Optometry Education Upliftment Program on vision therapy (OEUP: VT) is sub-specialty based on fellowship program for Eye health workers. It is especially design for optometrist (Dhristi Besesghya). It contains comprehensive course design from basic to advance step by step. It contains 45 to 55 lectures’ courses. Course can be taken by those candidates who had passed the entrance exam and first level.

2.1.  Criteria

To pursue Optometry Education Upliftment Program, the interested candidates need to fulfill the following eligibility criteria:

• Candidates must be pursuing or have completed bachelor’s degree or B.Sc. in Optometry from any recognized institute.
• Candidates who are ongoing with their bachelor’s degree must have a recognition letter from their college/university.
• Candidates need to secure at least 50% aggregate marks at graduation level.
• Clinicians must be registered to their country’s authorized Medical Council as Nepal Health Professional Council in Nepal.

3.1. Required Documents

The applicant is required to submit copies of the following documents with the application form:

• Graduation Certificate/Marksheet
• Students ID Card or Council Registration Number
• Recommendation Letter
• Passport Size Official Photo

All the certificates should be photocopied and submitted with proper attestation. Enrolment is conditional upon completion of all the registration formalities including payment of fee determined by the foundation. Incomplete application shall not be processed for intake.

3.1. Course contains

General concepts in behavioral vision care and optometric vision therapy
Objectives of this module

After the completion of this module, participants will have basic understand on
Introduction to behavioural concept of vision
• Visual Development and developmental milestones
• Primitive reflexes and its importance

3.1.1. Brain and vision: Neural anatomy of visual processing, Parvo and Magno functions, ambient and focal system), Vestibular system (anatomy and physiology and its relation to visual
system – 1.5 hrs

3.1.2. Model of vision: Skeffington model of vision, Top down and bottom up information
processing system – 1 hr
•

3.1.3. Milestone development: development of infants, Visual development and its relation to developmental milestones, importance of proper visual development, Emmetropization: 1 hrs

3.1.4. Primitive reflexes: Different types of major primitive reflexes, their role in development of different visual functions) 1.5 hrs
•

3.1.5. Scientific basis for optometric vision therapy: Clinical evaluation supporting the evidence of behavioral vision therapy), Individual consideration in vision therapy, Instrumentation of VT (fundamental principle in accommodation, vergence therapy) 1 hr

Total lecture hours: 5 hrs

3.1.1. NSBVD (Non-Strabismic Binocular Vision Disorders)

Visual dysfunctions related to near work (non-strabismic binocular vision disorders)

Non strabismic binocular vision anomalies are highly significant and prevalent condition among young generation people who spend most of their time in digital devices. This condition is often associated with headache, eye strain, blurred vision and many more. Proper diagnosis and treatment can be done with different tools and vision therapy which will improve quality of life of the patient.

Highlights

• Things to be considered while evaluating of visual dysfunctions due to near works (different vergence anomalies, accommodation anomalies)
• Recent concepts in management of visual dysfunctions due to near point stress
• Role of lens and prisms to rehabilitate visual dysfunctions
• Active vision therapy from behavioural approach

1. Course content for Non strabismic Binocular Vision Disorders
2. Assessment of non-strabismic binocular vision disorders

• CT, Phoria measurement using the Von Graefe/Modified Thorington Technique, Fixation disparity Assessment, AC/A ratio
• Assessment of fusional vergence:

Smooth Vergence testing, Step Vergence Testing, Vergence facility testing, Near Point of Convergence, Negative Relative Accommodation and Positive Relative accommodation

• Evaluation of sensory status: Worth Four-dot test, Bagolini Striated lenses, Stereopsis
• Assessment of Accommodative functions: Amplitude, Facility, Response (MEM)
• Evaluation of Eye movements: Fixation stability, Saccades (Direct observation, Visual verbal, Objective recording), Pursuits

1. Classification of accommodative and Non strabismic Binocular Vision Problems

• Anomalies with Low AC/A ratio (Convergence Insufficiency, Divergence Insufficiency)
• Anomalies with Normal AC/A ratio (Fusional Vergence Dysfunction, Basic Exophoria, Basic Esophoria)
• Anomalies with High AC/A ratio (Convergence Excess, Divergence Excess)
• Vertical heterophoria (Right or Left Hyperphoria)
• Accommodative anomalies (Accommodative Insufficiency, Ill sustained Accommodation, Accommodative excess, Accommodative infacility)
• Oculomotor Problems (Oculomotor dysfunctions)

1. Recent Concepts in Treatment

• Assessment of Symptoms (CISS survey, COVD-QoL)
• Recent concepts on Sequential Management: Optical correction, Prism, Tints, Filters, Occlusion, Vision Therapy

1. Tools Used in Vision Therapy

• Lenses (behavioural characteristics of plus and minus lenses, SILO concept, Staging the lenses for different vision therapy activities)
• Prisms (different forms of prisms, use of prism in vision therapy, spatial perception concepts of prism, Monocular, biocular, yoked)
• Filters (uses of different filters like polarized filters, anaglyphic filter in vision therapy)

1. Active Vision Therapy

• Research evidence in usefulness of vision therapy for NSBVD
• General concepts of active vision therapy for NSBVD
• Accommodation Therapies: Bulls eye, Near/Far Accommodative Rock, Lens sorting, Monocular/Binocular lens rock, Wach’s Mental Minus, Search and Say, Focus it)
• Fusional Vergence therapies: Tranaglyphs, Aperture Ruler, Life saver cards, Free Space cards, Eccentric circles, Barrel Card, Brock String (9-point gaze, jump slides, Push pull, Rocket-ship, walk back, bug on a string), Lens flippers, Thumb to thumb walk, Fusion cards, Overlapping pictures.
• Oculomotor Therapies: Eye Stretch, Central/Peripheral Saccades, Trace the ball, Spatial Circles, Race tracks, Figure 8, Column Jump, Ball games with Marsden Ball, Bunting, Circle tracing, Michigan Tracing, Saccadic strips, Pointer straw, Mapple’s Double Pursuits, Four chart fixations

3.1.2. Amblyopia and strabismus

3.1.2.1. Amblyopia

Aim and objective of the module

1. To discuss new concept and advances in amblyopia and strabismus.
2. To discuss how and why do strabismus and amblyopia develop.
3. To understand the supplemental test to diagnose the condition.
4. To understand the behaviours of strabismus and amblyopes.
5. To discuss behavioural vision therapy for amblyopia and strabismus.

Expected outcome:

The participants will be able to evaluate, diagnose and manage amblyopia and strabismus subjects.

3.1.2.2.  Strabismus (10hours)

1. Concepts in strabismus (1hour)

• The myths of critical period
• Binocular processing model
  • Sensory fusion
  • Motor fusion
• Classification of strabismus
• Behavioural aspects

1. Diagnostic evaluation of strabismus (2hour)

• Case history
• Assessing refractive status

Static retinoscopy

Dynamic retinoscopy

Cycloplegic retinoscopy

• Assessing Visual acuity
• Assessing monocular fixation (angle kappa, visuoscopy, haidingers brushes, After image transfer test)
• Assessing visual efficiency (ocular motility, accommodation)
• Assessing binocular status
  • ocular deviation (direction and magnitude) (Hirschberg, krimskey, CT)

Special consideration of CT

• Assessing comitancy
  • Paralytic strabismus
  • AV pattern
  • Dissociated vertical deviation
  • Duanes syndrome
  • Browns syndrome
• Sensorimotor fusion
  • Major Amblyoscope
  • Worth 4 Dot
• stereopsis

• Adaptive conditions (suppression, EF, correspondence)

Correspondence:

Bagolini Striated Lenses

Major Amblyoscope

Hering-Bielschowsky After-Image Test

• Assessing primitive reflexes
• Bilateral integration

1. Management strategy(3hour)

• Concepts underlying treatment

neuroplasticity and neurogenesis

• Prognostic factors
• Behavioural treatment
  • Behavioural use of Lens and prism

(ametropic correction, bifocal lens prescription)

• Behavioural Occlusion therapy
• Behavioural neuro-optometric vision therapy

• Treatment of suppression

Red green prism dissociation

Bar reader

Prisms

• Treatment of Eccentric fixation

Red filter treatment

CAM stimulator

Pleoptics therapy

Bangerters method

Cuppers method

• Treatment of abnormal correspondence
• Treatment of paralytic strabismus

1. Management of Exotropia(1.5hour)
   1. Classification
   2. Lens and prism therapy
   3. Monocular procedures:

(fixation, pursuits, saccades, EHC, accommodation, visuo-spatial perception)

1. Bi-Ocular Procedures: To eliminate suppression

Pathological diplopia awareness

1. Binocular Procedures: fusional activities

New concepts

1. Syntonics
2. Reflex interation procedures
3. Bilateral integration procedures
4. Kraskins eye control therapy
5. Central peripheral integration

1. Management of Esotropia(1.5hour)
   1. Lens prescription
   2. Monocular procedures: To eliminate eccentric fixation and to equalize performance of each eye

(fixation, pursuits, saccades, EHC, accommodation, visuo-spatial perception)

1. Bi-Ocular Procedures: To eliminate suppression
2. Binocular Procedures:
   1. Elimination of AC
   2. Develop binocularity and stereopsis
3. Bilateral integration

New concepts:

1. Binasal occlusion
2. Syntonics
3. Primitive Reflex Integration
4. Bilateral Integration and balance
5. Optokinetic Nystagmus – OKN
6. Vestibular – Ocular Reflex – VOR
7. Eye stretching exercises
8. Peripheral awareness

1. Case studies (1hour)

3.1.3. Special Needs Population

Objective:

This module will focus primarily on the optometric care of the population with special needs. We require modification with the evaluation and management of these population so in this module will primarily converge over the following objectives:

1. Identification of how vision and motor development is linked.
2. Understanding the factors of developmental delay and its impact on visual development.
3. Understanding the role of an optometrist in the management of the visual problems of individual with special needs.
4. Understanding the different types and aetiologies of conditions of populations with special needs
5. Development of the optometric clinical skills for the diagnosis and management of the population with special needs.
6. Identify modifications/ adaptive assessment techniques for the evaluation of special populations.
7. Identify common learning related visual problems, their evaluation and management.
8. Understanding the approaches for evaluation and management of traumatic/ Acquired brain injury.
9. Understanding the rationale of use of compensatory prism, lenses and Syntonic
10. Highlighting the importance of multidisciplinary approach to care of the population with special needs.

3.1.3.1. Course outline:

1. Understanding Developmental Delay
2. Factors influencing the developmental delay

• Prenatal development
• Parental lifestyle during pregnancy
• Environmental factors during pregnancy
• Complications during the process of the birth
• Prematurity and low birth weight
• Genetic

1. Types of developmental delays

• Cognitive delay
• Motor delays
• Social, emotional and behavioural delays
• Speech delay

1. Consequence of untreated visual deficit in children with special needs
   • spatial awareness, posture and movement skills
   • use of hands and fine movement coordination
   • Early concept development, for example, object permanence
   • Locating sound in space
   • Understanding of the meaning of words and therefore speech and language development
   • Social interaction and communication
   • Self-care skills.
2. Role of Optometrist In The Management Of Population With Special Needs

• The role of optometrist in the vision care of the population with special needs
• Role of the optometrist with the parents
  • Role of optometrist with other multidisciplinary team professionals
  • Role with educators and their educational settings
  • Role with physical therapist
  • Role with speech language pathologist
  • Role with occupational therapist

• Overview, Types and Etiologies of Populations with Special Needs
• Cerebral Palsy
• Down Syndrome
• Autism Spectrum Disorder
• Cortical Visual Impairment
• Intellectual disability of unknown etiology
• Rare Neurodevelopmental disorder
• Alzheimer disease
• Parkinson’s disease
• Huntington disease
• Learning disability
• Psychiatric illness
• Depression
• Bipolar disorder
• Schizophrenia
• Panic disorder
• Obsessive compulsive disorder
• Post-Traumatic stress disorder

1. Optometric Assessment of Populations with Special Needs
2. Case History

• Chief complaint
• Birth history
• Medical history
• Developmental history
• Previous assessment and treatment
• Visual history
• Psycho- educational evaluation
• Audiologic, speech and language
• Occupational and physical therapies
• Neurologic evaluation
• Other assessment and treatments
• Behavior and attention
• Family history

1. Visual acuity

• Snellen acuity test
• HOTV test
• Lea symbols test
• Broken wheel test
• Allen picture chart test
• Tumbling E test
• Forced choice preferential looking chart
• Cardiff acuity cards
• Bailey-Hall cereal test
• Bock candy Bead acuity test
• Optokinetic nystagmus
• Visual evoked potential

1. Binocular Posture

• Direct observation
• Bruckner’s test
• Hirschberg test
• Krimsky test cover test
• Worth four dot test

1. Refractive anomalies assessment

• Static retinoscopy
• Mohindra near retinoscopy
• Keratometry
• Cycloplegic retinoscopy

1. Ocular health

• Anterior and posterior segment evaluation

1. Color vision

• Farnsworth munsell D-15
• Ishihara plate test

1. Oculomotor system

• NSUCO method for saccade and pursuit
• King Devick test
• Developmental eye movement test
• Readalyzer/visagraph

1. Accommodation system

• Monocular estimation method
• Near point of accommodation
• Accommodation facility

1. Vergence system

• Near point of convergence
• Positive fusional vergence
• Negative fusional vergence

1. Stereo vision testing

• Lang stereo test I & II
• Frisby stereo test
• Pointer and straw
• Titmus fly test
• Randot stereo test
• Randot dot E test
• Stereo smile

1. Visual Information Processing
   1. Visual spatial skills –

• Bilateral integration & laterality
  1. Visual analysis skills
• Visual discrimination
• Visual closure
• Visual form constancy
• Visual figure ground
• Visual spatial relations
• Visual memory
  1. Visual attention and processing speed

1. Visual motor integration skills

1. Sequential Management Plan of the population with special needs

• Management of oculomotor dysfunction
• Management of binocular vision and accommodative disorder
• Management of strabismus and amblyopia
• Management of visual information processing disorders

1. Overview, Evaluation diagnosis and management of Learning Disability
2. Introduction to learning disability
3. Prevalence and etiology for learning disability

1. Types of learning disability

• Dyslexia
• Dyscalculia
• Dysgraphia
• Dyspraxia/sensory integration disorder
• Dysphasia/Aphasia
• Auditory processing disorder
• Visual processing disorder

1. Clinical Assessment of learning disability

• History
• Refraction
• Ocular motility and alignment
• Accommodative- vergence functions
• Visual system integrity
• Visual information processing
• Visual spatial skills
• Visual Analysis skills
• Visual Motor skills

• Auditory visual integration
• Rapid naming test
• Executive functions
• Supplemental test
• Magnocellular pathway functioning

1. Management of learning disability

• Management of the visual efficiency problems
• Management of oculomotor problems
• Management of visual information processing problems
• Interdisciplinary approach of management

3.1.3.2. Assessment and Management of Traumatic Brain Injury

1. Introduction
2. Potential visual symptoms and performance deficits  frequently reported  post TBI
3. clinical Assessment
4. Understanding Visual midline shift/ visual neglect and its evaluation
5. Sequential Management of TBI
6. Use of lenses and prism in the management of TBI
7. Syntonic phototherapy – Basics and its usage in management of TBI

3.1.3.3. Case Based Learning on Evaluation and Optometric Management of Condition With

• ASD
• CP
• learning disability
• TBI

3.1.3.4. Technology for Rehabilitation, Treatment and Enhancement

• Computerized vision therapy programmes(SVI/ VTS)
• Computerized perceptual Therapy
• Vision builder
• Neuro-vision Rehabilitator
• HTS- iNet
• Dynamic Reader