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,


-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.

Louder than Words

louder than words gif

There are many children with learning-related vision problems. Visual problems may exist in isolation or intermeshed with other learning problems. If the problems are ocular motor in nature (eye teaming, focusing, and tracking) and the children are not too far behind in reading, they will usually start to read on their own before the completion of their therapy and progress naturally from there.

If the reading problems are due to processing speed (slow visual-verbal processing or Rapid Automatized Naming) the challenge is greater. Fortunately, modest improvements in processing speed tend to reap significant benefits in interest in reading and comprehension with less frustration.


Benjamin K. Bergen
Perceptual problems are usually linked to ocular motor problems or developmental delays. While visual information processing (perception) has been broken down into many sub-skills, what we see as most important are:

-Visual consistency to develop perceptual constancy
-Attention to detail
-Storage, integration, and retrieval
-Perceptual sequencing
-Perceptual span
-Perceptual speed
-Foundations through experience and integration

In his book Louder than Words, Benjamin Bergen discusses how we store information and retrieve it from actual experiences and from the simulated experiences of spoken and written language. We must be able to visualize what we read. Bergen also calls this “embodied simulation” because of how the brain replicates what the body and brain have experienced together. When you recall things you reactivate the same brain circuits that you originally used to encode the sights, sounds, smells, and the feel of the memories in the first place.

He goes on to say that: You make meaning by creating experiences for yourself that – if you’re successful – reflect the experiences that the speaker (writer) intended to describe. Meaning is a creative process in which people construct virtual experiences – embodied simulations – in their mind’s eye…. Vision is the main way we collect information from the world, so it’s fitting that vision is also the sense we most closely associate with the internal life of our minds…. One of the main benefits of using eye movements as a way to measure what’s going on inside people’s heads is that, despite what you might think, most eye movements are not under conscious control…. During most of our waking lives, our eyes saccade from one fixation point to the next dozens of times a second, depending on the interesting things around us that we are trying to pay attention to…. Shortly after the sound waves of spoken words hit our ears or the light of written characters hits our eyes, we engage our vision and motor systems to recreate the nonpresent visions and actions that are described.

We know that the brain has a great deal of plasticity, especially in our youth. Visualization (embodied simulation) is developed and, therefore, it can be enhanced. Visualization is easiest for actual experiences we have had. It is more difficult to visualize from a verbal description in a conversation and is very dependent on experience. But conversations have the advantage of exchange and are enriched through movements and facial expressions. Reading (or a lecture) does not allow exchange. Without visualization they are boring. With visualization they can be engaging and drag us to the next page and next chapter. The development of visualization is stimulated through conversation, imaginative play, experience, and being read to. Many parents of children with reading problems stop reading to their children so the children will read more, but reading to them can maintain their interest in learning to read and stimulates the development of embodied cognition which is necessary for reading to become an enjoyable and meaningful experience.