufficiency, was present in 30-40% of the dyslexic children, compared to just 20% of controls. As can be seen from this control figure, visual processing problems are also quite common in non-dyslexic school-age children,” Eide continues.

Dr. Fernette Eide explains, “The bottom line is that visual problems are common, though not universal, in children who struggle to read; and optometric vision therapy can help address visual problems in children with significant visual dysfunction. A good visual examination is an important part of the workup of every struggling reader.” 


Ophthalmologist, Dr. Bruce Sumlin, writes, “Optometric vision therapy makes sense.  It is very similar to other kinds of treatment and therapies we provide in the medical disciplines which help to develop neural connections in the brain.”John B. Ferguson III, MD, an ophthalmologist who has been in practice for over 34 years, was not always a strong believer in vision therapy.  When asked what made him change his mind, Dr. Ferguson shared, "Among ophthalmologists, vision therapy has been thought to be reserved for certain eye muscle disorders. I was unaware, and I believe many other ophthalmologists are also unaware, of the significant effects that these eye muscle disorders have on the attitude and behavior of some children. I thought that at the most these children, if left untreated, might experience headaches or read less efficiently. However, I had the opportunity to speak with children and the parents of children who went through vision therapy and I was very impressed by the dramatic and positive academic and behavioral changes they experienced."

According to ophthalmologist, Robert Abel, in his book The Eyecare Revolution: 
“Vision therapy is taught at optometry schools; ophthalmologists know very little about it … It can change people’s lives, as it has for President Lyndon Baines Johnson’s daughter, Lucy, whose dyslexia was helped greatly by vision therapy.”
In an editorial responding to an article, “Optometric Vision Therapy &Training for Learning Disabilities and Dyslexia,” Dr. Paul Romano, ophthalmologist and editor of the Binocular Vision & Strabismus Quarterly states:

“…why should I think that my fellow ophthalmologists are correct about dyslexia and learning disabilities virtually never being a real eye problem and amenable to some eye directed therapy? I must trust my own 30 years of personal experience.”
“There is no doubt in my mind that the exams most orthoptists, ophthalmic technicians and ophthalmologists, including pediatric ophthalmologists, perform for the learning disabled or the dyslexic child are too often inadequate or incomplete and are unable to find these ‘subtle abnormalities of monocular and binocular vision which may give rise to these problems...”

“Also I simply do not believe the current organized ophthalmology-pediatric ophthalmology mantra that virtually nothing with regard to binocular vision (except maybe convergence insufficiency) can be affected, altered or improved by anything other than surgery. There are too many other areas in medicine where change is achieved without drugs or surgery.”

How to Identify a Vision Problem
Children should be referred for a comprehensive eye exam whenever visual symptoms are noticed or if they are not achieving their potential. Many of these vision problems will not be detected during a school vision screening or limited vision assessment as part of a school physical or routine pediatric health evaluation. 
Locate a Doctor in your area who is experienced and knowledgeable in diagnosing and treating learning-related vision problems.

Related article:

What teachers say about vision therapy

    Thursday, October 25, 2012

    Take your kids to see "Thor": doctor's orders!

    Vancouver's pediatric optometirst - doctor examining a child's eyes
    One of problems in diagnosing vision disorders in children is that children who have never had normal vision have no way to know that there is anything wrong with their vision.  They have always seen that way and they think that everyone else sees that way too.

    Most optometrists can tell you a story of a young child, perhaps 5 or 6 years old who goes to the eye doctor because she is not picking things up in school and a visual problem is suspected.  It turns out that the child is severely myopic and has likely never even seen the faces of her parents beyond identifying them as a particularly shaped blurr.  It is a heart warming moment when the child sees her mother clearly for the first time!  Here is a video of Dr. Randahwa telling this story about what happened with a five-year old girl in our Vancouver opometry clinic:

    The same is the case with patients who have strabismus or ablyopia.  While the former may present itself in the form of a noticeable eye turn, amblyopia (or lazy eye, as it is is sometimes known - a condition where one eye is not working properly and may even be legally blind) is not obvious.   Patients with these conditions suffer from binocular vision problems (when the two eyes do not work together properly) and will often have stereo vision problems that make it impossible for them to see in 3D.  The problem is that such a child will not be able to tell you that there is anything wrong with her vision, because it has been that way for her entire life.  Read my older post about the book "Fixing my Gaze" to learn about a famous case of 3D deficiency and how an optometrist used vision therapy treated the problem.

    Lack or depth perception and 3D vision could be a sign of a potentially life threatening disease.  It could be caused by eye cancer shutting off communication between one eye and the brain.  Cancer such as this should be caught early before it causes noticeable vision changes - that is the key to successful treatment and the reason why annual eye exams for children are so critical.

    Vision problems in kids show up when watching 3D movies - Vancouver's children's optometrist
    3D movies (like Thor, pictured to the right) and video games are an opportunity for parents to test 3D vision.  If a child does not experience the sensation of objects coming out at her from the screen, she may have a binocular vision problem.  You can ask your child to reach out for an object that is popping out of the screen.  If she does not reach out or does so at inappropriate times, you should take her to the optometrist for clinical testing.  

    You can also ask your child to describe what the 3D movie or game is like.  Be careful not to ask vague questions like, "is this movie different from an ordinary movie?"  The child will be wearing 3D glasses, which can alter color and so the movie will be different for those reasons alone. 

    While 3D media offer parents an opportunity to catch a visual problem, parents can always, and should regularly visit their optometrist where visual disorders like strabismus and lazy eye are routinely tested and diagnosed. 

    Properly functioning binocular vision is not just necessary for enjoying the latest entertainment but it is vital for learning, sports, driving and it is necessary for many careers (you can't be an eye surgeon without good binocular vision, for example).

    For more information of children's vision, eye care, and children's optometry, please visit

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