Chantal wrote:
Hello,
I am a psychotherapist working with a client who has an eye phobia. She would like to desensitize to this phobia so as to allow her to wear contact lenses.

I have created a desensitization plan for this client, which includes having her lightly touch the whites of her eyes with a clean finger dipped in contact solution.  Would you advise against this? or would it be okay to proceed with this step?
My other question pertains to practicing putting on contact lenses.  My client must desensitize to putting on contacts prior to being fitted for them.  Can an optomotrist provide “dummy” contact lenses (unfitted) for practice?  If not, would it be advisable for my client to purchase FDA approved novelty lenses to practice with?

Finally, any overall suggestions you may have to help me to care for my client would be greatly appreciated.

Thanks

ANSWER

Hello,
This is exactly what I would do in my clinic, get the patient comfortable with eye area, by practice touching the white part of the eye.  Usually works very well, just make sure fingers are always clean, and avoid nails touching the eye.

As far as purchasing soft contact lenses or getting them from your local Optometrist, it is absolutely wise to get familiar with lens texture and handling, however when it comes to inserting lenses into your eyes for the first time and training, It is better to be under a contact lens technician or an Optometrist supervision, this is to avoid potential trauma and eye infections.  Usually Optometrist will not hand over lenses without a current contact lens prescription, for safety reasons.

My advise as far as caring for this patient is to work together with your local contact lens technician, to train your patient handling of soft contact lenses and getting over eye phobia, they are absolutely prepared to handle patients with eye phobia, and succeed every time.

Thank you,
Sally Aldayeh

JBryan wrote:
Hi,

I am a pediatric Occupational Therapist.  I am often screening tracking/convergence, etc for children.  I have a couple of questions:
1. How to find a developmental optometrist?
2. Where could I get more information/courses on how to screen, refer, and help to treat visual perceptual issues?
3. As an Occupational Therapist, what role do you me having with respect to visual perceptual concerns?
4. What kind of information should I be forwarding on regarding my findings?
Thanks!

ANSWER

JBryan,
I would suggest that you contact your provincial Optometry Association to ask for the name of a developmental optometrist in your area. You can access all provincial Associations through the “links” section at  www.opto.ca  This Optometrist can answer all of the rest of your questions. Alternately, you might contact the School of Optometry at the University of Waterloo, where I am sure someone can help you.

Dr. Joan Hansen, Optometrist for CAO

Amanda wrote:
My 14-month-old son was born after suffering a prenatal stroke. As a result, he developed hydrocephalus and then epilepsy which first manifested in his eyes. He had noticeable nystagmus and a gaze preference to the right and recently had to have brain surgery to stop his seizures.

As a result of the surgery, my son’s vision has gotten worse. We were sure he had Cortical Visual Impairment before, but now he seems to be having even more trouble with his vision and eye movements. He is currently being followed at the Montreal Association for the Blind (MAB), where CVI has just been diagnosed, but we were not given any instruction about how to help his vision at home or how to adapt his environment.

Do you have any suggestions or can you recommend a vision therapist/specialist in Montreal?

Thank you for your help,
Amanda

ANSWER

Dear Amanda
I have consulted with one of the experts in low vision at the school and with a neuro-pediatrist at Montreal’s Ste Justine hospital. Both of them agree that your son is at the best place to address this issue. Optometrists from MAB are the most experienced clinicians regarding the type of disease you son suffers from. Very shortly in the process, a treatment plan will be put in place involving optometry, ergotherapists and psychologists, etc. This treatment plan involves many meetings with the patient and will last for several months. The parent’s collaboration is mandatory and very, very important in the process, in order to stimulate the patient according to the plan. As a mother, you can also provide the essential feedback that is necessary to customize the plan and to meet your expectations. Never hesitate to contact and discuss your concerns with the optometrist that is seeing your son at MAB. They are all very dedicated to their patients and the care they provide are among the best in Canada.

Good luck,
Dr. Langis Michaud, OD, MSc, FAAO (Dipl)
Associate Professor
Université de Montréal

Renatta wrote:
My 7 yr old son has just had an eye exam where the Dr. said he has convergence excess and needs eye therapy. The treatment is very costly and they also recommended readers as well. The therapy could be as long as 1 yr and I just want to make sure that this is serious enough to make this investment. I will do anything to help my son but I don’t have money to spend on something that doesn’t need to be done or isn’t as big of a concern as they have presented it to be.  Any light you can shed on this would be appreciated.
Thanks

ANSWER

Dear Renetta

You are lucky ! Your optometrist did a very good job considering that convergence excess is rarely diagnosed on time and represents the  no. 1 reason for school drop-out. Convervence excess means that your son’s eyes cross too shortly before the text he has to read. This leads to a reduced distance for reading (25 cm vs 40-50 cm). A shorter distance is very disturbing and demanding to the visual system. Imagine  seeing a computer screen at 25 cm as opposed to 60 cm where it is supposed to be. At 60 cm, a patient that suffers form convergence excess will see 2 screens (double vision). Ocular fatigue, migraine, headaches, nausea, loss of binocular vision could develop over time. It is not rare to see this condition, left untreated to lead to school failure. Most often, the student quits before graduation because their visual system cannot handle the demand.

This is why it is crucial to treat convergence excess. This treatment includes not onlyt the prescription of reading glasses (convex lenses help to reduce convergence excess) but also on orthoptics training. The visual system has to learn how to function properly even with the presence of glasses. Namely, with exercises the eyes will “learn” to converge less and to diverge more, making reading, computer work and any near visual tasks not only more comfortable but also for prolonged hours. The future at school of your son depends on the accuracy of this treatment.  Ask yourself how much money you would spend to assure a future to your chilldren and you will be able to balance  the value of the treatment that is proposed to you.

Thanks for your interest.

Dr. Langis Michaud, OD, MSc, FAAO
Associate Professor
Université de Montréal, School of Optometry

Valeva wrote:
My daughter started crossing her eyes about 2 months ago when she was 29 months old. We took her to see an optometrist who diagnosed far sightedness and put her in glasses (+3.00 bilaterally). These seemed to help her align her eyes initially, however, after about 3 weeks, she started to again cross her eyes. We returned to the optometrist, who reported that now that her eyes were able to relax, he was getting a reading of 5.25 bilat, but that she could be in fact worse still. He mentioned drops to get a true reading of her eye, however didn’t feel like this was needed at this time, and prescribed a new set of lenses at +5.00 bilat.

My questions are this: Will we be repeating this process again, and needing new lenses again in a month? Is this common? How soon should I be seeing a result from her new lenses? And finally, her optometrist noted that she is already having to work harder to use her left eye, and was inconsistent in recognizing pictures with it (she was right on with all images shown to her right eye) when should I start to worry about a lazy eye?

ANSWER

Valeva,

Congratulations to you for getting your daughter’s eyes looked at immediately. I personally would feel better measuring your daughter’s eyes with drops to relax her focusing.  It is the only way we can be sure that we know just how far sighted she is.  Even with the drops though, it is often necessary to adjust the strength of the glasses in a  month or so.  The stronger lenses should straighten her eyes almost immediately.  The glasses are the first step (often the only step needed) in preventing a lazy eye from developing.  Your Optometrist will follow your daughter closely to assure that both eyes see well, and if not will advise about further intervention.  Often eye exercises are required, alone or, along with patching.  Your daughter is young enough to overcome a lazy eye fairly easily.  Expect to see your Optometrist every 6 months at least for the next few years.

Dr. Joan Hansen - Optometrist, for CAO

Lil wrote:
I am looking into getting information about Accelerated Overnight Orthokeratology (AOOK). I can’t seem to find much information about this process in Canada, but there is quite a bit from the US. Is this a safe procedure? Are there many places in Canada that offer this method as I have only found one in Manitoba? When was this method created/discovered? It seems like a very suitable way to repair eyes, safe & easy, as well as reversible which is why I’m asking questions. So I am basically wanting as much info as I can get and feedback from people who have tried it and the success rate. A lot I know, but I don’t want to take any chances with my eyes as I already wear glasses. Thanks!

ANSWER

Dear Lil

Your question was forwarded to me for a response, but I have little experience with Accelerated Overnight Orthokeratology (AOOK). One of my colleagues in Halifax has more knowledge and practical experience in this area, and I have taken the liberty to forward your question to her. Here is her response. I think you will find it helpful.
Dr. Smit

Dear Lil

Ortho K lenses have been around for many years and have certainly come a long way with the new overnight corneal shaping lenses. One of the first FDA approved lens is the Paragon CRT contact lens, which I am familiar with. I have personally fit about 50 patients with this lens and have found it to be safe and effective. It does not work on everyone, especially if the cornea is resistant to being molded. Also, I find it is difficult to get a full effect if the prescription exceeds -4.00D and it will not correct astigmatism over 1.00 D.
However, when it is successful, patients are extremely happy. The lens is really quite comfortable to wear while sleeping, even for dry eye patients. It is also 100% reversible.
I have mainly been fitting the lens to children with rapidly increasing prescriptions. It has been very effective in slowing down or even halting the progression of myopia in my patients over the last 5 years.
If you are interested in finding a CRT practitioner in Canada, just go to the www.paragoncrt.com website and look for a doctor in your area.
Cheers,
Dr. Toby Mandelman
Halifax, Nova Scotia

Tyler wrote:
Hi I’m 16 and I have a lazy right eye my eye doctor told me there’s nothing to do but I have been reading things on the internet that say different. I don’t really care that I see better with my lazy eye I just want it to look straight. What kind of surgery would I need? My contacts aren’t really helping me right now. I would really just like to find out a solution to my problem.
Thank you

ANSWER

Hello Tyler,
First, I should tell you that “lazy eye” is a very broad term that can mean a few things.  I’m not sure exactly which type you suffer from, but based on your concerns I will assume that one of your eyes is not straight and that same eye does not see as well as the other “good” eye.  If that is the case, than your optometrist is correct in saying that there is not much that can be done to improve the vision of the affected eye.  However, if your concern is mainly cosmetic, you may be able to have the eye surgically straightened.  Ask your optometrist for a referral to a surgeon who specializes in strabismus correction.  He/she may be able to help.
Dr. Donati

Saravanan wrote:

What is inverse bifocal? Is it prescribed for patients with ac/a ratio deficient patients.

ANSWER

Hi Saravanan,

I’m not sure what you mean by inverse bifocal.  It is not a common term used to describe glasses.  Patients with a low AC/A ratio have problems turning their eyes in comfortably while doing close work such as reading or computer use.  A lot of times this is associated with what we call convergence insufficiency.  An AC/A ratio is the ratio of the eyes turning in to the amount of focusing power. When reading the eyes need to turn in slightly to allow clear, comfortable vision.  If the eyes have trouble turning in this can cause eyestrain and even double vision.  The most common treatment for this condition is vision therapy.  This usually consists of doing exercises to strengthen the eye muscles, which allow the eyes to turn in more comfortably.  In some cases prisms are prescribed to allow the eyes to turn in with less effort, but the problem with prism is that over time adaptation can occur and the prism may have to be increased.

Dr. Doman

Michelle wrote:

My 6 year old has recently been prescribed Atropine Sulphate 1% eye drops for amblyopia, however, from the little information I can find about it I am unsure if I want to use it on her as I am extremely concerned about its safety in children. I wasn’t given much information from the specialist who prescribed either, except that it could cause blurred vision (thought that was the point of it), flushing and fever.  Also, I’m not sure if it should be used on a child with a heart murmur.  If I’d known prior to the appointment about adverse effects that I’ve read online I would have questioned the doctor more.  Unfortunately, I am unable to contact that doctor about it. Any information would be greatly appreciated.

AMSWER

Hi Michelle,

Thanks for your question.  The main thing is that your daughter’s amblyopia (lazy eye) be treated to prevent permanent vision loss.  There are generally two ways to treat amblyopia.  The more common treatment is patching of the good eye to strengthen the amblyopic eye.  The other treatment is blurring of the stronger eye with eye drops (commonly Atropine) to strengthen the weaker eye.  The disadvantage of patching is that a lot of times compliance is an issue.  It can be hard for parents to get their children to wear the patch for the specified amount of time.  As you have mentioned above the disadvantage of Atropine is that there are potential side effects.  That being said the ocular dosage of Atropine is very small and only a small amount gets absorbed into the body.  Because of this side-effects of the ocular administration are uncommon.  Studies have shown that the treatment of amblyopia with patching or Atropine will give the same result.  However it has also been shown that compliance is higher with Atropine than with patching.  I assume that you must have a follow-up appointment with the specialist?  Can you phone their office to ask these questions? As far as the use of Atropine with a heart murmur it would be best to discuss this with your daughter’s family physician and pharmacist.  I always treat amblyopia with patching and this is consistent with most optometrists.  I educate the parents on the importance of the patching and that it is essential to prevent permanent vision loss, which usually helps to increase compliance.  This is one of those cases where there isn’t necessarily one right answer.

Dr. Carol Doman

Kimberly wrote:

My 2 year old son was recently diagnosed with a +7 in both eyes by an optometrist.  My pediatrician wants a second opinion, as we do, and is sending us to a Pediatric Opthalmologist.  My question is, would my son love to play with puzzles and read books all day long if his eyes were this bad?

We were shocked because he points out tiny details in all his books (in the dark!) before bedtime.

ANSWER

Dear Kimberly,

I am more than happy that you are concerned with your children vision. You are talking about important issues here. Your optometrist is surely more than competent but your pediatrician is right to send you for another opinion. My first recommendation would be do not delay this appointment (less than a month) since your children, based on the +7,00 findings, has to be corrected (visually speaking) as soon as possible. The development of each eye, separately, and of his binocular vision (coordination of the 2 eyes leading to 3D vision) are in play. Here is why…

At 2 years old, it is not rare to find children with hyperopia, which is the case of your child. However, +7,00 is a lot ! Too much for the system to handle by itself. Habitually, the level of hyeropia is around +2,00 or less at this age and fades away as the child is growing up. This is considered a normal evolution in the development of a normal visual system.

Hyperopia means that the images seen through the eye focus behind the back of the eye (retina). When they cross the retina, the images are blurred. More severe the hyperopia is, the more blurred are the images.  When this blur is interpreted by the brain, the natural crystalline lens of the eye receives the signal to act like a zoom of a camera and to make appropriate adjustments to this image. This helps the children to see clearly. Consequently it is not surprising that your children seems to see weel. It is because his natural “focusing” reflex is working well.  However, to compensate for a +7,00 instead of a +2,00 means the same thing that to ask him to raise a bar of 10kg above his head while is capacity does not exceed 3 kg. He can do that for short term period of time but not on a long term basis. This is why many high hyperopes patients can see well at far and at near but can not stand a near task for more than several minutes. They change their target most often: drawing for 3-4 minutes, looking at TV for 2 minutes, playing ball for 10 minutes. Habitually these patients are more active in sports and outdoors activities than at near, contrary to the myopes who are good and strong readers. Some hyperopic children are even considered hyperactive while their lack of attention comes only from their visual condition. Later, patients with uncorrected high hyperopia develops headache, malaise and can have strabismus also.

At this point, to make sure that your child will have all the tools necessary to fully develop his vision, it is important to confirm the level of hyperopia by performing an oculo-visual examination under cycloplegia. The eye doctor (your optometrist (more competent to evaluate that than a pediatrician) or an ophthalmologist) will instill some drops in the eye of the child. This product will sting a little bit but drops create, for 24h00, a paresis of the crystalline lens function (pupil is also dilated in the process). This is the goal of this procedure: to cancel the effect of the crystalline lens to measure accurately the full  amount of hyperopia – This will determine the level of visual correction needed.

Visual system develops in the first 6 to 8 years of life. By the age of 6 months, each eye should be as developed as adult’s ones. Between 6 months and 6 years, the brain integrates the images coming from each eye and coordinates them in order to create 3D vision.  At 2 y.o. a level of +7,00 is considered amblyogenic if not corrected. That means that even if the children seems to see well, his vision will never develop at its full capacity if the eyes remains uncorrected. The compensation for the blurring coming from +7,00 D hyperopia is too much for the system to handle.  This is why your child needs a correction by glasses as soon as possible. Any delay creates can alter his visual development furthermore. It will be harder to fill in the gap in the future if a correction is not prescribed and worn sooner than later.

Consequently please make sure that your appointment with the ophthalmologist will be given in the following days or weeks (not months) and if the hyperopia is confirmed (I have no doubt about it-  your optometrist cannot miss that) the prescription of glasses for a full time wear should be filled in rapidly. A close follow-up of the visual development will be mandatory.

In the future, the hyperopia will probably decrease but from +7,00 it is quite sure that the children will always have the need to wear visual correction, at least to read, do computer work, to study, etc. As soon as he will be able to collaborate enough to read some letters or pictures at far and at near (usually by the age of 3) the vision will be assessed. Any lack of development (amblyopia) will have to be addressed at this time- Orthoptics (visual exercices), penalization (to occlude one eye at the time to favour the development of the other) or other techniques could be proposed to improve the final outcome.  By the age of 7-8 y.o. contact lenses can be considered. They provide sharp and clear vision without the burden of thick glasses. They are well accepted by the young patients but they involve some parents help for the cleaning and handling of the lenses. A new study done at Ohio State University proved that they are a safe alternative to glasses for higher prescriptions.

I am quite confident that with a proper prescription and follow-up your children will see well and will develop all his visual skills in order to be successful in life.

Best regards,
Langis Michaud