WHAT’S NEW IN EYE CARE? Richard Madonna, OD Kirk Smick, OD Jack Schaeffer, OD Andrea Thau, OD Mark Dunbar, OD Peter G. Shaw-McMinn, OD Moderator

Ancient Wisdom “The road to success is always under construction” Lily Tomlin

One of the advantages of our profession is we have the opportunity to improve the quality of our patient’s life on a daily basis.

Today’s Objectives The attendee will be able to: Be aware of new technologies and practices developed in the past few years which can result in improved patient care Know how to access more information on the new technologies and practices Recognize how these new technologies and practices can be used in the clinic to improve patient care

Format minute presentations Q/A following each presentation Comments by experts Final Q/A

1. Description of treatment program 2. How it can benefit patients 3. Sources for more information

What is NeuroVision? NeuroVision is a computer based treatment program that improves visual acuity by improving the processing of visual stimuli by the visual pathways. This program requires examination by an optometrist and follow up exams by an assistant Virtually every type of patient can improve their visual acuity

What Determines Our Visual Acuity?

Retinal image + Neural Processing

Visual system

Cells in the retina

Neuronal morphology Dendrites: shaft, spines, specialized synaptic structures Extensions of cell body, with same membrane & organelles Shape and number characteristic of each type of neuron; shape determines number of synaptic sites, physiological properties

Lateral Geniculate Body

LGN has six layers of cells

Striate Cortex

Striate Cortex has 6 layers 1.3 million ganglion and LGN cells diverge to 260 million neurons in the visual cortex Layers 5 and 6 project back to the LGN Layer 4 goes on to higher cortical layers Cells are arranged retinotopically as in the LGN, so cells located next to one another in the cortex process information from areas of the visual field located next to one another. More cortical cells are devoted to processing macular information than peripheral information. 50% of the striate cortex is devoted to processing information from the central 10 degrees of visual field. Borish.

Visual Cortical Cells In 1959 Hubel and Wiesal discovered that cortical cells responded to certain orientation of bar targets. All cells within a column through the 6 cortical layers have roughly the same orientation preference.

Receptive fields in V1 of visual cortex Recall that the receptive fields of both ganglion cells and LGN neurons were center-surround, and that they responded optimally to points of light. Neurons in the cortex, however, respond very poorly to points of light. The optimal stimulus for most cortical neurons turns out to be a bar of light, in a very specific orientation. How did this come about?

How we see Light strikes our retinal photoreceptors which converts chemicals into energy releasing electrical stimulation to the bipolar cells with lateral interactions modulated by the horizontal cells which releases energy to ganglion cells whose lateral interactions are modulated by amacrine cells. The 1.3 million ganglion cells compose the optic nerve which goes to the lateral geniculate nucleus and organized into 6 layers where lateral interactions occur between on/off midget cells. From there, 1.3 million cells terminate in the striate cortex where lateral interactions occur in 260 million cells which further process the image allowing us to see.

What happens when something goes wrong with this? AMBLYOPIA

So, who is amblyopic? Could a 20/20 eye be amblyopic? During our developmental years, the visual pathway efficiency depends upon a sharp image on the retina. No sharp image, less cell interactions and decreased v.a. How many of us have sharp images on our retina during our formative years?

Lack of sharp image on retina Most kids are hyperopic, going into and out of focus. Many have uncorrected astigmatism. At age 4 2/3 have astigmatism. Borish Many have higher order aberrations. (20% of blur in average person.) Only a few of us have our visual pathways developed for maximal v.a. (Think Ted Williams)

What if we could improve the visual pathway efficiency in the adult? What if we could increase the cell size and number of connections throughout the visual pathway in adults?

NeuroVision Testing and Treatments The patient is examined and best prescription is determined. Baseline data is gathered on uncorrected v.a.s and best corrected v.a.s Baseline data on Contrast Sensitivity Function is obtained with uncorrected v.a.s and best corrected v.a.s Baseline data is entered into the NeuroVision system over the internet for the patient. This allows NeuroVision to determine at what level to begin the treatments.

FACT CSF chart and ETDRS Acuity chart

Treatment sessions The patient is seated at a computer 5 feet away. Each session lasts 25 to 30 minutes and is composed of 10 – 12 sections. During each session only one orientation of target is shown.

Treatment session The patient is asked to make a forced choice between flashes of targets. – Which one had the target (limits on spatial frequency threshold) – Which target was brighter (contrast differential) – Which one was aligned higher or lower (vernier acuity)

Treatment Targets Spatial Frequency Local Orientation Contrast Target-Flankers Separation Target Displacement Global Orientation

Treatment sessions 1 treatment a day 2 to 7 treatments per week. 15 treatments give 85% of the gain 20 to 30 treatments total

Lateral Masking – NVC Fundamental Technique  This stimulation-control technique is called “Lateral Masking”, where collinearly-oriented flanking gabors are displayed in addition to the target gabor image, in a specific controlled manner  Neuro scientists demonstrated that the contrast sensitivity function of adult subjects can be increased significantly through precise control of stimulus parameters

Controlled home/clinic environment Sessions of minutes each 20 to 30 Sessions (depending on the patient) Once a day or as few as two sessions per week Patient Management Treatment end – When patient’s vision does not further improve Treatment Set-Up Baseline Test by optometrist Computerized analysis of neural inefficiencies Administration Progress Interim tests by technician Results automatically sent to Data Center Individualized sessions adjust to progress Customization Each session directly treats neural inefficiencies Treatment

Results of Clinicals in US Amblyopia Low myopia Presbyopia Expect about 2.5 lines of v.a. improvement

Implications for our patients – Amblyopes – Low myopes, hyperopes, astigmats – Early presbyopes – Pathology patients – Post LASIK – Learning disabilities – Individuals who require or desire excellent visual acuity

Product Line  Existing  Presbyopia (Up to Add +1.5D)  Low Myopia (Up to -1.5DS DC)  Pediatric Myopia  Post Refractive Surgery  Adult Amblyopia (“Lazy Eye”)  Future  Super Vision—Sports Vision, Military, etc.  IOL Enhancement  Contact Lens Enhancement  Early AMD Enhancement

Solve Your Patient’s Visual Acuity Complaints by Prescribing NeuroVision Technology Course 3113 Saturday 8:30 – 9:30 Peter Shaw-McMinn, OD Assistant Professor Southern California College of Optometry

For more information:

Richard Madonna, OD Associate Professor at SUNY Chief of ocular disease and special testing Past adjunct professor at ICO and NEWENCO Staff optometrist at FDR VA hospital Private practice in New Paltz and Walden, NY Co-authored a book, several book chapters and articles Given presentations throughout the US Conducted research on pathological conditions Soccer, basketball and baseball coach