Optometry & Visual Performance 135 Volume 14 | Issue 2 | June 2026 Following 11 therapy sessions, the patient demonstrated improvement in accommodative facility (from 4 cpm to 10 cpm monocularly; from 2 cpm to 8 cpm binocularly), NRA and PRA (increased by 0.50 D), some improvement of convergence ranges at distance and near (by 9Δ and 19Δ, respectively), and vergence facility (from 6 to 13 cpm). She reported faster refocusing at varying distances, reduced headache frequency, and a marked improvement in subjective symptoms (BIVSS score decreased to 27, 56% improvement). Although she resumed biking and running, she had not yet returned to playing football. Optometric Vision Therapy Protocol This optometric vision therapy protocol was applied to all three patients, with individual adaptations as described above. All patients were treated by optometric vision therapy protocols based on Scheiman and Wick14 and Scheiman and Rouse,15 consisting of 12 in-office sessions (40 minutes each) and 30 minutes of daily home exercises. Accommodative therapy began with lens sorting, with an end point in the range of +5.00 D to -8.00 D in jumps of 0.50 D. These were followed by loose lens rock, where lens flippers gradually increased until the patient could use +2.50/-6.00 flipper monocularly. If the patient was between 30-35 years old, our end point was a +/-2.00 D flipper. The subsequent procedure was Hart chart, and the final stage was binocular accommodative rock with polaroid (bar reader and polaroid glasses), where the end point was the ability to use a flipper of +/-2.50 D at 20 cycles per minute. For patients between 30-35 years of age, the end point was a +/-2.00 D flipper. Vergence therapy included Brock string to develop an awareness of eye position in convergence and divergence and vectograms and tranaglyphs to normalize positive and negative fusional vergence (PFV and NFV), used until the patient reached 30Δ base out and 12Δ base in. The aperture rule was used until card number 12 for convergence and 7 for divergence were reached. Oculomotor therapy included Hart chart saccades, wall saccades, computer HTS program, Groffman tracings, letter tracing, multiple Brock strings, Marsden ball, Multi Matrix, Spot-It games, saccadic workbooks (Bernell), pegboard rotator, and MacDonald peripheral cards. Visual perception therapy included parquetry blocks, geoboard, memory workbooks, visual discrimination workbooks, and a tachistoscope, Pre-treatment findings Post treatment findings Right eye Left eye Right eye Left eye First visit since the last concussion 1 year (2017, 2022) Previous treatment PT Uncorrected VA LogMAR -0.08 0.00+ -0.08 -0.08 Habitual prescription (D) ---- ---- +0.25 +0.50 Cycloplegic refraction (D) +0.50 +0.50 Corrected VA -0.08 0.00+ -0.08 -0.08New Rx for distance (D) +0.25 +0.50 CT (distance, Δ) ortho ortho CT (near, Δ) ortho ortho Associated phoria (distance, Δ) No prism Associated phoria (near, Δ) No prism AC/A 4/1 NPC (cm) 5/7 TTN AOA (D) 5 5 8 7 BAF (cycles/ minute) 2 (difficulty with + and - lenses) MAF (cycles/ minute) 4 (difficulty with +) 4 (difficulty with +) 10 10 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: x/6/4 BO: x/16/10 BI: x/8/6 BO: x/25/20 Vergences (near, Δ) BI: 4/6/4 BO: x/16/14 BI: 4/8/6 BO: 12/35/30 VF (cycles/ minute) 6 (slow with base in and base out) 13 KD (years of age) 10 13 BIVSS 61 27 VOMS increase in symptoms VOR & visual motion No increase in symptoms reported Saccades (Maples) Head movement: 3 Ability: 4 Accuracy: 2 Head movement: 5 Ability: 5 Accuracy: 5 Pursuits (Maples) Head movement: 2 Ability: 4 Accuracy: 2 Head movement: 5 Ability: 5 Accuracy: 5 OVT sessions 12 recommended VT 11 sessions completed Table 4. Summary of Visual Evaluation Findings Before and After Vision Therapy (Case 3)
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