Vision therapy - analogous to Ear training?

Vision therapy is a lot like the ear training musicians go through. First the person has to become aware that the eyes can be tools for gaining information about the world. Some kids miss this idea preferring to touch everything or talk their way through life. Often these kids have not developed good intentional control of their eye muscles - this is what the activities in the Purple Book of the Eye Can Too! Read series helps. After they build automatic eye movement control, then it is time to work on eye teaming - skills that require the assistance of lenses, prisms, and other specialty equipment that eye doctors keep around. Kids who display dyslexia type symptoms like frequent reversals of letters and words when reading or writing, who can't easily cross their physical mid-lines. and who confuse left and right need to have an eye exam so that the eye doctor can rule out any deficits or delays in ocular motilities or eye teaming. Then they can work on the visual spatial skills of laterality and directionality - these are the topics of the Yellow Book of the Eye Can Too! Read series. At last it is time to consider the visual perceptual skills - discrimination, memory, figure ground, sequential memory, closure, and spatial relations. These are more analogous to ear training. What did you see and can you recognize it again or more specifically in another context or after it is slightly modified? These skills are the subjects of the Green Book of the Eye Can Too! Read series.

Helping a parent process through what the eye doctor said

Last week I received a call from a home-schooler who found my Eye Can Too! Read website and wanted to know which book she should order for her son. She recently took him to a developmental optometrist who diagnosed a cluster of visual diagnoses which do indicate a need for vision therapy. But the mother had not been given enough information to understand what had been found or what the therapy would accomplish. We talked for more than an hour. While the doctor did not use any of the normed diagnostic tools with which I am familiar, I could tell by the description of her assessment activities what she had done. The therapy assignment for the first several weeks was to use a Marsden Ball to introduce appropriate control of Pursuits, one of the two ocular motility skills we address in therapy. The therapy is only done at home facilitated by the parent - the mother was instructed to swing the ball three times in each direction for each eye once per day. She was to do nothing more for now. We concluded that her son would benefit from using either the Purple Book or the Yellow Book and since the activities are academic in nature, designed with home-schoolers in mind, they could be used without compromising the therapy prescribed by the doctor.

It's Developmental

Eye movements, eye teaming, visual perceptual skills, and eye-hand coordination are all developmental skills. This means that they typically emerge given the right opportunities and experiences like learning to walk, ride a bicycle, or swim. There is a range of normal vision development which can be tested and measured against standard age/grade norms. This is how developmental optometrists determine and diagnose any delays or deficits of normal visual development. What we do in vision therapy is help trigger a child to acquire and maximize their visual developmental skills. I can't tell you the number of times a parent has asked me whether their child will need to return to vision therapy in the future. My usual answer is that it is very like learning to swim but then not swimming all winter. Can you still swim when the pool opens in the spring? Yes, and what good swimmer hesitates to dive into the pool's deep end even if they haven't been swimming in ages? Unless the visual problem involves a diagnosis of amblyopia, or some other non-developmental condition or brain injury, once a child's visual skills have developed, they tend to keep improving.

Toes Matter

 In our vision therapy room we pay attention to our patients' toes as well as to their posture in general. Toes matter. Every ballet dancer knows that the eyes follow the toes.When a patient habitually stands with one toe pointed in or out and tries to do the Brock String, for instance, they typically find it easier when their feet are parallel to the string. If they twist their hips or stand with one shoulder raised, a head tilted, or a shoulder tipped back or forward, we notice that they often also have a problem performing the therapy activities that require them to team their eyes efficiently. So, if you have poor posture, walk toes in or out, or tilt your head, I suggest that you make an appointment to see a developmental optometrist to learn if your posture might be due to a binocular vision problem - besides, even if you have perfect posture, you should get a comprehensive eye examination once a year.

Look!

When a person does not have good control of their eye movements they often do not trust, value, or rely on the visual system as a means of gathering information. The other day I was working with a nine year old boy in a vision therapy session. I had made a "map" on the floor using a length of clothesline placed so that every few feet the rope made a 90 degree turn. The boy, who is 100% accurate about identifying left and right on himself, was told to walk along the rope, stop before making a turn and say which way the rope led. If he correctly identified "left" or "right" I allowed him to progress. He was inconsistent and as I watched, I noticed that he never looked at the rope. At least guessing gave him a 50% chance! I began to say, "look DOWN at the rope." When he did, his accuracy rate improved. After more than 30 turns (we repeated the activity a few times), I still needed to cue him to "look DOWN at the rope" .... This boy cannot follow a slowly moving target like a Wolf Want nor can he successfully make short hops between two stationary targets without his eyes shifting suddenly away from where he is trying to make them point. Yet! Even though each week he has better control but now I realize that in addition to building the muscle awareness and automatic control of his eye movements, for this boy, I have to help him gain an appreciation and the habit of letting his eyes participate in gathering the information needed to navigate through life and the world.

After six years as a vision therapist....

It has been about six years since Dr. Doell recruited me to become a vision therapist in her optometry practice. At the time, I was a classroom teacher with a master's degree and I was also her patient - we had met when one of my own children suffered from a convergence insufficiency close to 20 years ago. She did about six weeks of vision therapy on Nancy and treated the whole family happily ever after.

We clicked - come from the same area of New York City and find the same things funny so we laughed through each appointment and even went out to lunch for fun a time or two. So, when she told me she was looking for people with masters degrees in education or OT to train herself, I was interested - besides single parenting (not by design) six minor children on a teacher salary was not cutting it so the few extra bucks looked good.

I observed the VT room in action and started working after school a couple of evenings each week. I already knew how to read a child's personality and make them feel at ease. It was easy for me to set up an activity and make it meaningful but it took a lot of practice to learn how to observe the eyes at work, how to match the right therapeutic activity to the diagnoses, how to decode the medical notes in the patient's file, and how to record and then apply what I observed.

Reading optometry books and articles made me feel illiterate at first - a whole new vocabulary had to be grasped - and I felt really slow at the task in spite of being an insatiable very competent reader. But I persevered, attended workshops and optometry conferences and asked the same questions a million different ways not realizing that it was the same question sometimes.

Now I find myself watching the eyes of people being interviewed on television and wondering if there is a strabismus or some other problem to explain anything other than aligned normal looking eye contact or eye movements. I find myself wishing I could do some simple activities with random colleagues and relatives because they display familiar ocular behaviors or postures that I know I could perhaps address and provide the means to greater visual efficiency.

I wish I could interest every classroom teacher in my e-books because a few carefully chosen lessons using the activities I present might just make a few more kids into more adequate readers who could do better on the dreaded standardized tests. Why don't the graduate level reading classes incorporate basic visual efficiencies or present the list of classroom behaviors that signal probable learning-related vision challenges which proper optometric attention could resolve?

I don't know how many more years I will be doing vision therapy a couple of days each week but I do know that my life and outlook has been forever changed because I have been introduced to the profession.

Helping special needs students accept and tolerate transitions

A special needs patient has been coming to me for vision therapy for much of the last year. His original skill set included eye movement deficits, convergence excess, delays in most subsets of visual perceptual development, and delays in visual motor integration. In other words, this kid's learning-related visual skills were severely messed up. The progress he has made on all fronts took a quantum leap once he began to see that he could control his visual system and that the strategies he has successfully used to resist frustrating tasks are no longer needed now that the tasks themselves are achievable.

However, like most special needs kids, he continued to struggle whenever he had to make a transition - in the vision therapy context this meant that it took us forever to get him to move through the flipper sequence for monocular and then binocular accommodation.

When I taught in the inner city classroom, the issue of helping children accept and tolerate transitions was one of my big goals especially when students with special needs were mainstreamed into one of my classes. So, I consider myself to be somewhat competent at fostering this skill. My patient, however, was one of the most resistant and I was working with him one on one so I could just imagine the issues he faced in the classroom at school.

Over the past six sessions, I have introduced yoked prism glasses - switching the direction of the prism every few minutes. The patient calls them "drunk glasses". At first he could not manage to walk a taped straight line with yoked six base anywhichway prism glasses. The other day, he tolerated - even enjoyed 20 base up, down, right, and left yoked prisms - he walked straight lines and manipulated a hoop to trap and release a marsden ball without missing a beat.

His father was observing the session and I realized that he did not understand what a huge achievement this indicated. So...... guess what I did?

I put the base 20 yoked prism on the dad and asked him to walk the line - he barely managed it base down. Then I shifted the prisms base right and the man nearly fell off the floor to the delight of his son, my patient. The purpose of the activity was achieved though, because the dad totally understood the huge progress that my patient had made - to handle quick transitions, adjust to them, and enjoy it. Now, to transfer that ability to other areas of his life....