Vergence Therapy Activities

peripheral, central

initial targets for vergence VT should be _______, then move to ______ targets

stereopsis/3rd degree (then move to 2nd then 1st)

for pts performing therapy w/ an exo posture, you should start with ________ targets

simultaneous perception/1st degree (then move to 2nd then 3rd)

for pts performing therapy w/ an eso posture, you should start with ________ targets

15-20pd

for most NFV activities, the goal is _____

25-30pd

for most PFV activities, the goal is _____

easier, earlier

activities that are “in machine” or unnatural situations (stereoscope, synoptophore, vectograms, tranaglyphs) are often _______ & should be performed _______ in the therapy plan

1. kinesthetic/vergence awareness

2. tonic slow expansion

3. phasic fast expansion

4. free fusion

5. BIM/BOP

what is the outline for vergence therapy?

kinesthetic (vergence) awareness

• goal: allows the pt to understand, feel, & gain the sense of converging & diverging

• therapist focuses on gross vergence skills & having the pt gain the sensation of vergence at distance & near

• activities

  • stick n straw

  • brock string

  • binocular push-ups

  • barrel card

tonic (slow) extension of ranges

• goal: pt slowly extends their ability to converge or diverge using techniques to provide feedback on clarity & diplopia

• first performed in a highly controlled, focused environment, then can introduce small amounts of visual noise & distractors

• initial targets are peripheral then once accomm is normalized b/t 2 eyes, can change to central targets

• activities:

  • mirror stereoscope

  • vectograms

  • tranaglyphs

phasic (fast/jump) extension of ranges

• goal: have the pt be able to quickly jump from a convergence position to divergence position & vice versa while maintaining clarity & singularity w/o suppression

• can be peripheral or central targets

• activities:

  • prism jumps

  • vectogram/tranaglyph jumps

  • non-variable tranaglyphs

free fusion (chiastopic & orthopic) activities

• goal: pt to voluntarily fuse 2 images in space w/o the use of filters in a more natural environment

• activities:

  • lifesaver cards

  • eccentric circles

BIM/BOP activities

• goal: integrate accomm & vergence sysetms through antagonistic therapy

• vergence system reacts in 1 way while the accomm system reacts in the opposite direction

• activities:

  • BIM/BOP flippers

  • vectograms/tranaglyphs w/ acccomm flippers

stick-n-straw

• purpose: to allow the pt to gain awareness of converging & help normalize NPC

• record: # of reps, # of successful reups, closest distance to pt, additional comments

• goal: improvement of ability to converge & awareness of vergence

• easy for home therapy but requires training the parent/guardian to act as the therapist

binocular push-ups

• purpose: to develop awareness of convergence/divergence, voluntary convergence, & to normalize NPC

• record: target used, min distance from the pt’s BON to the target fused, any easy/difficulty

• goal: pt should be able to converge the target 3-5cm from their nose

• easy home therapy

brock string physiological diplopia & jumps

• purpose: develop awareness of convergence & divergence, voluntary convergence, & to normalize NPC

• record: distance of beads pt can successfully maintain fixation, suppression, easy at which activity was performed, episodes of under/over convergence & at what distance

• goal: pt should be able to appreciate the differences in how their eyes feel while converging or diverging, pt should be able to converge the near bead placed 5cm from their nose

• easy home therapy

brock string walking the bug

• purpose: develop voluntary convergence & divergence

• record: nearest & furthest distance the pt was able to fuse & the quality of the movement, was the pt able to do it smoothly, suppression

• goal: for pt to easily & proficiently move up & down the string w/o suppression or jumping

• easy home therapy once pt & family member are trained on how to perform

brock string loose prism jumps

• purpose: to improve pt’s vergence facility & flexibility

• record: distance of beads & prism amount for BI & BO the pt can perform consistently w/o suppression & w/ accuracy, any changes made to adjust difficulty

• goal: accurate fusion of the near bead at appropriate distance while alternately using 15pd BI & 25pd BO prism w/o suppression

• in office only

barrel card

• purpose: develop the ability to converge the eyes w/o suppression

• record: record placement of card, any difficulty w/ one of the barrels, # of reps or time, suppression

• goal: pt can hold fusion for 5-10sec easily on far, middle, & near barrels, pt should be able to complete 10 cycles of middle to far to near then back down w/o suppression

• easy home therapy once pt & family member are trained

mirror stereoscope

• purpose: to increase & improve fusional vergence amplitudes

• record: position of break/recovery, any adjustments made to increase/decrease difficulty

• goal: 25-30pd BO & 15-20pd BI w/ recovery w/in 5pd

• can be sent home if pt is having difficulty improving ranges

vectograms

• purpose: develop normal SILO/localization, develop normal vergence ranges & recoveries, improve speed & efficiency of vergence jumps

• record: type of activity, target used, tools to increase/decrease difficulty, presence/absence of localization & SILO, letter/number for break & recovery on ranges, highest setting for convergence/divergence pt can consistently keep single & clear & # of cycles performed for jumps

• goal: reach L & 30 on range extension & jumps

• in office

variable tranaglyphs

• purpose: initially used to improve NFV & PFV, later to decrease latency of vergence response & increase velocity

• record: WD, target used, direction of therapy, pd of break, type of break, assistance required, recovery point

• goal: successfully maintain fusion at 15-20pd BI &/or 25-30pd BO, recovery w/in 5pd

• in office

non-variable horizontal tranaglyphs

• purpose: to improve the pt’s vergence facility & flexibility

• record: card & prismatic demand for each direction performed that the pt was able to consistently clear & fuse, modifications done to increase/decrease difficulty, if one direction is easier/harder

• goal: pt should be able to clear & fuse 25-30pd BO & 15-20pd BI

• in office

aperture rule

• purpose: to help the pt improve their convergence & divergence ability w/ accurate accommodation

• record: # of card pt could easily clear & fuse for convergence & divergence, assistance or items used to increase difficulty

• goal: pt should be able to fuse card 12 for BO & 7 for BI while keeping targets clear

• in office

Bernell-O-Scope

• purpose: to increase fusional vergence amplitude

• record: BO/BI cards used, highest card completed, name of card set, if trombone method was used, distances cards were placed

• goal: to normalize PFV & NFV amplitudes & complete BI & BO sets

• in office

bottom

when looking at the BI Bernell-O-Scope books, which image is ortho?

top

when looking at the BO Bernell-O-Scope books, which image is ortho?

flip the card over

when using the non-variable tranaglyph cards, how do you switch b/t BI & BO?

tromboning

dynamic & alternative method to improve vergence amplitudes by moving targets in & out on the scale; as cards move further from pt, the BO demand increases

lifesaver cards

• purpose: increase the amplitude of NFV & PFV, decrease latency, & increase velocity of fusional vergence response

• record: type of activity, level achieved, use of pointer, suppression

• goal: pt should be holding floating 3rd circle keeping it clear for at least 10sec for each of the 4 levels of the card & be able to perform w/o pointer

• easy home therapy

eccentric circles

• purpose: increase the amplitude of NFV & PFV, decrease latency, & increase velocity of the fusional vergence response in free space

• record: type of fusion used, separation of the targets that allowed the pt to adequately fuse, any modifications,

• goal: clear fusion w/ a card separation of 6cm for orthopic & 12cm for chiastopic

• easy home therapy

1. minus lenses & tell pt to clear target & look hard

2. move target further away from pt

3. get feeling of looking close, cross eyes, work harder

how can you coach a pt that is struggling with chiastopic activities?

1. plus lenses & tell pt to clear target

2. move target farther away from pt

3. relax eyes, get the feeling of looking in the distance, look through the target

how can you coach a pt that is struggling with orthoptic activities?

look hard, pretend to look closer

how do you coach a pt struggling w/ PFV?

relax, think about looking in the distance

how do you coach a pt struggling w/ NFV?

1. look close, make eyes feel tighter

2. place pointer on top of window opening

how can you coach a pt struggling with convergence w/ aperture rule?

over

if the pt reports that the target is blurry when training convergence w/ aperture rule, the pt is most likely _____accommodating

instruct pt to keep their eyes crossed through aperture but relax their focus slightly to clear target

if the pt reports that the target is blurry when training convergence w/ aperture rule, how can you coach them?

look far, relax eyes

how can you coach a pt struggling with divergence w/ aperture rule?

under

if the pt reports that the target is blurry when training divergence w/ aperture rule, the pt is most likely _____accommodating

instruct pt to keep eyes looking straight to keep targets single but to tighten focus up to make it clear

if the pt reports that the target is blurry when training divergence w/ aperture rule, how can you coach them?

more dramatic, use a pointer

when performing vectograms, the further apart the pt pulls the pictures, the _______ the depth effect should be, if the pt is struggling you can _________

+3.00 lenses

how can you switch the mirror stereoscope to a distance activity?

1. cross eyes, look close

2. move card farther away from pt

3. use minus lenses

4. cut card in half lengthwise to decrease septum effect

how can you coach a pt that is having difficulty with convergence on barrel cards?

1. tell pt to line the stick up before attempting to insert into the straw

2. give the pt feedback on where their eyes are pointed during the activity

3. ask the pt how their eyes feel & if they notice a difference b/t when the straw is close or far

how can you coach a pt through the stick-n-straw activity?