Optometry & Visual Performance 133 Volume 14 | Issue 2 | June 2026 syndrome. Her treatment regimen included medications for cardiovascular, neurological, and pain management, including: amitriptyline, sumatriptan, Volidax, bisoprolol, pregabalin, Ajovy, midodrine, Cerazette, Sertral, Xeomin, Decortin, esomeprazole, magnesium, Procoralan, Telfast, Ovixan, and Elvanse. She also received bi-monthly Botox injections for migraines. In January 2019, she reported visual decline and visited an optometrist, where she was prescribed glasses for the first time. Her prescription was -0.75-0.50x015 OD and -0.75-0.50x180 OD. She was prescribed home-based Hart chart exercises, which she reported as mildly beneficial. In May 2023, the patient was referred by her physiotherapist for a binocular vision evaluation due to complaints of visual focusing difficulties at all distances, visual and general fatigue, reading difficulties, photophobia, clumsiness, headaches, migraines, and chronic pain. Examination findings are summarized in Table 3. Cycloplegic refraction (1% cyclopentolate) was +0.25-0.25x010 OD and +0.50-0.75x180 OS. She was prescribed her dry refraction (plano-0.25x180 OD, plano-0.50x010 OS; VA: 0.00 LogMAR) with a +0.75 D near addition due to reduced accommodative amplitude (6.00 D OD; 4.00 D OS; expected: 11.8 D). The patient reported reduced ocular fatigue, improved reading, and decreased clumsiness with the prescription, but she continued to experience unstable distance fixation, photophobia, and headaches. Near point of convergence was to the nose; however, recovery was delayed, with difficulty in regaining fixation. Pursuits were poor and jerky. Cover test revealed orthophoria at distance and 2Δ esophoria at near; associated phoria was unstable on the cross test. Vergence ranges were within normal limits, but vergence facility was reduced for both base-in and base-out. No suppression was reported. Visual fields (HS-Octopus 600) and pupil responses were normal. The King-Devick test score corresponded to an 11-year-old level, and the BIVSS score was 62. During the VOMS, symptoms increased with pursuits, saccades, vestibulo-ocular reflex testing, and visual motion. The Test of Visual Perceptual Skills (TVPS) was partially administered, with low scores in visual discrimination (age equivalent: 9), visual memory (5 years 10 months), and spatial relations (6 years). Anterior and posterior segment findings were unremarkable. Based on the low amplitude of accommodation and increased MEM lag of accommodation, Pre-treatment findings Post-treatment findings Right eye Left eye Right eye Left eye First visit since the last concussion 5 years (2017, 2018) Previous treatment Glasses, PT, medical treatment Uncorrected VA LogMAR 0.00- 0.10+ 0.00 0.00 Habitual prescription (D -0.75 -0.50x015 -0.75 -0.50x180 plano -0.25x010 plano -0.50x025 Cycloplegic refraction (D) +0.25 -0.25x010 +0.50 -0.75x180 Corrected VA 0.00 0.00 0.00 0.00 New Rx for distance (D) plano -0.25x010 plano -0.50x025 New Rx for near (D) +0.75 -0.25x010 +0.75 -0.50x025 +0.75 -0.25x010 +0.75 -0.50x025 CT (distance, Δ) ortho ortho CT (near, Δ) 2 esophoria ortho Associated phoria (distance, Δ) No prism Associated phoria (near, Δ) No prism AC/A 4/1 NPC (cm) TTN TTN AOA (D) 6 4 10 10 BAF (cycles/ minute) Failed +, took 10 sec to clear minus 9 cpm MAF (cycles/ minute) Failed + 11 12 14 MEM (D) +1.00 +0.75 +0.75 +0.25 NRA (D) +1.50 +2.25 PRA (D) -1.25 -2.25 Vergences (distance, Δ) BI: 4/8/4 BO: x/25/12 BI: x/8/6 BO: x/25/20 Vergences (near, Δ) BI: 6/16/12 BO: x/30/25 BI: 6/14/12 BO: x/30/25 VF (cycles/ minute) 6 (slow with base in and base out) 14 KD (yr equiv) 11 13 BIVSS 62 28 VOMS increase in symptoms Saccades, pursuits, VOR, & visual motion Very light increase in dizziness during visual motion Saccades (Maples) Head movement: 3 Ability: 4 Accuracy: 2 Head movement: 5 Ability: 5 Accuracy: 5 Pursuits (Maples) Head movement: 3 Ability: 4 Accuracy: 3 Head movement: 5 Ability: 5 Accuracy: 5 OVT sessions 12 recommended 12 sessions completed Table 3. Summary of Visual Evaluation Findings Before and After Vision Therapy (Case 2)
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