Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,

-focusing,

-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

Automation and Technology

In the book Messy, Tim Harford reveals some of the dangers of overconfidence in the increasing competency of technology. The most dramatic example is the unnecessary crash of Flight 447 with the loss of the lives of everyone on board. The plane was an Airbus 330, one of the world’s safest airplanes. The three pilots’ experiences made them overconfident. Instead of using technology to assist them, they abdicated their judgment and responsibility. It is a paradox that the likelihood of having serious outcomes increases from problems with technology as technology becomes more proficient.

This problem also exists in healthcare as doctors become more reliant on tests than on observation and patient interviews. We can also fall into the trap of expecting everything to be better with enhanced technology. The use of computer screens does not make everything better. Due to their efficiency, they are likely to increase vision-related problems. Most visual problems develop incrementally. It is fortunate that we do not notice every little change and it is usually an advantage that we are able to adapt. But adapting for this many hours a week can cause people to be unaware of or ignore problems which should be treated sooner.

This also applies to vision and driving. People who have not needed glasses to drive are often reluctant to accept when glasses will enhance their comfort and safety while driving. Seeing better can provide more time to make decisions, speed up reactions to sudden changes which need to be interpreted, and ameliorate the problems associated with night driving. Driving requires sustained attention and working memory. If seeing requires more effort and attention, the result can be similar to when people are talking on their phones; their useable visual field constricts.

This attitude about glasses and driving is not new. What is new is the response: “I don’t need glasses to drive. I have GPS.” Driving in unfamiliar places is stressful. Most of us do at least 95% of our driving where we know the roads and traffic patterns and know how we will get to our destination. Satellite navigation does help but it does not eliminate the importance of vision for judging distance and speed, and for seeing everything around us which an efficient visual system processes simultaneously. Vision enables us to see into the future and predict what will happen. It enables us to catch a ball. It also enables us to predict the movement of our car and those around us to avoid collisions.

We all have GPS stories. Problems occur when we are not using technology to assist us but to replace planning and judgment. Our GPS world is narrowed to what is on the screen and what we are being told. Tim Harford shares these examples.

Our learned helplessness in the hands of technology is sometimes more amusing than horrifying. In March 2012, three Japanese students visiting Australia decided to drive to North Stradbroke, guided by their GPS system. For some reason the GPS was not aware that their route was blocked by nine miles of the Pacific Ocean. These things happen, of course, but the reaction of the three tourists was extraordinary: in thrall to their technology, they drove their car on to the beach and across the mud flats towards the ocean. As the water lapped around their Hyundai, they realized, to their embarrassment, that they were stuck. With astonished ferry passengers looking on, the students abandoned their car and waded to shore. It’s fun to laugh at incompetent tourists. But it is also worth asking how on earth three sentient beings can drive into the Pacific Ocean on the instructions of GPS gone haywire.

The incident is far from unique. People following GPS guidance have driven their cars into a lake in Washington state, straight on a T-intersection and into a house in New Jersey, down a flight of stairs in Manhattan, along a rocky footpath to the brink of a cliff in Yorkshire and into a large sand pit at a construction site in Hamburg. This is known as automation bias; once a computer has made a recommendation, it is all too easy to accept that recommendation unthinkingly.

This is also an example of perceptual bias. Seeing is not passive. When we look, we usually have an expectation of what we will see. We recognize the object or person faster due to our expectation. Our perception is slower when we are just looking around without an expectation. But when our eyes are looking at something that is very different from what we expected, our perception may not only be slower, we may become temporarily overwhelmed and freeze. When this happens when we are driving, it may be humorous, but it may also be dangerous. Knowing that it is normal human behavior, Tim Harford suggests that a solution may be to require more human input (introduce a degree of messiness) even though it is not required by the technology.

For More:

Look To See

Narrative Medicine

Your Inner Fish

Neil Shubin

            Neil Shubin is a paleontologist whose team discovered fossils in 2004 of an animal which is a transition between a fish and a land-living animal. How we have evolved is fascinating and much more than a curiosity. He uses examples from living animals, fossils, and DNA to show how we are all related and how that information can be used to help understand our health problems and is being used to develop new treatments. The links are fascinating. How can it not be fascinating when we realize that all of our cells have the same genetic code and our cells differentiate and develop into thousands of kinds of cells which link to become our organs through communicating with each other and turning genes on and off. It is, as Neil Shubin states, like a pile of bricks being able to build a house by themselves. Mutations have enabled evolution but are also the cause of cancers. Did you know…

            Our sense of smell allows us to discriminate among five thousand to ten thousand odors. Some people can detect the odor molecules in a green bell pepper at a concentration of less that one part per trillion. That is like picking out one grain of sand from a mile-long beach…. Fully three percent of our entire genome is devoted to genes for detecting different odors…. Our large number of odor genes makes sense – mammals are highly specialized smelling animals….  But when geneticists looked at the structure of human genes in more detail, they found a big surprise: fully three hundred of these three thousand genes are rendered completely functionless by mutations…. Why have so many of our odor genes been knocked out? The answer was found by comparing genes among different primates. Primates that developed color vision tend to have large numbers of knocked-out smell genes. The conclusion is clear. We humans are part of a lineage that has traded smell for sight. We now rely on vision more than smell, and this is reflected in our genome.

            If we look around the animal world, we can assess whether animals are specialized for daylight or night by looking at the percentage of each type of light-sensing cell in their eyes. In humans these cells make up about 70 percent of all the sensory cells in our body. That is a clear statement about how important vision is to us.

            The whole system we use to perceive position and acceleration (our vestibular system) is connected to our eye muscles via connections in our brain. The motion of our eyes is controlled by six small muscles attached to the side walls of the eyeball. The muscles contract to move the eye up, down, left, and right. We can move our eyes voluntarily by contracting these muscles each time we decide to look in a new direction; but some of the most fascinating properties of these muscles is related to their involuntary action. They move our eyes all the time, without our even thinking about it. To appreciate the sensitivity of this eye-muscle link, move your head back and forth while looking at the page. Keep your eye fixed in one place as you move your head. What happened during this experiment? Your eyes stayed fixed on a single point while your head moved. This motion is so commonplace that we take it for granted, but it is incredibly complex. Each of the six muscles in both eyes is responding to the movement of the head. Sensors in your head record the direction and velocity of your head’s movement. These signals are carried to the brain, which then sends out signals telling your eye muscles to fire. This system can misfire, and misfires have much to tell us about our general well-being. This is one of the many things that our ambient visual system does subconsciously. This system can be disrupted from drinking too much alcohol. It can also be disrupted when the connections and timing are disturbed by a head injury and is often the most debilitating problem in post-concussion syndrome. So few things in life are simple.

For More:

Plasticity in Sensory Systems

The Body: A Guide for Occupants

Visual Paradox

It was interesting to find the following information about vision in The Beautiful Cure: The Revolution in Immunology and What it Means for Your Health by Daniel M. Davis. In trying to understand more about the immune system and how it makes an appropriate level of response, the immunologist Ralph Steinman discovered accessory cells by looking at cells from the spleen which stuck to glass, cells with a unique appearance and movement from within a hodgepodge of cells. This was not only an exceptional act of science but also an exceptional act of perception.

 A scientific discovery such as this, made by just watching cells down a microscope, doesn’t happen as simply as might be imagined. One of the reasons it is so difficult has been strikingly illustrated by two Harvard psychologists, Christopher Chabris and Daniel Simons, who asked volunteers to watch a video of six basketball players – three in white T-shirts and three in black – walking around and passing basketballs between them. Chabris and Simons asked the viewers to count the number of times a basketball is passed between two players both wearing white T-shirts, which takes a bit of concentration. Halfway through the video, which you can watch for yourself online, a woman in a gorilla costume walks onto the scene, stands among the players, beats her chest facing the camera, and walks off. Afterwards, the viewers are asked if they noticed anything unusual. Despite the fact that eye-tracking equipment showed that all the viewers had gazed straight at the gorilla for an equivalent length of time, only half had noticed her. This ‘perceptual blindness’ was even worse when tested on a group of expert radiologists, who were asked to look through computed tomography (CT) scans of lungs in search of nodules, which would appear as bright white circles. While some of the scans also showed pictures of a gorilla that was forty-eight times larger than the nodules the experts were told – and trained – to look for, 83% of the radiologists missed seeing the gorilla despite gazing right at her.

These experiments emphasize an important truth: we see with our brains rather than with our eyes. Our brains filter and interpret everything detected by our body’s sensory organs and because of this, we often see only what we are looking for and fail to notice the unexpected.  

        

When vision is enhanced or re-mediated, most of the changes take place in the brain. The effects of vision therapy cannot be understood without realizing this.

For More:

Reading as a Perceptual Skill

Visual Perception and Who We Are

Stress and Mindset

The Body: A Guide for Occupants

Bill Bryson

Bill Bryson is a talented communicator who has written about travel, language and science and manages to insinuate humor to increase the reader’s pleasure and to inject emphasis which makes facts more meaningful and memorable. The Body is his latest book which would make a wonderful Christmas gift for any curious readers on your list. Instead of attempting a review, I will include two excerpts as examples.

“The great paradox of the brain is that everything you know about the world is provided to you by an organ that has itself never seen that world. The brain exists in silence and darkness, like a dungeoned prisoner. It has no pain receptors, literally no feelings. It has never felt warm sunshine or a soft breeze. To your brain, the world is just a stream of electrical pulses, like taps of Morse code. And out of this bare and neutral information it creates for you – quite literally creates – a vibrant, three-dimensional, sensually engaging universe. Your brain is you. Everything else is just plumbing and scaffolding.”

“Just sitting quietly, doing nothing at all, your brain churns through more information in thirty seconds than the Hubble Space Telescope has processed in thirty years. A morsel of cortex one cubic millimeter in size – about the size of a grain of sand – could hold two thousand terabytes of information, enough to store all the movies ever made, trailers included, or about 1.2 billion copies of this book. Altogether, the human brain is estimated to hold something on the order of two hundred exabytes of information, roughly equal to “the entire digital content of today’s world,” according to Nature Neuroscience. If that is not the most extraordinary think in the universe, then we certainly have some wonders to find yet….”

“There is a huge amount we have left to learn and many things we may never learn. But equally some of the things we do know are at least as amazing as the things we don’t. Consider how we see – or, to put it slightly more accurately, how the brain tells us what we see.”

“Just look around you now. The eyes send a hundred billion signals to the brain every second. But that’s only part of the story. When you “see” something, only about 10 percent of the information comes from the optic nerve. Other parts of the brain have to deconstruct the signals – recognize faces, interpret movement, identify danger. In other words, the biggest part of seeing isn’t receiving images; it’s making sense of them.”

“For each visual input, it takes a tiny but perceptible amount of time – about two hundred milliseconds, one-fifth of a second – for the information to be processed and interpreted. One-fifth of a second is not a trivial span of time when a rapid response is required – to step back from an oncoming car, say, or to avoid a blow to the head. To help us deal better with this fractional lag, the brain does a truly extraordinary thing: it continuously forecasts what the world will be like a fifth of a second from now, and that is what it gives us as the present. That means that we never see the world as it is at this very instant, but rather as it will be a fraction of a moment in the future. We spend our whole lives, in other words, living in a world that doesn’t quite exist yet….”

All the richness of life is created inside your head. What you see is not what it is but what your brain tells you it is, and that’s not the same thing at all.What Bill Bryson does not say is that much of this function is learned though experimentation and experience disguised as play and we all learn a little differently.

For More:

Action in Perception

The River of Consciousness

Visual Suppressions

Adverse visual suppressions are frequently an important complication of visual problems, while normal suppressions of visual and other input are advantageous. Suppressions facilitate the processing of information by filtering distracting stimuli. Suppression of extraneous stimuli is essential for sustained, selective attention. It is not possible to be consciously aware of all of the external and internal input that bombard our visual system.

Our eyes send more data to the brain than all of our other senses combined and there are as many nerve fibers from the brain to the eyes as there are from the eyes to the brain. These guide what the eyes look for and also influence the processing of input at the retinal level. Without suppressing non-essential stimuli, accurate visual perception would not be possible.

Adverse suppressions are caused by sensory mismatches. This is usually a binocular dysfunction in which the two eyes are not sending coordinated data to the brain. These occur when the two eyes do not focus equally or when they do not align precisely. Adverse suppressions reduce confusion to enable the individual to function, albeit with compromised efficiency and visual processing. Adverse suppressions can lead to prolonged maladaptations such as amblyopia and difficulty processing print.

Suppression of vision during rapid eye jumps is critical to visual function and comfort. Our eyes move four times a second even when we think that we think that we are locked onto a target. This is how the brain constructs our view of the world since our vision is only clear in the central 5o of our visual field. If vision is not suppressed during rapid eye movements the individual sees a smear. The brain fills in during rapid eye movements as it does when our eyes close during a blink.

These saccadic suppressions are critical for reading. When the timing of these suppressions is off, it makes it very difficult to get information from print. If it is a developmental visual problem, and the person has never seen any other way, they assume that this is what everyone experiences. When it happens as a result of a concussion, the individual is aware of the changes and is disabled and sickened by the effects.

Most people are aware of the fallacy of multi-tasking; that we cannot actually do two separate cognitive tasks at the same time. Alex Pang explains that this is over-generalized. If we are listening to someone and texting something else, we cannot process both simultaneously and must be switching back-and-forth rapidly. This impairs performance compared to doing each task separately. Alex Pang describes this as “switch-tasking” not multi-tasking. On the other-hand, being able to multi-task efficiently is essential to many things we do such as driving a car. Efficient reading is another example of what appears to be a unitary task it that requires a great deal of multi-tasking.

Vision must coordinate with other systems for us to function well. When they do not, when the systems are overloaded, adverse suppressions and sensory processing disorders occur. These include poor eye-hand coordination, dizziness, spatial disorientation, affective disorders, reading problems, attention disorders, and clumsiness.

For More:

Why Effective Amblyopia Treatment Requires Binocular Vision Rehibilitation

Tracking

Visual Perception and Who We Are

Vision, Body Schema, and Clumsiness

Optometric Vision Therapy

Our body image is how we see ourselves. Our body schema is our subconscious sense of our body and how it relates to the space immediately around us. Movement is necessary to develop vision and body schema and to integrate them which enables us to move effectively. Our conscious brain has difficulty accepting that most of what we do is subconscious. Even when our movements are consciously ordered, not reflexive, the implementation is largely subconscious. Our conscious mind and focal vision are the strategists which make the overall plan while the subconscious mind, body, and ambient vision direct the tactics. It is now thought that learning does not take place solely in the brain but also in the body.

Focal vision is conscious: seeing objects, colors and symbols; recognizing what we see despite differences in size, distance, and position. Ambient vision is as complex as focal vision but is subconscious. It monitors where we are and where things are around us. It assists our balance. It directs eye movements to obtain information with phenomenal speed and precision. It helps us simultaneously process the movement of multiple objects around us. It enables us to navigate while our conscious mind is occupied. It stabilizes the images of what we are moving past so we perceive that it is our body that is moving and not our surroundings. Ambient vision is faster than focal vision and is able to multitask to accomplish all that it does.  We are unaware of its existence until there is a problem.

Most of us develop adequate ambient visual skills and, if we don’t, we probably don’t realize it. We are who we are. We may become carsick easily, be clumsy, have difficulty tracking across a page to read, perceive movement that is not there, not coordinate our two eyes well, be uncomfortable in busy places, and be easily overstimulated compared with others, but we adapt and compensate. Unless the deficits are extreme, it also goes unnoticed by others. But these problems are obvious when they develop suddenly such as after a head injury and may be extreme.

It is intriguing to watch vision and body schema develop in infants. We have an infant grandson who just started sitting in a highchair. Being able to sit expands what he can do with his hands and vision. He can pick up food and start to get it into his mouth. Sometimes he can control letting go of things to accomplish the all-important milestone of dropping objects and watching them fall to the floor. This is the beginning of thousands of experiences of trying and developing.

If vision and body schema have not developed adequately, they have the potential to be improved through therapy. A surprising degree of plasticity remains even into old age. Just trying harder tends to reinforce inefficient behaviors, not foster change. The visual system can be incrementally modified through optometric vision therapy; an individualized sequence of activities. The new or modified skill must then be practiced with attentive repetition to become automatic. Effective attention is subconscious as is effective vision. Forced attention (concentration) is much less effective.

Attentive repetition is difficult to achieve in the infant and young child. When possible, carefully chosen games which rely on the developing visual skill are employed which stimulate engagement. Success in the game is dependent on improving the deficient visual skills. Games may also reduce the rehearsal required to become automatic because the skill is developing implicitly. The roles of the therapist and doctor are critical. They plan and modify the sequence of activities for each patient based on the diagnosis and progress. Knowledge and experience are critical, but the success of care is equally dependent on empathy and support as in all of the healing arts. Being scientific and evidence-based does not reduce the importance of the personal connections.

Most change has to be done consciously at first and then practiced until it becomes automatic. The actions are consciously directed, but all action is too intricate to be consciously controlled. The conditions need to be arranged to facilitate the subconscious creation of new patterns. Trying to guide a ball instead of looking at a target and throwing it naturally is a good example.

The role of personality in development and in therapy cannot be ignored. Some children are more adventurous. Some are less flexible and less resilient. Mindsets can change dramatically as a child becomes empowered through growth, but some are still resistant to change. This is influenced by a history of failures, but it can also be their inherent temperament.      

Some of the brightest and most determined patients can be the most challenging. Their intelligence and determination have enabled them to find ways to compensate. It can be difficult to get them to stop overthinking to enable their subconscious to guide the development of automaticity. A dog which loses a leg can soon learn to run effectively on three legs. Having minimal consciousness may be an asset in this circumstance.

The success of vision therapy is dependent on a team effort and dedication. Appointments need to be kept and reinforcement activities need to be practiced at home to foster automaticity. Temporary accommodations may be necessary in school to relieve the visual load.

Helping develop vision is natural. Our species would not survive without it and it does not usually require professional guidance. It is a primary reason for the importance of play. Further development of visual skills is critical for athletes, dancers, artists, TSA workers, those in law enforcement, and all children who are learning to read. However, this is not the same as rehabilitating visual dysfunctions. Doctors and therapists who have been certified by the College of Optometrists in Vision Development have demonstrated their knowledge and clinical skills in vision development and vision therapy.

For More:

The Brains Sense of Movement

Vision Therapy Changes in the Brain

Action in Perception