Orthoptics

Your child may see an Orthoptist if there are concerns regarding:

• A turn in one or both of the eyes (squint/strabismus)
• Reduced vision in one eye or both eyes (Amblyopia/Lazy Eye)
• Wobble in the eyes (nystagmus)
• Droopy eye lid (Ptosis)
• Focusing problems
• An uneven or high glasses prescription

We also routinely assess babies who are premature and/or have low birth weight, as they are more susceptible to vision problems.

You may just see an Orthoptist for your child's appointment, or this may be a joint appointment with the Paediatric Ophthalmologist (Eye Doctor); this may be a longer appointment and can last up to a few hours. Your child may also need eye drops if they are seeing the doctor as well.

We also offer a School Screening Service, for reception children aged 4-5 who attend schools within the Stoke-on-Trent area. We screen for a number of vision defects including reduced vision, squints or eye movement defects. Your child will be seen by an Orthoptist in school and may be referred to local opticians to check for glasses before seeing an Orthoptist at the hospital or a local community clinic to monitor their eyes and potentially start treatment.

It is important that we catch eye problems early as vision stops developing around the age of 7-8 years. Spotting conditions early gives a better outcome for treatment.

We run a Special Schools Service where we routinely visit the special schools within the Stoke-on-Trent and Staffordshire area to provide routine eye tests for children with known eye problems in their school environment.

We also routinely screen reception children in these schools to check for any vision or eye movement problems.

We hold clinics for children both at Royal Stoke Hospital and County Hospital, as well as community clinics. You may request to be seen at a community clinic if this is more convenient. These include:

• Bentilee Neighbourhood Centre

• Biddulph Primary Care Centre

• Blurton Health Centre

• Lucie Wedgwood Health Centre

• Cheadle Health Centre

• Loomer Road Health Centre

• Fenton Health Centre

• Hanley Health Centre

• Kidsgrove Health Centre

• Leek Health Centre

• Longton Health Centre

• Meir Primary Care Centre

• Milehouse Surgery

• Ryecroft Surgery

• Smallthorne Health Centre

• Tunstall Primary Care Centre

Your child may be given various treatments depending on the nature of their eye problem, which is unique to every child. These may include:

• Eye patches or Eye drops – to improve reduced vision in one eye
• Glasses
• Exercises to improve focusing of the eyes

We may also refer to the Visual Impairment Team for help and support both at home and in Nursery/School.​

See below for Information Leaflets relating to treatment options that include help and guidance.

You may attend an orthoptic clinic if:

• You are experiencing double vision (diplopia)
• You have had trauma/injury to the eye/eye area
• You have had a stroke which has resulted in eye problems
• You are experiencing field loss
• You have a turn in the eye (squint/strabismus) that may have been present in childhood
• You are struggle to focus/having trouble with reading

We work closely with other departments including Maxillo-facial, Neurology and Stroke.

Treatments may include:

• Prisms to help join the double vision
• Glasses to improve sight/prevent double vision
• Exercises/Eye Training to aid rehabilitation

You may be given suggestions on websites to visit if you are experiencing double vision, or field loss following a stroke. You may have also been advised by your orthoptist that you are not able to drive following your stroke.

What is a lazy eye?

A lazy eye or amblyopia occurs when the sight of one or both eyes is underdeveloped causing reduced vision.

What causes amblyopia?

A squint(a turn in the eye) is the most common reason for one eye to be amblyopic. Amblyopia can also occur when one eye is more long or short sighted than the other or if there is an obstruction to light reaching the back of the eye e.g. cataract or scarring.

How do we treat amblyopia?

Amblyopia can be treated with glasses and/or occlusion (patching/drops) therapy. Glasses help by letting the eye focus properly, but occluding /blurring one eye may often also be needed. A patch can be used to cover the good eye or a medically prescribed atropine eye drop can be used to blur the vision in the good eye.

How does the occlusion (patching/drops) help my child’s sight?

The sight should improve if the child uses the eye more since it is lack of proper use that has caused it to be lazy. Covering or blurring the good eye should make the lazy eye work harder. If the child needs glasses then these should be worn at the same time as patching or eye drops.

Should my child do anything different when being occluded?

Reading, drawing or playing with small toys or computer games (e.g. a DS) are good activities to encourage the eye to work harder when whilst
wearing a patch for a set time . Atropine drops give a constant blur therefore no one activity is best. Your Child may like to watch TV but may need to sit closer to see properly. If your child’s sight is very poor it is best to play with things that are big and bright so that they can be seen more easily.

How long will the occlusion take?

This varies from child to child and depends on their age and how long the eye has been lazy. The Orthoptist will see you regularly to monitor progress and will develop a treatment plan to suit you and the visual needs of your child.

Does occlusion therapy really work?

Occlusion will only work if your child wears the patch or instills the eye drops as instructed. Occlusion will only help your child’s lazy eye and will not improve a squint. Squints are treated with glasses and/or surgery.

Will it get better on its own?

NO. If left untreated the child may have permanently damaged sight which cannot be corrected when they are older.

Tips

• Encourage
• Keep trying - despite opposition
• Ask for support from others
• Make it fun
• Keep them busy
• Reward good behaviour

For more information please contact : Orthoptic Department Telephone: 01782 674333

What is a squint?

A squint occurs when an eye turns and stops working with the other eye. Most commonly the eye may turn towards the nose or turn out outwards and more rarely up or down.

What causes a squint?

In some cases the squint is caused by longsightedness and the child needs glasses. The strain made by the child to see without the glasses causes the eye to turn in. In other cases there may be no obvious reason but
there is often a history of glasses and/or squint in the family.

Will my child grow out of a squint?

No, although some squints improve as the child gets older.

Will my child need treatment?

Yes, if you wish for your child to undergo treatment.

There are two aims for treatment:

1. To improve the child’s vision. Glasses will help some children. If the vision in the squinting eye is poor, patching of the good eye may be necessary.
2. To improve the squint. Glasses may help some children. Surgery may be required to correct some squints. Some children do not need glasses.

Are all squints treated the same?

No, there are many different types of squints and therefore many types of treatment.

Who will treat my child’s eyes?

There may be a few people of differing specialities looking after your child’s eyes.

• The Consultant Ophthalmologist has overall responsibility for your child’s general eye care.
• The Orthoptist works closely with the Ophthalmologist and is a specialist in the treatment of squints and children’s eye development.
• The Optician/Optometrist will test for glasses and advice you when changes are needed. Your child will usually have a test once a year or more frequently if necessary.

How long does treatment take?

This varies from patient to patient. The only general rule is that with a squint a better result is easier to achieve if treatment is started at an early age. Most children remain under hospital care until about 7 years old.

How do I find out about my child’s eye condition?

Ask any of the eye care professionals dealing with your child’s eyes. Every case is different and with your child’s record to hand, it is easier to answer any specific questions you may have.

Therapy Apps you may find useful:

Visual Attention Therapy

-free version
-paid version
-useful with vision field loss and vision neglect
-helps your scan your eyes to your bad side
-uses searching puzzles

Constant Therapy

-free trial
-offers tasks to improve:
memory
speech
cognition
language

Exerciser 3.0

-Free version
-Paid version
-uses targets on the screen
-helps improve accuracy of eye movements

DREX

-Free
-Durham Reading and
-Exploration training
-teaches how to cope with vision field loss

Games you may find useful:

• Still – Original
• Stroke Monster
• Shades
• Eyesight
• The Eagle Eye
• Impossible Eye Test
• Word Run
• Word Search

Websites you may find useful:

-Read Right (www.readright.ucl.ac.uk) - a free therapy to improve reading
speeds in patients with vision field loss.
-Eye Search (www.eyesearch.ucl.ac.uk) - a free therapy for patients with
vision field loss or vision neglect.

Information Apps you may find useful:

VisionSIM

-free
-allows family members and carers to see what it’s like to have a vision problem

Stroke

- free
- general information on stroke

Stroke Patient

- free
- general information on stroke

The Stroke App USA

- free
- information
- exercises
- stories

see www.orthoptics.org.uk/ for more information

1. WHAT IS VISUAL FIELD LOSS?

Visual field is a term used to describe the whole of what you see when you are looking straight ahead. It includes both your peripheral and central vision. Each eye has its own field of vision. The fields of vision of either eye overlap so some objects are seen by both eyes. Objects to the extreme right or left are only seen by one eye.

Visual field loss is when you have lost an area of vision in your visual field. It may be central and/or peripheral. Visual field loss following stroke or head injury usually affects both eyes.

Usually the part of your vision lost is to the same side as any weakness in your face, arms or legs. Strokes which only affect the very back of your brain may cause visual field loss without any other problems. There are different types of visual field loss. The most common visual field loss following a stroke is a homonymous hemianopia. Hemianopia means loss of half of your vision. In other words the right half or the left half of your vision is missing from each eye.

Other types of visual field loss seen following a stroke or head injury are:
■ loss of quarter of the visual field (quadrantanopia)
■ loss of central vision (low vision)
■ random areas of visual loss (random scotomas).

2. HOW CAN I TELL IF I HAVE VISUAL FIELD LOSS?

If you have visual field loss you may:
■ notice that you cannot see objects on one side i.e. you have a blind side
■ some people feel they have lost the vision in one eye i.e. if they have lost their vision to the right they may describe it as having lost the vision in the right eye
■ bump into objects on your blind side
■ easily trip and fall over objects in your blind field
■ find crowded areas more difficult as people and objects suddenly appear in front of you from your blind side
■ experience difficulties with reading and writing. If you have a left sided field loss it is difficult to find the start of the line. In right-sided field loss, reading may be more difficult because you cannot see ahead along a line of text and you can easily lose your place.

3. HOW WILL VISUAL FIELD LOSS AFFECT SOMEONE FOLLOWING A STROKE?

■ People with visual field loss may be disorientated and easily alarmed when objects suddenly appear from their blind side.

■ They have an increased risk of trips and falls.

■ Visual field loss will affect their general mobility and independence.

■ can suffer depression and impaired quality of life.

■ If the visual field loss is associated with visual inattention they may have no awareness that their vision is defective (see leaflet on Visual Inattention following Stroke or Head Injury).

■ They may have visual hallucinations related to their visual field loss (see leaflet on Charles Bonnet syndrome).

■ They will not be able to drive and should notify the DVLA.

4. CAN VISUAL FIELD LOSS RECOVER AND HOW LONG WILL IT TAKE?

Recovery depends on the area of the brain affected and how much damage has been done. Some visual field loss can improve by itself. Improvement has been reported in about 50% of patients with visual field loss following stroke. Recovery is usually seen within the first 3-6 months if it is going to occur.

5. ARE THERE ANY TESTS NEEDED TO CONFIRM THE DIAGNOSIS?

Initially your visual field loss will be detected by a simple bedside test. This is known as a confrontation visual field test. More formal testing of your visual field is done on a machine called a perimeter. If you have had your eyes tested by an Optician you may already have had one of these tests. It is not painful but does require a bit of patience and concentration.

6. CAN VISUAL FIELD LOSS BE CURED?

Visual field loss cannot be cured if it does not spontaneously recover. There are a number of strategies that may be used to allow the patient to adapt to their visual loss. These aim at improving awareness of the visual field loss.

7. WHAT DOES THE TREATMENT FOR VISUAL FIELD LOSS INVOLVE?

Most treatment for visual field loss involves targeted advice for individual patients. None of the treatment options below will permanently cure the visual field loss but may help faster adjustment to the loss.

■ Visual search strategies help to improve awareness of your blind side and help your ability to scan into the blind field. These include increasing head movements and fast eye scanning movements into the blind area.
■ Reading can be helped by using a variety of methods e.g. line guides, typoscopes or magnifiers.
■ Prisms (Pelli prisms) can be used to temporarily to expand your field of vision. They work by displacing images from your blind side onto your seeing side.
■ Visual restorative treatment is a computer based treatment that stimulates the blind field. It has been reported to improve navigation skills, reading ability and visual sensitivity. This treatment is not available on the NHS.

Your Orthoptist will discuss with you the best strategies to use and how to go about doing them.

8. WHAT CAN BE DONE AT HOME TO HELP SOMEONE WITH VISUAL FIELD LOSS?

A number of things can be done to help people with visual field loss. Some methods make the person more aware of their affected side and attend to it better and others are designed to make the best use of the seeing side. For example:
■ encourage visitors to sit on their unaffected side
■ put important things on their seeing side i.e. cup of tea so they can see it easily
■ put a line or tape down the left hand side of books or newspapers so the person knows where the line starts.

9. CAN SOMEONE WITH VISUAL FIELD LOSS DRIVE?

If someone has a hemianopia or visual field loss that affects their central vision, the DVLA states that they are not normally accepted as safe for driving. Persons may be eligible to reapply on an individual basis as exceptional cases subject to strict criteria. These include a stable visual field defect for at least 12 months, absence of a progressive condition and full functional adaptation to the defect. A specialist driving assessment may be undertaken if reapplication is accepted by the DVLA. If in any doubt consult the DVLA website direct for the latest information www.dft.gov.uk

10. WHERE CAN I FIND MORE INFORMATION ABOUT VISUAL FIELD LOSS?

If you would like to know more about visual inattention or have any questions or concerns, please contact the British and Irish Orthoptic Society at:

British and Irish Orthoptic Society
62 Wilson Street, London EC2A 2BU
Tel: 01353 665541
Website: www.orthoptics.org.uk
Email: bios@orthoptics.org.uk

Additional help and advice is also available from:

The Stroke Association
Stroke House, 240 City Road, London EC1V 2PR
Tel: 020 7566 0300
Website: www.stroke.org.uk

Headway – the brain injury association
Bradbury House, 190 Bagnall Road, Old Basford,
Nottingham NG6 8SF
Helpline: 0808 800 2244
Email: helpline@headway.org.uk
Website: www.headway.org.uk

Royal National Institute for the Blind (RNIB)
105 Judd Street, London WC1H 9NE
Tel: 0845 766 9999
020 7388 2525
Website: www.rnib.org.uk

1.WHAT IS VISUAL INATTENTION?

Visual inattention is a condition experienced by people who have had a stroke or head injury. It is when a person ignores every thing on one side of their visual world. It usually affects people who have had a right sided stroke and they ignore things on their left side. Right sided visual inattention is less common and tends to affect people in different ways.

This condition is also known as visual neglect or spatial inattention. People with visual inattention may also have a more general neglect where they ignore or do not attend to one half of their body, mainly the left side. Visual inattention can vary from being very mild to very severe. As well as visual inattention some people may also have a hemianopia, loss of vision to the same side, which is being ignored. For more information on hemianopia see leaflet on ‘Visual Field Loss Following Stroke or Head Injury’.

2. HOW CAN I TELL IF SOMEONE HAS VISUAL
INATTENTION?

People who have visual inattention will be unaware of anything or anyone on their affected side. They may hear you but will not look at you or acknowledge you until you move around to their non-affected side.

They may only eat one half of the food on their plate, struggle to read because half of the page is missing, bump into people and objects on their affected side.

3. HOW WILL VISUAL INATTENTION AFFECT SOMEONE FOLLOWING A STROKE?

The majority of people, with visual inattention, tend to be symptom free. The brain is unaware that the affected side exists and the patient is unaware that anything is wrong, so they deny that they have a problem. Visual inattention can affect a person in all aspects of their daily life e.g.
■ ability to walk with out bumping into objects
■ losing their sense of direction i.e. not taking the correct right or left turn when walking somewhere and getting lost
■ crossing roads unsafely by not checking for oncoming traffic on the affected side
■ all aspects of self-care such as dressing, washing, shaving; they may only dress, wash, shave the unaffected side etc.
■ reading does not make sense because they only read the text on the unaffected side e.g. only read the right half of the page
■ telling the time as they only see one side of the clock face.

People with visual inattention are dependent on others for help and ensuring they are safe.

This can cause problems with their rehabilitation and safety as well as a longer period of hospitalization.

4. CAN VISUAL INATTENTION BE CURED?

The mechanism for recovery of visual inattention is complex and still not fully understood. In many people there is frequently good recovery from visual inattention. However when it is present, continued input from health care professionals and carers is important to promote awareness of the affected side.

5. WHAT DOES THE TREATMENT FOR VISUAL INATTENTION INVOLVE?

Visual inattention is described as a disorder in ‘looking’ rather than ‘seeing’. Orthoptic treatment involves getting the patient to look to their affected side. This is done using eye exercises and encouraging the patient to ‘look’ or scan for objects on their affected side.

Strategies to help with reading and other tasks are discussed and used. Occasionally prisms, eye patches, mirrors and games may also be used

6. WHAT CAN BE DONE AT HOME TO HELP SOMEONE WITH VISUAL INATTENTION?

A number of things can be done to help people with visual inattention; the following are all designed to make the person more aware of their affected side and attend to it better:
■ encourage visitors to sit on their affected side – hold their hand on the affected side to draw their attention to this side
■ put interesting things more over to the affected rather than unaffected side
■ put a line or tape down the left hand side of books or newspapers so the person knows where the line starts
■ put colourful lights on the patients left side to draw their attention
■ any games, puzzles etc including computerized games that will encourage the affected person to attend to there side.

7. CAN SOMEONE WITH VISUAL INATTENTION DRIVE?

No, it is not safe for some one with visual inattention to drive. People with visual inattention are not aware of anything on their affected side but often think their vision is normal. This makes it dangerous for them to
drive. However each stroke is different and depending on how well the visual inattention and other stroke related problems recover some people are able to return to driving.

8. WHERE CAN I FIND MORE INFORMATION ABOUT VISUAL INATTENTION?

If you would like to know more about visual inattention or have any questions or concerns, please contact:

British and Irish Orthoptic Society
62 Wilson Street, London, EC2A 2BU
Tel: 01353 665541
Website: www.orthoptics.org.uk
Email: bios@orthoptics.org.uk

Additional help and advice is available from:

The Stroke Association
Stroke House
240 City Road
London
EC1V 2PR
Tel: 020 7566 0300
Website: www.stroke.org.uk

How does the Doctor or Optician know my child needs glasses?

The Doctor/Optician can see the back of the eye once prescribed eye drops have enlarged the pupil. Moving a line of light with a torch like instrument in front of the eye enables the Doctor/Optician to judge what strength of glasses is needed. This test is called “a refraction” and is usually done once a year.

Will my child always need to wear glasses?

This will depend on the age of the child, the strength of the glasses and on whether they are also required as part of the treatment of squint or lazy eye. The use of glasses may change as your child gets older and this will be monitored by the Orthoptist.

Should my child wear glasses all day?

Yes in most cases. If the glasses are not needed full time, your Orthoptist will tell you. Some schools require children to remove glasses during activities for the child’s safety; however this is not always advisable. If your child has poor vision without wearing glasses, it may be better that the glasses are left on (the Orthoptist will give you advice on this.) Some young children need lots of encouragement to wear their glasses full-time and you may need time to build up the time gradually.

My child claims to see better without glasses

This is quite a common complaint in the early days of wearing glasses. Initially the glasses may not help the child very much as it can take time to gain the full benefit from the glasses. Please keep trying - this is a very important stage of the treatment, but contact the Orthoptist if you have any concerns.

The glasses look very strong!

If you do not wear glasses or your glasses are for a different condition, your child’s glasses may look odd to you. We prescribe glasses that will help your child achieve the best possible vision.

Will my child become dependent on glasses?

No. Glasses do not weaken the eyes in any way. Your child may be reluctant to be without their glasses because they can see so much better
with them on.

What is long sight, short sight and astigmatism?

Long sight- (Hypermetropia) is caused by the eye being too short, so that the rays of light entering the eye focus behind the retina (back of the eye) instead of on the retina. Long sighted children may have reduced vision for near and distance.

Short sight- (Myopia) is caused by the eye being too long, so that the rays of light entering the eye focus in front of the retina instead of on the retina. Short sighted children may have reduced vision for near but tends to affect distance vision more.

Astigmatism- in addition to being long or short sighted, your child’s eyes may be an irregular shape and as a result of this the vision is affected at all distances.

How do I find out about my child’s eyesight?

Ask any of the eye care professionals involved with your child’s treatment and they will be able to answer any specific questions you may have.

Contact Information

For more information please contact the:

Orthoptic Department,
Main building,
UHNM,
NewcastleRoad,
Stoke-on-Trent
ST4 6QG
Telephone: 01782 674333