Vision Therapy’s Role

ARTICLE
After thorough evaluation of binocu­ lar skills
in Basic Intermittent and accommodative function with a binocular
vision evaluation, he was referred for a vision
Exotropia: A Case Report therapy program to improve fusional ranges,
Katharine Funari, OD, FAAO accommodative function, and symptoms.
Instructor of Ophthalmology at This program consisted of 20 sessions and
Johns Hopkins, Wilmer Eye Institute, significantly improved his binocular skills.
Bethesda, Maryland
Discussion
Basic intermittent exotropia can be treated in
various ways. Vision Therapy is a worthwhile
option. Surgical correction and overminus
treatment have also been effective treatments.
Assessment should include the intermittent
ABSTRACT exotropia control scale and the convergence
Introduction insufficiency symptom survey. Vision therapy
Vision therapy has been shown to be treatments focus on diplopia awareness, anti-
a successful treatment option for basic suppression, and fusional vergence ranges.
intermittent exotropia as long as a complete
workup is performed to assess prognosis and Conclusion
appropriate management. Though more research is necessary, vision
therapy has been proven to be a very effective
Case Presentation treatment option in basic intermittent exotropia.
A 9 year old hispanic male presented to the
clinic for a comprehensive exam and was Introduction
subsequently diagnosed with a basic type Intermittent exotropia exhibits many differ­
intermittent exotropia with a V-pattern deviation. ent clinical presentations. In order to effectively
treat the condition, a full evaluation must be
performed to assess the magnitude of the
Correspondence regarding this article should be emailed deviation, the pattern of the deviation, the
to Katharine Funari, OD, FAAO, at Katharine.Funari.od@
gmail.com. All state­ ments are the author’s personal presence of anomalous retinal correspondence,
opinions and may not reflect the opinions of the and the control score of the deviation.1 These
College of Optometrists in Vision Development, Vision
Development & Rehabilitation or any institu­ tion or factors all contribute to decisions on proper
organization to which the authors may be affiliated. treatment and management. While high
Permission to use reprints of this article must be obtained magnitude intermittent exotropia may tend
from the editor. Copyright 2020 College of Optometrists
in Vision Development. VDR is indexed in the Directory to require surgical correction,2 there are many
of Open Access Journals. Online access is available at patients who might be able to forgo this option
covd.org. https://doi.org/10.31707/VDR2020.6.1.p64.
and solely rely on vision therapy to improve
Funari K. Vision Therapy’s Role in Basic Intermittent symptoms and control of their deviation.
Exotropia: A Case Report. Vision Dev & Rehab 2020; Orthoptics or vision therapy has been shown
6(1):64-73.
to be an effective treatment in 88.3% of
basic intermittent exotropia cases in a study
performed in 2009.3 This case specifically details
Keywords: Basic Intermittent Exotropia, the orthoptic treatment of basic intermittent
Orthoptics, Strabismus, V-Pattern Exotropia, exotropia with a V-pattern deviation.
Vision Therapy
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
Case Presentation reduced accommodative amplitudes of 8.5D
A 9-year-old Hispanic male presented in the right and left eyes. Anterior segment
to the clinic on 04/13/2018 for a routine eye examination showed Van Herrick angles of 4
examination. This visit was managed by OD and OS, normal adnexa OU, normal lids
another provider. Due to the nature of our and lashes OU, a clear cornea with negative
clinic, patients are frequently comanaged in NaFl staining, papillae on the inferior
our binocular vision service. He was recently palpebral conjunctiva OU, white and quiet
treated for a mild corneal abrasion with artificial bulbar conjunctiva OU, normal iris OU, deep
tears. He reported no complaints except and quiet anterior chambers OU, and clear
occasional itching, yet his mother reported lenses OU. He was then dilated with 1 drop of
having had noticed his eye “wander” at the tropicamide 1% and 1 drop of phenylephrine
age of 6. His medical and family histories were 2.5%, OD and OS. Fundus evaluation was
unremarkable. He had no known allergies unremarkable with clear vitreous OU, flat, sharp
and was not currently taking medications. He and good color optic nerves with cup to disc
previously had occupational therapy for poor ratio in the OD of .55/.55 and .5/.5 in the OS.
handwriting skills. The patient was oriented to His maculas were flat with no hemorrhages,
time, person, and place. His uncorrected visual exudates, pigmentary changes, or macular
acuities were 20/20 in both the right and left edema OD and OS, normal vasculature OU,
eye and .4/.3M- at near in the right and left and a flat and intact periphery OU.
eyes. Best corrected acuities were 20/20 OD
and OS with +0.25sph OD and +0.50sph OS. The differential diagnoses of this case
Pupils were equal round and reactive to light include:
with no afferent pupillary defect. Confrontation Basic Intermittent Exotropia
fields were full to finger counting in each eye
Divergence Excess Intermittent Exotropia
and extraocular muscles had full range of
motion. Intraocular pressures were measured  onvergence Insufficiency Intermittent
C
with a non-contact tonometer as 14mmHg Exotropia
OD and 12mmHg OS. Color vision was normal A Pattern Exotropia
with the Ishihara color vision test OD and OS V Pattern Exotropia
and he had 25 seconds of local stereopsis with
Decompensated Exotropia
randot stereopsis testing. Cover test revealed
a 25 pd basic intermittent exotropia as the
• Basic intermittent exotropia classically
magnitude was the same at both distance and
presents with a deviation of equal exo
near with equal fixation preference. In up gaze,
deviation at distance and near and also
the magnitude of the exotropia increased to
presents with a normal AC/A ratio.4
35 prism diopters and in downgaze reduced
• Divergence excess intermittent exo­
to 22 prism diopters consistent with v-pattern
tropia presents as a higher magnitude
exotropia. His near point of convergence (npc)
exo deviation at distance and lower
with an accommodative target was fairly normal
magnitude at near. The AC/A ratio
with a break at 2.5cm and recovery at 5cm,
would be higher than normal.4
however, with a penlight his npc receded to a
• Convergence insufficiency intermittent
12.5cm break with no recovery. He displayed
exotropia demonstrates a higher magni­
good positive voluntary convergence and
tude exo deviation at near than distance.
his step vergences at near were BI, no blur,
The AC/A would be lower than normal.4
break at 12pd, recovery at 10pd and BO, no
blur, break at 12pd, recovery at 10pd. He had
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
 • A pattern exotropia presents with an Binocular vision testing was performed as
exo deviation of greater magnitude in well as a Convergence Insufficiency Symptom
downgaze. Survey, on which he scored 20. Cover test
• V pattern exotropia has an exo deviation with correction was measured as 20PD IAXT
of greater magnitude in up-gaze. at distance and near. Comitancy testing was
• Decompensated exotropia occurs in performed without correction at this visit and
the adult years while in childhood it showed 30PD exo in primary gaze, 25PD exo
manifests as a heterophoria.5 As this in right gaze, 25PD exo in left gaze, 35PD exo
child is 9 years old, this is an unlikely in up gaze and 16PD exo in down gaze with
diagnosis. a control score in primary gaze of 1-2 based
upon the intermittent exotropia control scale.
The patient presented with an alternating Worth 4 Dot testing showed fusion at distance
fixation deviation of equal magnitude at and near in bright and dim lighting; at
distance and near at intermittent intervals intermediate the patient reported intermittent
as well as a deviation which was of higher suppression and fusion. Step vergences at
magnitude in up gaze and lower magnitude near were BO break at 10PD, recovery at
in downgaze. Therefore, this patient was 6PD and BI Break at 10PD, recovery at 6PD.
diagnosed with a V-pattern basic intermittent Accommodative amplitudes were 7.14D OD
alternating exotropia. He also was diagnosed and OS. Extraocular muscle testing revealed
with a secondary accommodative insufficiency a mild overaction of the inferior oblique.
based on his mildly reduced accommodative Stereopsis testing showed 250 seconds
amplitudes. His mother was educated on of random dot stereopsis. Near point of
the findings and a complete binocular vision convergence with accommodative target was
workup was recommended and a referral for break at 21cm with recovery of 25cm. Repeated
vision therapy given. Due to the mild hyperopia with a +1.00sph lens was a break at 20cm and
noted OU and the potential for plus lenses to recovery at 28cm. This was performed with a
increase the magnitude of the exo deviation, penlight and the break was 31cm and recovery
no spectacle correction was given at this time. and 33cm and with a red lens it was break at
Though this was the initial visit, it would 24cm and recovery at 28cm. This information
have been helpful to also have information is significant as near point of convergence
regarding his AC/A by assessing cover test testing was dramatically different between
with a +1.00sph lens OU as well as his potential previous examination and this visit. However,
for random dot global stereopsis. this is due to fatigue as NPC was performed
near the end of testing and repeated by the
Binocular Vision Evaluation Follow Up 1 attending optometrist. Also, retesting the
The patient presented two months later for NPC with a +1.00sph lens without significant
his binocular vision evaluation. This visit was improvement shows that this patient did not
performed by another provider in the clinic present with a pseudo-CI or accommodative
as well. At this visit, the patient notes that he insufficiency driven convergence insufficiency.
does experience diplopia at distance and near, Patient reported crossed diplopia using the red
but he is able to blink and it “goes away”. lens and penlight. Binocular accommodative
He occasionally has headaches which are facility was 9 cycles per minute. Monocular
managed with over the counter medications. accommodative facility was OD 11 cycles per
All medical and ocular history, entrance testing, minute and OS 10 cycles per minute. Vergence
anterior segment evaluation, and undilated Facility at near with 12BO and 3 BI was 14
examinations revealed stable findings. cycles per minute. MEM with a grade level 2
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
text was OD and OS +0.25sph. Bagolini testing introduced into the treatment protocol. The
was performed. The patient reported an X activities used were Vectograms, Tranaglyphs,
when aligned and diplopia when dissociated Aperture Rule, Computer Vergence Activities,
signifying normal correspondence. With the Monocular Loose Lens Rock, Hart Chart
Hering Bielschowsky After Image test with the Saccades, and SVI saccades.
vertical flash over OD, the patient reported Significant improvement was noted by the
normal correspondence. The mother and seventh session therefore, barrel card, lifesaver
patient were educated on vision therapy cards, and eccentric circles were added to
as the treatment plan and a re-evaluation the program. As fusional vergence skills
approximately every 12 weeks to determine if improved, the computer program activities
more vision therapy would be necessary. shifted from RDS targets to flat fusion targets,
jump vectograms and distance projected
Treatment and Management Vision Therapy vectograms were also utilized.
Vision Therapy consisted of 20 sessions After 14 sessions a re-evaluation was
of in office vision therapy for which I was the performed, and results are shown below.
direct provider. These sessions occurred once However, due to poor performance on saccadic
per week for 45 minutes with supplemental activities, 6 more sessions were performed
home therapy activities to last anywhere from focusing on saccadic function. The remainder
15-20 minutes per day. The goals of therapy of these sessions were focused on saccadic
were to show improvement in function and dysfunction while still using a few vergence
fusional ranges, accommodative function, and accommodative activities. The saccadic
and reduction of the patient’s complaints of activities used were Hart chart saccades both
headaches, and diplopia. The first 3 sessions of regular and split Hart chart, VIPS character
therapy focused on positive fusional vergence searching, Ann Arbor Tracking™ SVI saccades
training, diplopia awareness, accommodative and rotator, tachistoscope, visual tracings,
facility and amplitude. Therapy techniques and track and read. At the completion of the
utilized in this training were Brock string, last therapy session, the Developmental Eye
Multiple Choice Vergence RDS on the Movement Test™ was performed which showed
Computer Vergence programs, Red Green normalized saccadic function. The parent
Ratchet, BO Vectograms, and Monocular Near and patient were educated on continuing
Far Hart Chart. home therapy activities for maintenance
After these sessions and once his converg­ and to schedule a binocular vision follow up
ence skills were improved, negative fusional appointment in 6 months.
vergence skills and saccadic skills were

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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
RESULTS
Table 1
Re-evaluation 14
First VT Post VT
Initial BV sessions (Provider
(Provider Funari) (Provider Funari)
Funari)
Chief complaint Headaches and Denies headache,
and symptoms horizontal double vision diplopia
CISS 20 9
CT at distance D:20 IAXT D: 12 IAXT
and near N: 20 IAXT N: 7 IAXT
Control Score D and Near: 1-2 D: 1 N: 1
NPC Accommodative Target: Brock String: initial 24 Accommodative Target: Brock String
21/25cm inches; with effort and 7cm/12.5cm 4cm
transient suppression: 14cm
Step Vergences BO: -/10/6 Computer Vergences: BO: -/25/16 Computer Vergences
at near BI: -/10/6 BO: 24 BI: -/16/14 BO: 63.50
BI: 37.50
Vergence Facility 14CPM 11.5CPM
Accommodative OD:7.14D OD:11D Measured with Near
Amplitudes OS:7.14D OS: 9D Hart Chart (set at 4 in.)
OD: 10D
OS: 10D
Binocular/ OU: 9CPM OU: 5.5 CPM -6.50/+2.00 lenses
Monocular OD:8CPM
Accommodative OS: 8.5CPM
Facility
W4D D: Fusion D: Fusion
N: Fusion N: Fusion
Comment: intermittent
alternating suppression
DEM Poor saccadic Vertical Time:
performance 35 seconds
Vertical Time: 52 seconds Horizontal time:
6th percentile 35 seconds
Horizontal time: 108 Ratio: 1.0
seconds <1 percentile No Errors
Ratio: 2.07 <1 percentile
No errors

Discussion ship between active convergence and

Basic exotropia by definition is an exo divergence mechanisms.”1 This however,
deviation of equal (within 5 p.d.) magnitude according to Bielschowsky did not account
at distance and near. “There is no agreement for “the abnormal position of rest associated
as to the underlying physiology of divergent with exodeviations [which] is determined
strabismus, nor is there definite agreement as by anatomic and mechanical factors [of]
to treatment.”6 Some believe that it occurs orientation, shape and size of orbits, size
“as a result of … obstacles to development and shape of globes, volume and viscosity
or maintenance of binocular vision and/or of retrobulbar tissue, functioning of the eye
due to defective action of the medial rectus muscles as determined by their insertion,
muscles.”7 Duane was of the opinion that length, elasticity, anatomical and structural
“exodeviations are caused by an innervational arrangement and condition of fascias and
imbalance that upsets the reciprocal relation­ ligaments of the orbits.”1 Current theories
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
incor­porate the opinions of both Duane and motor and sensory criteria was 38% while using
Bielschowsky. New research into the structure motor criteria alone was 64%.12 The success of
of extraocular muscles by Bruenech details the orthoptics alone in basic exotropia has been
implication of a “congenital scarcity” of MIFs, reported as high as 88.3%.13 Long term success
multiply innervated fibers, “which constitute of treatment modalities for intermittent
18-23% of all fibers” within extraocular muscles exotropia still require much research however,
as contributory to the etiology of oculomotor William Ludlam and Burton Kleinman from the
anomalies.7 This could bring in new information Optometric Center of New York assessed the
into the pathophysiology of extraocular long range results of 81 strabismus patients
muscles and their influence in strabismic who were dismissed from therapy as cured
deviations. Intermittent exotropia deviations in 1960. The patients were brought back 3-7
are “controlled by fusional mechanisms and years after completion of therapy. Success
[often are] most noticeable when children of orthoptics in all forms of strabismus for
are tired, sick, inattentive or after long time cosmesis was 96%. Refractive success was 92%
near reading task” as this is when breakdown and Flom’s functional cure success was 89%.13
of fusional control mechanisms is most likely While this study does not specifically detail
to occur.8 These deviations may occur from long term success of intermittent exotropia,
a variety of factors including changes to it does show maintenance of success after
extraocular muscle anatomy, loss of fusional completion of orthoptic therapy for strabismus.
control, or convergence insufficiency.8 Inter­ A literature review performed by Zeigler,
mit­tent exotropia comprises between 50- Huff, and Rouse discussed that for studies
90% of all exotropias. The overall prevalence using Flom’s functional cure or an equivalent,
is about 1% in the general population.1 This intermittent exotropia had a 62% cure rate.14
patient also presented with a V-pattern type Overminus treatment in intermittent exo­
deviation which is present in about 30% of all tropia is another option. Often this is per­
strabismus patients.9 formed in children younger than 7 years of
Treatment modalities have varied depend­ age. This treatment protocol is still being
ing on the magnitude of the deviation. studied for effectiveness of long-term control
Many recommend surgical intervention, but after discontinuing overminus prescription.
“for exotropia of 25pd or less, orthoptics The Pediatric Eye Disease Investigator group
is the treatment of choice.”10 This number performed a pilot study on children age 3-6 years
is particularly important for this patient as old with Intermittent Exotropia and overminus
the deviation was less than 25pd at distance therapy of -2.50D. This showed improvement
and near. Surgical intervention would require in control of the distance deviation after 8
significant post-operative care and is not weeks.15 However, this was not considered
always predictable. In fact, surgical treatment for this case due to the patient’s complaint
of exotropia alone has a 42% success rate.10 of near point symptoms, his mild secondary
Long term follow up in IXT patients with accommodative insufficiency, the age of the
surgical intervention (approximately 6.1 years) patient and the potential for side effects
was studied by Hardesty and was reported to similar to the symptoms that this patient was
be 32%.11 Another study at the Jules Stein Eye already experiencing. There is little research
Institute and Department of Ophthalmology, into the long-term effectiveness of overminus
David Geffen School of Medicine at UCLA lenses for intermittent exotropia however, this
reported that after 10 years, the surgical was addressed by the Pediatric Eye Disease
success for intermittent exotropia using both Investigator Group who recommended more

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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
research in a longer randomized treatment trial These goals are all achieved by fusional
and research to determine lasting effects of vergence activities, accommodative activities,
control of IXT after discontinuing treatment.15 transition from random dot stereopsis fusion
In assessing the potential of success targets to flat fusion targets and creating
with implementing therapy, evaluation diplopia awareness for good control of
incorporating the Intermittent Exotropia the intermittent exodeviation. This patient
Control Scale16 is warranted. This patient completed a therapy program aimed at
had fairly good control of his intermittent targeting these specific goals and with good
exodeviation and did not display exotropia therapy compliance and home therapy
until dissociated. As he was scored as a 1-2 maintenance, the patient was able to show
initially, demonstrating he recovered from 1-5 good control and fusional vergence ability to
seconds or >5 seconds, this showed a good compensate for his exodeviation. This patient
prognosis, as the goal of therapy is to improve did not specifically note significant differences
control to a scale of 1. in symptoms in alternate positions of age.
In intermittent exotropia, vision therapy Therefore, another specific goal for this case
should include not only vergence therapy but was initially working in downgaze, where his
also anti-suppression and diplopia awareness exotropia manifested as a smaller deviation
techniques progressing in difficulty to flat fusion and working toward techniques in primary
activities. This aids in continued maintenance gaze and up gaze. This is consistent with
and control of the exo deviation after the recommendation that “binocular therapy
completion of vision therapy.17 This treatment should be extended from primary gaze into
protocol was followed for this patient and as much of the affected gaze(s) as possible.”19
contributed to the success of his management. Regarding work on eye movement awareness,
The therapy approach to treating exotropia it is important to ensure appropriate
begins with motor processing and extends to saccadic therapy treatments are initiated
sensory processing.18 As noted in the Clinical for improvement in fixational accuracy and
Management of Strabismus, the goals of oculomotor coordination. While the results
exotropia treatment include the following:22 have yet to be published, Medipol University
• Take advantage of voluntary convergence is in the process of conducting a study on the
• Stimulate strong accommodative effect of Oculo-Motor exercises in Intermittent
convergence response Exotropia.20 Clinically, effective oculomotor
• Teach eye movement awareness control allows for better biofeedback
• Stabilize voluntary vergence mechanisms during vision therapy. Hart Chart
convergence control saccades as well as other saccadic training
• Establish sensory fusion at the ortho tools were utilized in this manner. After week
position three of vision therapy, these skills were
• Teach diplopia awareness whenever introduced, and the patient was educated
dissociated on proper utilization of the hart chart for
• Teach fast voluntary convergence maximum training potential. As a thorough
recovery of IXT assessment had not yet been performed, a
• Teach accommodative accuracy DEM was included during the re-evaluation
• Teach fusional convergence accuracy and subsequently based on performance,
• Stabilize efficient binocular vision in increased saccadic training was implemented
open visual space during the sessions.
New technology has continued to augment
the treatment that clinicians and therapists
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
have been able to provide for intermittent and convergence.”23 While this served as a
exotropia. The department of Ophthalmology decent measure of symptom improvement,
at the Guangdong Eye Institute in Guangzhou, this specific endpoint number should be
China recently published a study on dichoptic referred to only as a decrease in symptoms
virtual reality training for intermittent not a clinically relevant measurement as a
exotropia. Their virtual reality technology consequence of the child’s age. This patient
“used visual perception and neural plasticity also displayed reduced accommodative
training to remove the obstacle in the visual amplitudes at initial visit. While they improved
processing channel and repair the defect of from 7.14 Diopters to 10D (still reduced from
visual function by nonsurgical therapy.”21 Their the minimum of 12.75 D for a 9 year old),
results showed success and improvement in this was attributed to this particular patient’s
visual sensory perception, stereopsis, and reservation and quiet nature. Throughout
eye position in all 25 intermittent exotropia therapy, he consistently hesitated to ensure he
patients after 6 months of training.21 While this was correct in his answers. His performance on
treatment was not available for this patient, all other accommodative testing was normal
this data allows for possible implementation and he was no longer symptomatic at the end
of virtual reality into intermittent exotropia of the course of vision therapy.
therapy protocols. This study is the first of
its kind, researching virtual reality training Conclusion
for intermittent exotropia, and it shows good This case demonstrates that basic type
promise for the future of vision therapy and intermittent exotropia has the potential for
research with virtual reality implementation in significant improvement with vision therapy
intermittent exotropia. treatment alone. It is important when
Symptom improvement is a significant evaluating these patients to provide continuity
measure of success along with the patient’s of care with the provider as well. This was
alignment and binocular findings. The a significant limitation in this case as the
convergence insufficiency symptom survey was vision therapy provider and initial evaluations
used in this case. While the symptom score did were performed by different optometrists.
improve, understanding that the responses When evaluating these patients, testing for
children give can be unreliable at times is alignment, magnitude of deviation, control,
essential in determining true improvement in accommodative function, anomalous retinal
symptoms. A symptom score of greater than or correspondence, and symptoms are significant
equal to 16 is clinically significant in diagnosing in assessing prognosis and in monitoring
convergence insufficiency.22 Though our progress. While there are many different
patient did not have a CI type intermittent avenues for treatment, the age of the patient,
exotropia, he displayed some of the clinical the prognosis, and assessing the motivation
measurements correlating with convergence of the patient should play a key role in the
insufficiency including low positive fusional decision for vision therapy.
vergence and a reduced near point of If vision therapy is advised, an appropriate
convergence. A recent study in 2015 concluded management plan should be devised including;
that the convergence insufficiency symptom diplopia awareness, anti-suppression, fusional
survey scores “significantly overestimated vergence techniques, accommodative tech­
near visual symptoms in children with normal niques, saccadic activities and eventually
binocular vision compared with symptoms flat fusion to aid in maintained control of
caused by preferred near activities that exodeviation in free space. Appropriate
require similar amplitudes of accommodation re-evaluations should be performed and
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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020
consistent monitoring of progress throughout 2. Caloroso, E. E., Rouse, M. W., & Cotter, S. A. (2007).
Clinical management of strabismus. Boston: Butterworth-
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not understand that improvement in symptoms Intermittent Exotropia. Iranian Journal of Ophthalmology,
21(1). Retrieved from http://bit.ly/2x7ehFs.
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4. Caloroso, E. E., Rouse, M. W., & Cotter, S. A. (2007). Clinical
measurable factors for completion of therapy. management of strabismus, 223. Boston: Butterworth-
This is often a significant reason why patients Heinemann.
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6. Arthur Jampolsky (1964) Physiology of Intermittent
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due to unique presentation of binocular vision does the structure of extraocular muscles and their nerves
affect their function?. Eye (London, England), 29(2), 177–
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and patient were interested in continuing with 8. Kelkar, J. A., Gopal, S., Shah, R. B., & Kelkar, A. S.
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for home therapy and was scheduled to return mittent exotropia. A comparison of the results of surgical
for a maintenance evaluation in 6 months. and non-surgical treatment. Am Orthopt J 27: 61-67.
Vision therapy is a significant and suf­ 11. Hardesty HH, Boynton JR, Keenan JP (1978) Treatment of
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13. Ludlam, W. M., & Kleinman, B. I. (1965). The Long
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Acknowledgement 53:979–83.
The author wishes to thank her mentors: 15. Pediatric Eye Disease Investigator Group, Chen, A. M.,
Dr. Erin Jenewein, Dr. Stanley Hatch, and Dr. Holmes, J. M., Chandler, D. L., et al. (2016, October). A
Bhawan Minhas, as well as the entire faculty Randomized Trial Evaluating Short-term Effectiveness
of Overminus Lenses in Children 3 to 6 Years of Age
of the Pediatrics and Binocular Vision Service with Intermittent Exotropia. Retrieved from http://bit.
at The Eye Institute of Salus University for ly/2TBTcdA.
guidance in this case and in preparation of 16. Mohney, B. G., & Holmes, J. M. (2006, September). An
this article. office-based scale for assessing control in intermittent
exotropia. Retrieved from http://bit.ly/3apxekS.
17. Peddle, A., Han, E., & Steiner, A. (2011). Vision therapy
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18. Caloroso, E. E., Rouse, M. W., & Cotter, S. A. (2007). Clinical
management of strabismus, 231. Boston: Butterworth- AUTHOR BIOGRAPHY:
Heinemann. Katharine Funari, OD, FAAO
Bethesda, Maryland
19. Caloroso, E. E., Rouse, M. W., & Cotter, S. A. (2007). Clinical
management of strabismus, 226. Boston: Butterworth- Katharine Funari, OD, FAAO is an
Heinemann. Instructor of Ophthalmology at the
Wilmer Eye Institute specializing in infant
20. The Effect of Oculo-Motor Exercises in Intermittent and pediatric eye care and binocu­
Exotropia. (2019, March 13). Retrieved from http://bit. lar vision disorders including strabis­
ly/2TCC9bB. mus, amblyopia, and convergence
21. Li, X., Yang, C., Zhang, G., et al. (2019). Intermittent insufficiency. She has particular interest in myopia control,
Exotropia Treatment with Dichoptic Visual Training Using acquired brain injury including concussion and vision
a Unique Virtual Reality Platform. Cyberpsychology, rehabilitation. Dr. Funari received her Bachelors of Science
Behavior, and Social Networking, 22(1), 22–30. http://bit. degree from Villanova University. She then received her
ly/3am0SaM Doctor of Optometry degree in 2018 from the Pennsylvania
22. Bartuccio M. The treatment of convergence insufficiency: College of Optometry at Salus University where she was
A historical overview of the literature. J Behav Optom awarded clinical honors and the Good-Lite Award for
2009;20:7-11. Retrieved from http://bit.ly/2VKiIjF advanced competency in binocular vision and pediatric
vision care. She completed her residency training at The Eye
23. Clark TY, Clark RA (2015). Convergence Insufficiency Institute in Philadelphia, PA in Pediatrics and Vision Therapy
Symptom Survey Scores for Reading Versus Other Near in 2019. Dr. Funari is currently an investigator in the Pediatric
Visual Activities in School-Age Children. Am J Ophthalmol Eye Disease Investigator Group at the Wilmer Eye Institute
(Nov);160(5)905-912. Retrieved from http://bit.ly/3crbJSx of Johns Hopkins Medicine.

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Vision Development & Rehabilitation Volume 6, Issue 1 • March 2020