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.

Children’s Vision Exams

Back to school, or back in school?

Back to school exams are advocated as a way to help prepare your child for a successful school year, but if you are concerned about visual problems that are possibly interfering with your child’s reading and learning, back in school exams are much more likely to diagnose learning-related visual problems.

Children who have visual problems rarely recognize that their vision differs from that of other children and rarely complain about their vision. (Signs and Symptoms of Visual Problems) Signs such as disliking reading, losing their place while reading, rubbing their eyes, difficulty copying from the Smart Board, extreme difficulty getting their homework done, poor spelling, difficulty decoding words, poor handwriting, or just not performing to their potential are indications of possible vision problems. These signs are usually not present in the summer without the visual demands of school. If they are not mentioned to the doctor, the doctor may not administer the extended testing necessary to assess the visual functions that cause these problems.

If you suspect learning-related vision problems, it is best to have your child examined during the school year. Bring in information about how they are struggling (Convergence Insufficiency Symptom Survey). It is good for them to have been in school long enough to adapt to the change from summer, the new grade, and the new teacher; long enough for the teacher to get to know them; and long enough for the stress of schoolwork to cause the signs and symptoms to appear. Some visual problems are not observable during the summer vacation because they only occur doing schoolwork. Some visual problems make a partial recovery over the summer when the visual stress is reduced. This is similar to other bodily problems responding to rest. Focusing ability and convergence insufficiency, for example, tend to get progressively worse over the course of the school year and may get better over the summer. Assessing these problems in the summer may be misleading. Some visual problems only become obvious as the visual demands increase; smaller print, closer spacing, and the need to read for longer periods of time.

It is important to recognize that not all doctors consider these problems in their exams. They may do a thorough job of examining visual acuity and eye health but do not investigate problems of visual function or refer to doctors who do. Some doctors specialize in this area. There are other doctors who don’t specialize in this area but detect problems and refer appropriately so the patient’s care can be co-managed. An exam that does not consider these problems will cause you to assume that your child’s vision is fine, enabling the frustration to continue for all concerned.

For More:

Convergence Insufficiency

Identifying Children’s Vision and Learning Problems

Convergence Insufficiency

Convergence Insufficiency (CI) is the most common interference with maintaining precise binocular alignment in which a person’s eyes cannot be seen to turn. It is one of a class of conditions which produce similar signs and symptoms. Each of these conditions are treated with lenses, prisms, and/or optometric vision therapy. To be visually comfortable and efficient, binocular alignment must be within a ½ degree angle. Eyes that slip in, out, up, or down from this precise alignment compromise visual input. The effects are most obvious in reading due to the complexities of the task and the requirement for sustained ocular motor precision and speed. Eyes jump and stop to look four times a second while reading, or about 250 times a minute. When eye alignment drifts even minutely during these jumps, the eyes must realign at each stop or the degraded visual input will interfere with perception.

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Because there is no obvious deviation of the eyes, these conditions are often overlooked. Problems are observed but it may not be realized that they are visual. Individuals, particularly children, may not report their visual disturbances because the disturbances are normal for them. A problem-focused history may bring them out. (See the Convergence Insufficiency Symptom Survey at the end of this blog.) Diagnosis of these conditions requires additional testing, beyond what is usually considered to be a comprehensive examination. Examinations which do not include this testing tend to add to the confusion when patients are told that there is nothing wrong with their eyes.

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Convergence insufficiency causes a person’s eyes to not triangulate accurately and automatically for reading, writing, and using electronics. The system may work for a limited time but not have the stamina to maintain comfort, attention, and accuracy.

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Convergence insufficiency rarely occurs in isolation. It is almost always associated with difficulty focusing and is often coexists with poor tracking. Like other neuromuscular coordination problems which lead to compensations, it is subject to fatigue. The problem is exacerbated by prolonged eyestrain. This occurs as the school year proceeds or after additional eyestrain at work over a period of weeks or months. Staring is particularly stressful. This happens to children when they must stare to decode words as they are reading. It also takes place in the early years of writing before making letters and words become automatic and children must stare at their pencil point as they are drawing letters.

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Avoidance is the most common sign in children. For adults who find avoidance impossible, eye fatigue, headaches, and sleepiness are most common. When the limits are exceeded, double vision, blurring, and apparent movement of print can occur. Convergence insufficiency is common with post-concussion syndrome and is associated with amplified symptoms in this population.

Lenses, prisms, optometric vision therapy, and modifications of workstations and lifestyle are necessary to treat binocular vision dysfunctions. There must be adequate rest. Each visual system has its own tolerance for how long it can stare at illuminated screens without symptoms. Many work stations are set up poorly and people often do not take sufficient breaks. Children often have excessive homework in the early grades.

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Adequate treatment requires that eye alignment, focusing, and tracking become automatic and sustainable for extended periods of time. Being able to consciously align your eyes is not adequate. We cannot think about our eyes and simultaneously think about what we are doing. Analogously, I can still run, but ball sports do not work well when getting to the ball uses attention needed for deciding what to do and doing it when I get there.

Optometric vision therapy uses techniques to develop accurate eye movements and perception supported by practice at home to develop automaticity. Trying harder may work for a time, but performance will be inconsistent and cannot be sustained. When treatment is continued to completion and appropriate visual habits are maintained, these problems should not recur.

Convergence Insufficiency Symptom Survey

Other blogs you may find interesting:

Vision and Learning: A Guide for Parents and Professionals

Copying

Have Smartphones Destroyed a Generation? by Jean M. Twenge

Adding Vision to Concussion Testing