Volume 13 | Issue 4 | December 2025 Thank You from Optometry & Visual Performance Remembering the Life and Legacy of Bob Sanet On the Etiology of Eccentric Fixation The Success of Patching Therapy in an Infant Population at Rehabilitative Kindergartens/Nursery Schools Knowledge, Attitude, and Perception of School-Aged Children Towards Spectacle Use in Delta State, Nigeria Effectiveness of Vision Therapy for Divergence Insufficiency: A Case Series Effect of Forward Neck Posture on Ocular Accommodation Awareness, Attitudes, and Perceptions of University Students in Nigeria Toward Contact Lenses for Refractive Error Correction An Approach to Understanding Strabismus Diagnosis Let the Students Speak: Essays on Pediatrics and Vision Therapy from Southern College of Optometry 4th Years
Optometry & Visual Performance 224 Volume 13 | Issue 4 | December 2025 OVP EDITORIAL STAFF For Editorial Staff biographies, please go to http://bit.ly/OVPedit Editor-in-Chief Marc B. Taub, OD, MS, EdD . . . . . ...... mtaub@sco.edu Memphis, Tennessee Managing Editor Pamela H. Schnell, OD . . . . . . ....... pschnell@sco.edu Memphis, Tennessee Associate Editor Steven J. Gallop, OD . .. gallopintovision@comcast.net Broomall, Pennsylvania Associate Editor James Kundart, OD, MEd . . . . .... kundart@pacific.edu Forest Grove, Oregon Associate Editor Rebecca Marinoff, OD . . . . ..... rmarinoff@sunyoptedu New York, New York Advisor Leslie Holland, MLIS . . . . . . . . ........ lholland@sco.edu Memphis, Tennessee SUBMISSION OF MANUSCRIPTS All manuscripts should be submitted via the submission portal at http://bit.ly/OVPed. For more information see the Guidelines for Authors at http://bit.ly/OVPguidelines. Optometry & Visual Performance (OVP) (ISSN #2325-3487) is published quarterly. Copyright 2024 by the Optometric Extension Program Foundation. The entire contents, both text and illustrations of OVP, are copyrighted, and no part may be printed without written permission from the managing editor. All manuscripts and correspondence, including letters, reports, subscriptions, and address changes, should be addressed to the Managing Editor, Pamela Schnell, OD (pschnell@sco.edu). All editorial contributions should be addressed to Marc Taub, OD, MS, EdD (mtaub@sco.edu). All requests for information about advertising should be addressed to Marc Taub, OD, MS, EdD (mtaub@sco.edu). All expressions of opinions and statements of supposed fact published in signed articles do not necessarily reflect the views or policies of the sponsoring organization, OEPF. This organization does not endorse any specific educational program or products advertised in OVP. Acceptance of advertising or optical industry news for publication in OVP does not imply approval or endorsement of any product or service by either OVP or the sponsoring organization, OEPF. MISSION STATEMENT Optometry & Visual Performance (OVP) is an international, peer-reviewed journal dedicated to the advancement of the role of optometry in enhancing and rehabilitating visual performance. The mission of OVP is to increase the awareness and availability of clinically relevant information in functional, developmental, behavioral, and vision therapy aspects of optometry through an internet-based, open-access format. OVP is an effort of the Optometric Extension Program Foundation. ISSN 2325-3487 Volume 13 | Issue 4
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Optometry & Visual Performance 227 Volume 13 | Issue 4 | December 2025 Editorial: Thank You from Optometry & Visual Performance . . . . . . . . . . . . . . . ................ 230 Marc B. Taub, OD, MS, EdD • Southern College of Optometry • Memphis, Tennessee Tribute: Remembering the Life and Legacy of Bob Sanet . . . . . . . . . . . . . . . ................ 232 Viewpoint: On the Etiology of Eccentric Fixation . . . . . . . . . . . . . . . . . . . . ...................... 235 Kenneth J. Ciuffreda, OD, PhD • SUNY College of Optometry • New York, New York Daniella Rutner, OD, MS, MBA • SUNY College of Optometry • New York, New York Article: The Success of Patching Therapy in an Infant Population at Rehabilitative Kindergartens/Nursery Schools . . . . . . . . . . . . . . . . . . . . . . . . . .......................... 238 Kenneth Koslowe, OD, MS • Eliya, The Association for Blind and Visually Handicapped Children • Petach Tikva, Israel Article: Knowledge, Attitude, and Perception of School-Aged Children Towards Spectacle Use in Delta State, Nigeria . . . . . . . . . . . . . . . . . . . . . . ....................... 244 Kelvin Ucheka Imasua, OD, MPH, Prof Cert Med Ret, Prof Cert Glauc, MCOptom • University of Benin Teaching Hospital • Benin City, Edo State, Nigeria Vivian Ossaidiom Omuemu, MBBS, MPH • University of Benin Teaching Hospital • Benin City, Edo State, Nigeria Article: Effectiveness of Vision Therapy for Divergence Insufficiency: A Case Series . . ... 252 Santosh Chhetri, M. Optom • Metro Eye Care • Butwal, Nepal Umesh Belbase, M. Optom • Shrawan Child Center & Metro Eye Care • Butwal, Nepal Mario Cantó-Cerdán, DO, PhD • Vissum (Miranza) & University of Alicante • Alicante, Spain Aashish Kant Shah, M. Optom • Biratnagar Eye Hospital • Biratnagar, Nepal TABLE OF CONTENTS ISSN 2325-3487 Volume 13 | Issue 4
Optometry & Visual Performance 228 Volume 13 | Issue 4 | December 2025 Article: Effect of Forward Neck Posture on Ocular Accommodation . . . . . . . . . . ........... 261 Mitali Rane, MS • Southern California College of Optometry at Marshall B. Ketchum University • Fullerton, California Lawrence R. Stark, PhD • Southern California College of Optometry at Marshall B. Ketchum University • Fullerton, California Article: Awareness, Attitudes, and Perceptions of University Students in Nigeria Toward Contact Lenses for Refractive Error Correction . . . . . . . . . . . . . . . . . .................. 272 Oghenevwode Precious Omotor, OD • University of Benin • Edo, Nigeria Eghosasere Iyamu, OD, PhD • University of Benin • Edo, Nigeria Clinton Ifeanyi Okechukwu, OD • University of Benin • Edo, Nigeria Student Corner: An Approach to Understanding Strabismus Diagnosis: Part 1 . . . . . ...... 280 Tamara Petrosyan, OD • SUNY College of Optometry • New York, New York Student Corner: Let the Students Speak: Essays on Pediatrics and Vision Therapy from Southern College of Optometry 4th Years . . . . . . . . . . . . . . ............... 296 TABLE OF CONTENTS ISSN 2325-3487 Volume 13 | Issue 4
More Information OEPF CERTIFICATION At OEPF, we are committed to advancing behavioral and developmental vision for the benefit of our patients and fostering a supportive community. Utilize OEPF's resources to enhance your preparation. Scan the QR code below to learn more about OEPF Certification www.oepf.org Are you pursuing OEPF Certifcation?
Optometry & Visual Performance 230 Volume 13 | Issue 4 | December 2025 I have other family to thank. My grandparents are all here to celebrate this occasion. The Executive Board members of OEPF are the best. They take me out for ice cream when I visit and let me stay up late watching awful movies. I have a feeling that Grammy Line Vreven is talking about me when she speaks in a different language in front of me, but I have no proof! Grampy Eric Hussey tells the most awful jokes, Grampy Brad Habermehl thinks he is funny, but his jokes are as bad as Grampy Eric's. I hope I have his awesome hair when I get to be his age! My newest grandparent is Nana Tamara Petrosyan, and I can already tell you that she is going to make me eat my vegetables when I visit her! Hopefully I can sucker her kids to eat them for me. I have two special cousins to mention. James Kundart is the funcle...or "fun uncle." Unlike my grandfathers, he is super funny and always seems to be working on something! Auntie Rebecca Marinoff is a blast, and I love visiting her in New York City. She always takes me for pizza and bagels! I have two parents, but they act more like brother and sister. They are always making fun of each other, and I am pretty sure they battle it out to see who can be the most sarcastic. I get my sense of humor from both of them. My parents, Pam Schnell and Marc Taub, make a great team. Marc is the big-picture guy, and Pam is detail-oriented. She constantly gets on me about proper grammar and something called the Oxford comma. I am not British, Mom! (Mom is reading this, and she just said, "Too bad, kiddo. When it's right, it's right!") Dad is always putting words, tables, and pictures in my pages and moving them around. He never leaves me alone and does not understand the concept of personal space. I am so happy that you could join me for this wonderful occasion. I am headed to high school in a few years, and then I am off to college...hopefully at Wash U in St. Louis or the University of North Carolina at Chapel Hill...since my parents swear that those are the best colleges. Happy holidays and a healthy 2026! Introduction As part of the Jewish religion, when a child turns 13, they become a bar mitzvah. This is the transition from childhood to adulthood in the Jewish religion. There is a ceremony at which the child reads from the Torah and makes a speech to the friends and family in the audience. Since Optometry & Visual Performance turned 13 this year, I thought it was time for the journal to speak on its own behalf instead of everyone else putting words in its mouth. I am stealing the concept from the late, great Irwin Suchoff, the founding editor of the Journal of Behavioral Optometry. He edited that journal for over two decades, and his editorials are gold. Hello, my name is Optometry & Visual Performance. My friends and family all call me OVP for short. You can call me anything you want, as long as you don't call me late for dinner! My grandfather, Eric Hussey, said that was a funny joke, and I had to put it in the speech, but based on your faces, I am not so sure about that. I wanted to thank all of my family and friends for coming and being a part of my childhood. You have all watched me grow up to become the Journal I am today. Even though I am now 13 years old, you are reading my 66th edition, so I think I will start collecting social security and get on Medicare soon! I have worked with over 200 authors from over 25 different countries. It has been a privilege to help so many authors find their voices and bring their work to the rest of the world. I promise you that they work hard, especially when my father, Marc Taub, and the rest of his extended family on the Review Board ask for changes or edits. The Review Board is the lifeblood of the Journal. Even though we are not exactly related, I consider them my cousins. I have known some of them for over a decade and get to meet new cousins every year when their time on the Board is done. I want to thank each and every cousin for helping me be the best that I can be. Editorial • Thank You from Optometry & Visual Performance Marc B. Taub, OD, MS, EdD • Southern College of Optometry • Memphis, Tennessee
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Optometry & Visual Performance 232 Volume 13 | Issue 4 | December 2025 The life and legacy of Dr. Bob Sanet remind us that true vision goes far beyond eyesight. Bob helped all of us see the world through a different lens—one shaped by possibility, purpose, and human potential. He had a rare gift for connecting the dots, sharing insights that illuminated not only our clinical understanding but also our sense of what is possible for every patient we serve. Bob’s passion was contagious. He inspired us to step into our own roles as facilitators of change, teaching us to help others see the world more clearly—both literally and metaphorically. He believed deeply in brighter vision, in hope, and in the power of understanding space and applying it to life. His influence expanded far beyond the exam room; it shaped the way we think, the way we practice, and the way we care. He always supported us as we asked questions and applied concepts! Bob will forever live on in our hearts, in our practices, and in every life touched by the knowledge he so generously shared. We are better vision therapists, better doctors, and better human beings because of him. His legacy is not only what he taught us—but how he made us see. Thank you, Bob, for your life, kindness, and love. Patti and Alex Andrich Bob and his lovely wife Linda gave so much to optometry over the past several decades, both nationally and internationally. He will be missed. When he came to NYC to visit, we always had dinner together, with great conversation. Ken Ciuffreda When Bob and I were in the Residency program at SUNY we were given one day a week of "library time." One of our mentors Marty Birnbaum suggested we try to put together a research paper on Amblyopia treatment. With no computers or internet this turned in to a one year of hard work project which resulted in a paper still referenced over 50 years later. When deciding on the authorship of the paper Bob insisted on alphabetic order in order to ensure that Marty's name would be first. This resulted in all of the citations On behalf of the Optometric Extension Program Foundation Board of Directors and the entire OEPF community, we share our heartfelt condolences with you on the passing of your beloved husband, Dr. Bob Sanet. Bob was not only a remarkable clinician, teacher, and leader in behavioral optometry—he was a man whose kindness, humor, and generosity touched everyone who had the privilege of knowing him. His passion for helping others, his visionary approach to patient care, and his dedication to elevating our profession have left a lasting legacy that will continue to inspire us. Those who learned from Bob often recall how, after a long day of lectures, he would stay late in the lecture hall or clinic, pulling up a chair next to a young practitioner or therapist to answer “just one more question.” In those quiet moments—often long after the official program had ended—Bob turned formal teaching into genuine mentorship, making each person feel seen, encouraged, and capable of more than they believed possible. We also recognize the unwavering partnership you shared with Bob throughout his career. Your support, presence, and warmth enriched the lives of so many in our community. Please know that the OEPF family holds you close in thought during this difficult time. Dr. Bob Sanet transformed vision therapy by combining clinical excellence with a deeply human, patientcentered approach that helped practitioners worldwide see vision as integral to learning, performance, and quality of life. Through decades of teaching and mentorship, he inspired generations of optometrists and vision therapists to embrace neuroplasticity, think beyond symptoms, and use vision therapy as a powerful tool for meaningful change in their patients’ lives. Bob will be deeply missed, but the impact of his life and work will live on in every practitioner, patient, and colleague he influenced. With deepest sympathy, The OEPF Board of Directors and Community Eric S. Hussey, Pamela Schnell, Bradley E. Habermehl, Fred Brecheen, Tam Petrosyan, & Line Vreven Tribute • Remembering the Life and Legacy of Dr. Bob Sanet
Optometry & Visual Performance 233 Volume 13 | Issue 4 | December 2025 stating Birnbaum, Koslowe, et al. Throughout his lifetime Bob always gave credit to his mentors and colleagues. Ken Koslowe I felt was a mutual respect from his comments to and about me from others. I think it was something he did for a lot of people which makes him very unique. Robert Hohendorf Dr. Bob Sanet was more than a giant in the world of vision therapy and behavioral optometry; he was the rare teacher who could make the most complex neuro-optometric concepts feel like common sense while simultaneously challenging you to see the world (and your patients) in an entirely new way. His boundless energy, wicked sense of humor, and genuine love for every person who walked through his door transformed thousands of careers and countless lives—he never just taught vision therapy - he taught us how to care fiercely, think creatively, and never accept “good enough” when “remarkable” was possible. Bob had the unique gift of making every student, colleague, and patient feel like they were the most important person in the room, because to him, in that moment, they truly were. His passing leaves an irreplaceable void in our profession, but the light he ignited in all of us will guide optometrists and the patients we serve for generations to come. Tamara Petrosyan I first met Bob at a COVD meeting at which I took his pre-course on visual information processing. I was struck at how down to earth he was; he just had this casual way about him. He had a way of pushing you out of your comfort zone…but with a nudge, not a push. He had a way of making you think about what you did and how you did it and challenged you to think differently…with a nudge, not a push. I take on the same teaching philosophy with my students and residents. trying to embrace my inner Bob. May his memory be a blessing to all who knew and loved him. Marc Taub
Optometry & Visual Performance 235 Volume 13 | Issue 4 | December 2025 Viewpoint • On the Etiology of Eccentric Fixation Kenneth J. Ciuffreda, OD, PhD • SUNY College of Optometry • New York, New York Daniella Rutner, OD, MS, MBA • SUNY College of Optometry • New York, New York ABSTRACT Amblyopia is a complex visual condition consisting of abnormal and interactive sensory, motor, and perceptual aspects. One such abnormality is eccentric fixation (EF). A description of EF, along with its proposed etiology, will be considered. Introduction The condition of human amblyopia is a major public health concern, as it affects at least 2% of the U.S. population.1 It is a complex phenomenon, with a range of abnormal and interactive sensory, motor, and perceptual components (Table 1).2 One of the most interesting, and important, visual abnormalities is eccentric fixation (EF), not to be confused with eccentric viewing (EV).2 EF is an anomaly of monocular vision in which the time-average position of the fovea is off the object of regard.2 That is, with the fellow eye fully occluded with a black eye patch, the amblyopic eye fixates, and localizes, a target as "straight-ahead" using a non-foveal point (i.e., abnormal oculocentric localization). EF is found in approximately 80% of amblyopic eyes3 and is therefore a major factor to consider in its diagnosis and remediation. However, the question remains: "What is the etiology of EF?" This important question has had a long history. One of the most interesting and logical proposals was expounded by Worth in 1943.4 He believed that EF resulted from binocular suppression. Worth conceptualized the central, retino-cortical pathway as having a foveal "invagination" of sensory depression, with the immediately surrounding region exhibiting relatively higher visual acuity (Figure 1). Thus, one eccentrically fixated to maximize the residual visual acuity. This seemed like a plausible explanation. However, if true, then the EF point could logically occur anywhere along this rim of equi-acuity, with equal probability, and moreover vary its position over time (e.g., nasal retina one moment and temporal retina the next moment). However, EF is typically located at one relatively fixed retinal position (e.g., nasal 0.5 degrees), with some variability centered around this point. In a careful experiment performed in 1978,5 Worth's idea was disproven. Essentially, the researchers trained the amblyopic eye of adults to fixate centrally and steadily over a 5-10 hour pre-test period. Then, visual acuity was assessed across the horizontal retinal Figure 1. Retinal profile reflecting Worth's concept of binocular suppression effect and resultant central depression of visual acuity as a function of retinal eccentricity. Equi-visual acuity rim depicted by arrow. Symbols: F=fovea, T=temporal retina, and N=nasal retina. Kenneth J. Ciuffreda, OD, PhD New York, New York SUNY College of Optometry, Distinguished Teaching Professor Emeritus PhD, UC-Berkeley/Optometry, 1977 OD, Massachusetts College of Optometry, 1973 BA, Seton Hall University, 1969 Fellow Dipl-AAO, ARVO, COVD, & NAP Table 1. Major Sensory, Motor, and Perceptual Abnormalities in the Amblyopic Eye • Reduced visual acuity • Eccentric fixation • Reduced stereoacuity • Monocular spatial distortion • Abnormal eye movements • Reduced accommodation • Impaired threshold and suprathreshold contrast perception • Abnormal pupillary responses • Abnormal visually evoked responses • Abnormal visual-motor control
meridian at several retinal loci. They found visual acuity to be highest at the fovea, and NOT the EF point, with visual acuity overall depressed in the amblyopic eye as compared to the fellow eye (Figure2). Given the above important finding, what might be the etiology, or underlying mechanism(s), of EF? The following is a proposed scenario. In strabismic amblyopia, where EF is typically the largest, there is also the presence of monocular spatial distortion (MSD) out to approximately 15 degrees of retinal eccentricity in all directions with respect to the fovea (Figure 3).6 That is, the visual directional values are not organized in an orderly, sequential manner across the central retinal region (i.e., abnormal Lotze's "local signs"),2 as found in normal eyes. In the dominant eye, the spatial pattern resembles a "bulls-eye" target of concentric circles, demonstrating a uniform and orderly spatial arrangement/oculocentric localization throughout the region. The fovea retains its zero, sensorimotor value of "straight-ahead" (i.e., normal oculocentric localization). In contrast, in the fellow strabismic amblyopic eye, there is directional distortion, with this being maximal in the central retinal region. Now the EF point, and NOT the fovea, acquires the zero, sensorimotor value with straight-ahead localization. This abnormality may reflect the underlying MSD. Such marked, central, directional distortion would shift the spatial "centroid," or zero point, from the fovea to the EF point. Thus, its proposed etiology: a central directional spatial shift, and a relatively simple scenario. Lastly, how could this proposed mechanism be tested? One could assess visual acuity, EF, and MSD before and after "successful" treatment in strabismic amblyopes. If the MSD normalized, and fixation centralized, this finding would support the proposed idea. However, if not, then other factors/mechanisms would be involved. For example, the MSD might shift directionally and independently of the EF. Or the EF might become central in the absence of any change, or just partial change, in MSD. Other factors might be involved, such as contrast perception and eye movement patterns. Thus, experiments should be performed in the future to answer this most important clinical and basic science question. References 1. Flom MC, Neumaier RW. Prevalence of amblyopia. Pub Health 1966;81:329-41. 2. Ciuffreda KJ, Levi DM, Selenow A. Amblyopia: Basic and Clinical Aspects. Boston, MA; Butterworth-Heinemann, 1991. 3. Brock FW, Givner I. Fixation anomalies in amblyopia. Arch Ophthalmol 1952;47:1465-6. 4. Worth, CA. Squint: Its Causes, Pathology, and Treatment. Philadelphia, PA; 7th ed., Blakiston, 1943. 5. Kirschen DG, Flom, MC. Visual acuity at different retinal loci of eccentrically fixating functional amblyopes. Am J Optom Physiol Opt 1978;55:144-50. 6. Bedell HE, Flom MC. Monocular spatial distortion in strabismic amblyopes. Invest Ophthalmol Vis Sci 1981;20;263-8. Optometry & Visual Performance 236 Volume 13 | Issue 4 | December 2025 Figure 2. Results showing schematic representation of dissociation between reduced visual acuity and eccentric fixation in the strabismic amblyopic eye. Symbols: D=dominant/ normal eye, A=amblyopic eye, F=fovea, EF=eccentric fixation point, T=temporal retina, and N=nasal retina. Figure 3. Results of experiment (schematic representation) showing orderly array of oculocentric spatial values in the normal eye, and abnormal distorted disarray of oculocentric values in the strabismic amblyopic eye. Symbols: f=fovea, EF=eccentric fixation point. Correspondence regarding this article should be emailed to Kenneth J. Ciuffreda, OD, PhD at kciuffreda@sunyopt.edu. All statements are the authors’ personal opinions and may not reflect the opinions of the representative organization, OEPF, Optometry & Visual Performance, or any institution with which the authors may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2025 Optometric Extension Program Foundation. Online access is available at www.oepf.org and www.ovpjournal.org. Ciuffreda KJ, Rutner D. On the etiology of eccentric fixation. Optom Vis Perf 2025;13(4):235-6.
A Vital Cornerstone of Vision Science: The Rediscovered Works of Dr. Frederick W. Brock Unearth the Foundational Principles That Shaped Modern Practice. For medical professionals, researchers, and students committed to the deep understanding of vision and its mechanisms, the Optometric Extension Program Foundation (OEPF) is proud to present a meticulously restored volume of the essential works of Dr. Frederick W. Brock, D.O.S. Originally published as a landmark serialization in Optometric Weekly from 1947 to 1957, Dr. Brock’s writings offer profound insight into the clinical and theoretical concepts that underpin contemporary vision care. These texts represent a crucial link to the historical development of our field yet have been largely inaccessible for over seventy years. Visual Training (2-Part Set): Visual Training Preliminary Considerations Part 1 The Problem of Subnormal Vision and Amblyopia Part 2 What This Volume Offers You: This book includes the first and second parts in a planned threepart sequence, bringing Dr. Brock’s complete decade-spanning contribution back into circulation. It is an indispensable addition to any clinical or academic library, offering: Historical Context: A direct look at the evolution of key diagnostic and therapeutic vision concepts. Primary Source Material: The opportunity to study the original ideas of a foundational figure. Enhanced Clarity: A cleaned and verified text, making complex historical concepts accessible for modern study.
Optometry & Visual Performance 238 Volume 13 | Issue 4 | December 2025 Article • The Success of Patching Therapy in An Infant Population at Rehabilitative Kindergartens/Nursery schools Kenneth Koslowe OD, MS • Eliya, The Association for Blind and Visually Handicapped Children Petach Tikva, Israel Introduction The use of patching one eye as a treatment for or prevention of amblyopia in infants and children has a long history.1-3 While there continues to be a debate about the hours patched and whether this is the best treatment protocol, it is still widely accepted.4-12 One basic measure of the success of the treatment is the change in visual acuity. While here also there are differences of opinion of whether this is the best measure of “success,” it continues to be the standard measurement of treatment.13 The basic theory behind the use of patching is not to “strengthen the weak eye,” but to improve the communication between the eye and the visual cortex. As such, in most cases, patching is instituted after correcting pathological and optical causes for poor vision. In some cases, patching has been used without correcting such defects, although the reasoning behind this seems to be much weaker. Eliya is a non-profit organization under Government supervision, with a network of five rehabilitative nursery school/kindergarten frameworks. Our purpose is visual rehabilitation and training for infants who are blind or visually impaired. In Israel, this also includes children who are visually impaired in one eye, even if this is due to recommended patching. The early intervention programs and professional services foster the full potential of children who are visually impaired or blind. Adopting a holistic approach, Eliya nurtures children’s visual, emotional, social, and intellectual skills. Learning happens best in a sensoryKenneth Koslowe, OD, MS Petach Tikva, Israel BS, Yeshiva University, 1969 OD, PCO, 1974 Residency in VT, SUNY MS (Psychology), Ferkauf Graduate School Founding faculty member, Hadassah College of Optometry and Bar Ilan University School of Optometry ABSTRACT Purpose: Patching has long been an accepted treatment method in treating or preventing amblyopia and strabismus, particularly in infants. Eliya is a non-profit network of rehabilitative kindergartens/nursery schools for the blind or partially sighted in Israel. As many of our children are accepted with recommendations for patching, it was felt that it would be useful both for our staff and the referring doctors to monitor the results of the recommended patching regimen. Methods: An initial group of 29 was identified by the referring documents as having patching recommended. They were located in four out of our five centers throughout the country. In each center, a staff member underwent training by the primary author (an optometrist with 50 years of experience) until they were proficient. The test chosen for monitoring was the Lea Paddle Acuity test. This was both available, easily trainable, and successful. All infants with a recommendation for patching were included in this project; no preselection was done regarding diagnosis or the amount of patching that was recommended. From the initial group of 29, nine children dropped out either due to total non-compliance with patching or a change in the recommendation of the referring doctor. The twenty remaining children consisted of 14 post-cataract surgery (average age at time of surgery was 6.8 weeks) and six with varying retinal problems. They were tested every three to four months for a final testing period of approximately one year from the start of the study Results: At the end of one year, 12 of the 14 postcataract children showed marked improvement or had normal acuity in the affected eye, while only one of the retinal cases showed any improvement. Conclusions: Patching one eye produced satisfactory results in cases of post-surgical monocular cataracts. It was largely ineffective in cases of retinal defects, especially so as the defects themselves were not resolved prior to the treatment. Keywords: amblyopia, infants, patching
Optometry & Visual Performance 239 Volume 13 | Issue 4 | December 2025 rich, developmentally based curriculum based on fun and exploration. Eliya provides treatment in all phases of infant development: speech/communication therapy, physical therapy, occupational therapy, and emotional support, all integrated with visual development therapy. The guiding principle is integrative therapy, in which each discipline interacts and coordinates with the others to maximize the visual aspects of all treatment, whether it be in the therapeutic swimming pool, the outer playground, the meal table, the music room, or any activity in our facility. There are general outlines for programs for all the children, and additionally, each child has his own specific Individual Educational Plan (IEP) tailored to his needs. The children who were patched took part in all the treatment programs, the only difference being that this was done while they were wearing a patch. During the course of this study, all the patching was done at Eliya. Eliya does not have its own eye clinic, and all patient referrals undergo opthalmologic exams, usually in a hospital setting, before being accepted to our program. As such, we are charged with fulfilling the referring doctor’s recommendations in full. This is true even when our own opinions may differ from those of the referring source. Needless to say, not following the outside recommendations would harm our relations with our referring sources. As was noted, all infants referred to Eliya had previously been evaluated by pediatric ophthalmologists, and all recommendations for patching were given in writing. All of the infants referred had no previously measured visual acuity recorded. The previous assessments were observational, such as F&F (fixates and follows) or CSM (central steady fixation maintained). As our staff have the time to develop a rapport with the infants and children, we often have an easier time achieving the cooperation necessary to test visual acuity in infants than in a hospital setting. The patching was performed while the children were exposed to various visual, visual motor, and sensory motor enrichment tasks in order to promote normal development. This included but was not limited to sessions in a dark room and a sensory room. No specific amblyopia therapy activities were performed. Numerous studies have indicated that although amblyopia can be treated at any age, the earlier the intervention, the more success that has been noted.14-17 Most of these studies have had their early entry age level at age 3 years, which further underscores the importance of this study. Methods A review of all the records of children currently at Eliya produced a list of 29 subjects for the study. All the infants selected had congenital impairments present at birth, whether cataract or retinal problems. However, before implementation of the testing protocol, nine children were dropped either due to total lack of success in patching or a change in the medical recommendation. The remaining 20 were then tested every three to four months, for a final testing period of approximately one year from the start of the study. The age range at the start of the study was 6 months to 3 years 6 months, and the average age was 1 year 5 months. Visual acuity testing was performed using the LEA paddle test, with a screening set consisting of the following options: 0.25 CPD, 0.50 CPD, 1.0 CPD, 2.0 CPD, 4.0 CPD, and 8.0 CPD when tested at 57 centimeters. Other values were available by altering the testing distance to 25.5 or 85.5 centimeters. The LEA paddle test was chosen for both economic and practical reasons. The staff already had 3 years’ experience using the LEA paddles before starting the study, and the LEA paddles were already available in each branch before beginning this study. Before initiating the study, selected staff underwent additional training to ensure their proficiency in performing the test. The age 4-5 group were also tested at the end of year using a 9.6 CPD paddle and additionally checked using the LEA Symbol chart with a Snellen notation. If there were any doubts as to the accuracy of the testing, the result was rechecked by the supervising optometrist. All of the patching was unilateral of the better eye. At the initiation of the patching, in the cataract cases, the vision in the normal eye was within the normal range of the LEA test, and in most cases was 8.0 cpd. All cataract patients had been operated on before age 2 months, with the exception of two: AG (21 months) and YA (7 months). All of the unilateral cataract children were corrected with a contact lens; none of the subjects had intra-ocular lens implants. As was stated previously , the treatment at Eliya is designed to improve visual functioning, with no specific goals or methods to improve visual acuity. The treatment stresses integrating vision with all other capabilities, such as kinesthetic and auditory skills. Results Tables 1 & 2 summarize the results in the group of subjects with cataracts, and Table 3 shows those with retinal problems. Table 1 gives the initial and
final acuities in the better eye in order to indicate any possible harm to the better eye due to the patching (occlusion amblyopia). Table 2 shows the initial and final acuity results of the non-patched eye. Although it was not the purpose of this study to determine the optimum amount of patching, Table 4 shows that the amount of time that patching was administered did not seem to affect the outcome. Discussion As can clearly be seen by the results, patching Optometry & Visual Performance 240 Volume 13 | Issue 4 | December 2025 Table 1. Cataract (Mono): Testing of Patched (Normal) Eye Name Amount of patching Initial VA Change (CPD) Final VA Better eye AA * 30 minutes 4.0 +4 8.0 RA 3 hours 8.0 0 8.0 AA 4 hours 1.0 +1 2.0 AG 3 hours 1.0 +7 8.0 AH 3 hours 4.0 0 4.0 HB 6 hours 8.0 0 ** 8.0 (6/12) YA 6 hours 4.0 +4 8.0 MM 6 hours 8.0 0 8.0 MM 6 hours 8.0 0 (+1.6) 9.6 MN 2 hours 8.0 0 8.0 IG 3 hours 8.0 0 (+1.6) 9.6 AS 6 hours 8.0 0 8.0 SA 4 hours 8.0 0 8.0 AZ 6 hours 8.0 0 8.0 Table 3. Other Causes of Poor Vision Name Amount of patching Defect Change (CPD) Final VA (CPD) KA 2 hours Cone/rod dystrophy 0 2.0 HD 2 hours Coloboma of optic nerve 0 2.0 LK 30 minutes Coloboma of optic nerve 0 1.0 PG 3 hours Retinal dystrophy 0 1.0 GB 5 hours Albinism, Foveal hypoplasia +2 4.0 TS 2 hours Albinism, Foveal hypoplasia 0 4.0 Table 2. Cataract (Mono): Testing of Non-Patched Eye Name Amount of patching Initial VA in Better Eye Change (CPD) Final VA AA * 30 minutes 2.0 0 ** 2.0 RA 3 hours 4.0 +4 8.0 AA 4 hours 1.0 +1 2.0 AG 3 hours 2.0 +6 8.0 AH 3 hours 1.0 +1 2.0 HB 6 hours 8.0 0 ** 8.0 (6/12) YA 6 hours 2.0 +6 8.0 MM 6 hours 8.0 0 ** 8.0 MM 6 hours 8.0 0 ** 9.6 MN 2 hours 2.0 0 2.0 IG 3 hours 2.0 +7 9.6 AS 6 hours 2.0 +2 4.0 SA 4 hours 0.8 +4 4.0 AZ 6 hours 8.0 -4 4.0 *Bilateral cataracts ** The reason for no change was excellent VA from the start Table 4. Children Who Achieved Either Normal (8.0 or better) or Greatly Improved Visual Acuity as a Function of Hours Patched. Hours patched Number of children with significant change or normal VA 3 4/5 4 2/2 6 5/6 30 minutes 1/2 along with the typical visual enrichment program at Eliya was very effective in improving the visual acuity in post-cataract infants and largely ineffective in other cases, where the cause for the poor acuity obviously could not be eliminated. In addition, one can see that there were infants with apparently normal visual acuity before the patching was initiated, and therefore it is questionable whether they needed to be patched at all. This supports the need for some form of visual acuity testing before instituting patching in order to determine whether patching is necessary. Additionally, one can see the need for visual acuity to be monitored during the patching regimen in order to check the efficacy of the treatment and the need to modify or even to cease the patching regimen. While there were no cases of occlusion amblyopia (damage caused to the eye that was patched), one cannot ignore the possible deleterious effect of early patching on the development of binocular vision. While some believe that early patching will either help or do no harm, there is evidence to show that early monocular functioning can be detrimental to the general and motor development of the infant.18,19 The necessity for
Correspondence regarding this article should be emailed to Kenneth Koslowe OD, MS at kenkoslowe@yahoo.com. All statements are the author’s personal opinions and may not reflect the opinions of the representative organization, OEPF, Optometry & Visual Performance, or any institution or organization with which the author may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2025 Optometric Extension Program Foundation. Online access is available at www.oepf.org and www.ovpjournal.org. Koslowe K. The success of patching therapy in an infant population at rehabilitative kindergartens/nursery schools. Optom Vis Perf 2025;13(4):238-41. Optometry & Visual Performance 241 Volume 13 | Issue 4 | December 2025 automatically recommending patching originated at a time when cataract surgery for infants was performed at a later stage (1-3 years of age) than today, when most infants are operated on at age 6-8 weeks.20 While it was not the purpose of this study to determine what amount of patching was most effective, it is interesting to note the similar results of various patching regimens. It should be noted that the author and the facility had no ability to alter the treatment recommendations, and if given such an opportunity, would have opposed using patching on some of these patients. Patching can be traumatic for the patient and the parent and can affect both general development and the development of binocular vision. As such, it should be approached with caution. Conclusions This study shows that in cases of unilateral cataracts, patching, along with a visual enrichment program, is an effective method of improving visual acuity. Additionally, the lack of success in the cases where the defect remained casts doubt on the wisdom of recommending patching in these cases. It does not show which of these elements is critical if either one alone would be sufficient. Additionally, given the lack of any evidence-based research to support patching in retinal disorders, or any patching without first treating the underlying cause for poor vision, this study confirms the lack of success of this treatment paradigm. Recommending patching without first testing the need for patching by evaluating the visual acuity in infants should no longer be considered standard practice. The various methods available to test visual acuity in infants certainly support this philosophy of care. References 1. Strong N, Thompson JR, Minshull C, Woodruff G. Occlusion for amblyopia comprehensive survey of outcome. Eye (Lond)1992:6(Pt 3):300-4. 2. Olson RJ, Scott WE. A practical approach to occlusion therapy for amblyopia. Semin Opthalmol 1997;12(4):161-5. 3. Hiscox F, Thompson JR, Smith LK. The presentation of children with amblyopia. Eye (Lond)1994:8(Pt 6):623-6. 4. Pediatric Eye Disease Investigator Group A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmol 2003;110:2075-87. 5. American Academy of Ophthalmology. Preferred practice pattern: Amblyopia. American Academy of Ophthalmology; San Francisco: 2002. 6. American Optometric Association. Care of the patient with amblyopia. Optometric clinical practice guideline. American Optometric Association; St. Louis, MO: 1994. 7. Scheiman MM, Hertle RW, Beck RW, Edwards AR, et al. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123:437-47. 8. Stewart CE, Moseley MJ, Stephens DA, Fielder AR. Treatment dose-response in amblyopia therapy: The Monitored Occlusion Treatment of Amblyopia Study (MOTAS). Invest Ophthalmol Vis Sci 2004b;45:3048-54. 9. Repka MX, Beck RW, Holmes JM, Birch EE, et al. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003;121:603-11. 10. Holmes JM, Kraker RT, Beck RW, Birch EE, et al. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmol 2003;110:2075-87. 11. Stewart CE, Stephens DA, Fielder AR, Moseley MJ. Objectively monitored patching regimens for treatment of amblyopia: Randomised trial. BMJ (2007) 335:707. doi: 10.1136/ bmj.39301.460150.55. 12. Wallace MP, Stewart CE, Moseley MJ, Stephens DA, et al. Compliance with occlusion therapy for childhood amblyopia. Invest Ophthalmol Vis Sci 2003;54:6158-66. 13. Zagui R. Amblyopia: Types, diagnosis, treatment, and new perspectives. June 2019 https://www.aao.org/education/ disease-review/amblyopia-types-diagnosis-treatment-newperspective 14. Williams C, Northstone K, Harrad RA, Sparrow JM, et al. Amblyopia treatment outcomes after screening before or at age 3 years: Follow up from randomized trial. BMJ 2002;324(7353):1549. doi: 10.1136/bmj.324.7353.1549. 15. Schmucker C, Kleijnen J, Grosselfinger R, Riemsma R, et al. Effectiveness of early in comparison to late(r) treatment in children with amblyopia or its risk factors: A systematic review. Ophthalmic Epidemiol 2010;17(1):7-17. 16. Papageorgiou E, Asproudis I, Maconachie G, Tsironi EE, Irene Gottlob I. The treatment of amblyopia: Current practice and emerging trends. Graefes Arch Clin Exp Ophthalmol 2019;257(6):1061-78. 17. Webber AL, Wood J. Amblyopia: Prevalence, natural history, functional effects and treatment. Clin Exp Optom 2005;88(6):36575. 18. Ellemberg D, Lewis TL, Maurer D, Brent HP. Influence of monocular deprivation during infancy on the later development of spatial and temporal vision. Vis Res 2000;40(23):3283-95. 19. Celano M, Hartman EE, DuBois LG, Drews-Botsch C. Motor skills of children with unilateral visual impairment in the Infant Aphakia Treatment Study. Dev Med Child Neurol 2016 Feb;58(2):154-9. 20. Lambert SR. The timing of surgery for congenital cataracts: Minimizing the risk of glaucoma following cataract surgery while optimizing the visual outcome. J AAPOS 2016;20(3):191-2.
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Optometry & Visual Performance 244 Volume 13 | Issue 4 | December 2025 Article • Knowledge, Attitude, and Perception of School-Aged Children Towards Spectacle Use in Delta State, Nigeria Kelvin Ucheka Imasua, OD, MPH, Prof Cert Med Ret, Prof Cert Glauc, MCOptom • University of Benin Teaching Hospital • Benin City, Edo State, Nigeria Vivian Ossaidiom Omuemu, MBBS, MPH • University of Benin Teaching Hospital • Benin City, Edo State, Nigeria ABSTRACT Background: Visual impairment is a global public health concern in the younger population. This study assessed the knowledge, attitude, and perception of school-aged children in Agbor, Delta State, Nigeria towards spectacle use. Methods: This cross-sectional study was conducted among school-aged children in Agbor, Delta State. A multistage sampling technique was used to select 822 school children. Data were collected through a pretested, interviewer-administered questionnaire that gathered socio-demographic information and ocular history, as well as assessments of knowledge about refractive errors, attitudes toward spectacles, and practices regarding spectacle use. Results: A total of 822 schoolchildren participated in this study. The participants consisted of 364 (44.3%) males and 458 (55.7%) females, aged 5 to 17 years, with a mean age (SD) of 10.05 (3.05) years. Only 230 children had heard of the term ‘refractive error,’ among whom 22 children (9.6%) demonstrated good knowledge of refractive errors, while 208 children (90.4%) had poor knowledge. 792 (96.4%) schoolchildren had a positive attitude to spectacle use, while thirty (3.6%) schoolchildren had a negative attitude to spectacle use. Among 36 children wearing spectacles, only 6 children (16.7%) exhibited adequate practices regarding Introduction Refractive errors pose a significant public health challenge,1 as they are the number one cause of visual impairment and the second leading cause of visual loss globally, according to WHO 2010 reports.2-4 They are the most common cause of visual impairment worldwide.4 The WHO estimates that approximately 19 million children are visually impaired, with 1.4 million blind and 17.5 million with low vision, many of whom reside in Africa.4 Uncorrected refractive error (URE) is identified as the primary cause of global visual impairment, with over 90% of those affected living in rural and developing countries.3,4 In a review study,5 it was observed that uncorrected refractive errors were responsible for visual impairments in about 100 million people and blindness in approximately 7 million people. In 2015, it was estimated that 124 million people were blind due to uncorrected refractive errors.6 Refractive errors impact a significant proportion of the global population, regardless of age, sex, or ethnic group.1 Refractive errors can easily be diagnosed, measured, and corrected with spectacles or other refractive corrections to restore normal vision. However, if uncorrected or inadequately corrected, refractive errors can lead to a significant vision impairment and even blindness.7,8 Various Kelvin Ucheka Imasua, OD, MPH, Prof Cert Med Ret, Prof Cert Glauc, MCOptom Benin City, Edo State, Nigeria OD, University of Benin, Nigeria, 2015 MPH, University of Benin, Nigeria, 2023 Professional Certificate in Medical Retina, Univeristy College London, UK, 2025 Professional Certificate in Glaucoma, University of Bradford, UK, 2025 FAAO, 2025 spectacle use, whereas 30 children (83.3%) showed inadequate practices. Conclusion: The findings of this study indicate that the overall knowledge of refractive errors among schoolchildren was limited, and the practice of spectacle use was insufficient. Based on these results, it is recommended that the Delta State Government enhance the implementation of the school health program to promote greater awareness of eye care and the importance of spectacle use among students. Keywords: knowledge, refractive error, spectacle
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