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.

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

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

To See and Not See

Oliver Sacks’ case study about Virgil appeared in An Anthropologist on Mars in 1994. Virgil was 50-years old and had been blind for 45 years due to dense cataracts prior to having surgery to allow him to see, but would he have vision? Like all of Dr. Sacks’ case studies, the story is interesting in itself, but is most valuable for what it tells us about the underlying neurological processes; the development and integration of vision with our other senses to enable us to make sense of the world. We have to be careful not to overgeneralize. Learning to see at 50 is not the same as learning to see at birth, but it does reveal complexities that we take for granted because they are subconscious and usually function well-enough to not interfere with our day-to-day activities. Everyone’s visual skills differ. In addition to not developing equally, visual skills can be disrupted due to injuries, neurological conditions, and aging. I will not presume to be able to improve on Dr. Sacks’ words. The italicized words are excerpted from his text.

The rest of us, born sighted, can scarcely imagine such confusion. For we, born with a full complement of senses, and correlating these, one with the other, create a sight world from the start, a world of visual objects and concepts and meanings. When we open our eyes each morning, it is upon a world we have spent a lifetime learning to see. We are not given the world: we make our world through incessant experience, categorization, memory, re-connection. But when Virgil opened his eye, after being blind for forty-five years – having had little more than an infant’s visual experience, and this long forgotten – there were no visual memories to support a perception; there was no world of experience and meaning awaiting him. He saw, but what he saw had no coherence. His retina and optic nerve were active, transmitting impulses, but his brain could make no sense of them. Everyone, Virgil included, expected something much simpler. A man opens his eyes, light enters and falls on the retina: he sees. It is as simple as that, we imagine.

But though his best vision was a respectable 20/80, he lacked a coherent visual field…it was almost impossible for the eye to fixate on targets; it kept losing them, making random searching movements, finding them, then losing them again.

One does not see, or sense, or perceive in isolation – perception is always linked to behavior and movement, to reaching out and exploring the world. It is insufficient to see; one must look as well.

Three days after surgery, they had gone to an IGA, and Virgil had seen shelves, fruit, cans, people, aisles, carts – so much that he got scared. “Everything ran together,” he said. He needed to get out of the store and close his eyes for a bit. People experience this who have post-concussion syndrome and who are on the autism spectrum. They are overwhelmed by stimuli most people assimilate.

While Virgil could recognize individual letters easily, he could not string them together – could not read or even see words. I found this puzzling, for he said that they used not only Braille but English in raised or inscribed letters at school – and that he had learned to read fairly fluently. Indeed, he could still easily read the inscriptions on war memorials and tombstones by touch. But his eyes seemed to fix on particular letters and to be incapable of the easy movement, the scanning, that is needed to read. This is what people experience with amblyopia and some forms of dyslexia. Since most people with amblyopia primarily have the problem in one eye, their reading is different with each eye.

As Virgil explored the rooms of his house, investigating, so to speak, the visual construction of the world, I was reminded of an infant moving his hand to and fro before his eyes, waggling his head, turning it this way and that, in his primal construction of the world. Most of us have no sense of the immensity of this construction, for we perform it seamlessly, unconsciously, thousands of times every day, at a glance.

Virgil had now had two hours of testing and was beginning to get tired – both visually and cognitively tired, as he had tended to do since the operation – and when he got tired he could see less and less, and he had more and more difficulty making sense of what he could see. Most of us have visual, mental, and physical reserves so we don’t experience this or the effects are minimal. Once again, this is not true for people who have less resilience; those whose vision requires conscious attention and compensation, or have early dementia, head injuries, or autism.

For More:

Scanning

Growing up with Sensory Issues: Insider Tips from a Woman with Autism

Resilience

Crowding

Reversals

Children who reverse letters and numerals do not see them backwards. They have not developed the visual perceptual skills which are necessary to master orientation-specific symbols.

Infant’s perception starts with recognizing faces and people. Early visual perception is global. Children’s ability to see detail and color gradually emerges over the first three to six months as the visual pathways develop. They quickly learn to recognize their mothers from the front and from the back. They can recognize them when they are seeing them right-side-up and when they see them upside-down, depending on how they are laying or being held. This impressive ability is known as object constancy. At an early stage, children also start to associate important people and objects with sounds (names).

Young children learn to place objects and animals that have a wide range of appearances, but a distinguishing similarity, into categories, such as chairs and dogs. This is an amazing accomplishment. It is only when children start to encounter symbols that the rules change and even more sophisticated perceptual skills are required. Now instead of being able to look at 62 different breeds, sizes, ages, and colors of dogs in various positions and categorize them all as dogs, they have to learn what makes each of 62 stick shapes unique. The shapes all have names and orientation is now critical. Furthermore, some of the stick shapes are not only incorrect if they are not properly oriented, they actually turn into a different stick shape. How confusing is that?

Mastering 62 symbols is dependent on many perceptual and developmental skills being ready at the same time; a time that is set by the curriculum and, therefore, cannot be right for all children. This mastery requires the ability to: discriminate detail; appreciate directionality; be able to visualize and store symbols; sustain attention; and match visual and auditory input. When these criteria are not met on time, learning the 62 symbols will take longer, require more rehearsal, and confusion is more likely (while the curriculum progresses to more complicated perceptual demands – strings of symbols in specific sequences). Under these conditions, persistent confusion may develop. Untangling confusion and relearning is much more difficult than initial learning and is further complicated by stress.

Think of being introduced to two brothers on the same day who look very similar. Their names are Jacob and Jared. It is going to be difficult to keep them straight. It would have been much easier if you had met the second one after you already knew the first one. If you always see them together, the confusion tends to become embedded.

Once you are confused, you may need to develop a trick, a mnemonic, to help you to remember who is who. This will be slow, but it will be dependable as long as it is your mnemonic. This will get faster over time and eventually will not be needed. The same is true for children with symbols if the incidence of reversals is not decreasing.  

It is important to respect development and how we learn when children are working to make letters and numerals. Tension interferes with learning and with smooth movement. Early movements should be large and flowing, using large muscles and joints which are easier to control and provide more feedback. This also avoids the need for fingers to struggle to hold and control a thin, slippery pencil.

Manuscript letters are complicated combinations of basic shapes which should be mastered first (the copy form shapes). Dr. Arnold Gesell started to research many areas of child development in the 1920s including when children master making the basic shapes. This research was repeated recently at the Gesell Institute and it was confirmed that children master the basic shapes at the same ages that they did 100 years ago. Children have not changed as much as have expectations. Development is uneven between individuals and within individuals. It can be stimulated and it can be retarded but it cannot be pushed, and it should not be ignored. It must also be remembered that development and intelligence are distinct traits. Expecting red marks on early writing to improve writing, when the child does not have the prerequisite skills, is like expecting a child to catch a ball better when you yell at them. It is more likely to create discouragement, failure, and learned helplessness than to suddenly stimulate confidence and success.

For those of you who would like additional information and resources on reversals, we recommend this blog by Dr. Leonard J. Press.

For More:

Visual Factors in Reading

Visualization

Handwriting

Visual Word Form Area in Visual Cortex Remembers Words as Pictures

The Awe of Depth Perception…the Emotional Glue That Wires Binocular Vision

The VisionHelp Blog

We enter this world with two eyes ready to receive information and work together, an experience of which can not be described as a mere summation of two visual signals painting a flat picture in the brain. Instead with two eyes working together, known as binocular vision, there is a synergy of visual function that creates our ability to see our environment as it is with beauty, awe, depth and perspective. This binocular visual experience that provides us with depth perception (called stereopsis, measured as stereo acuity) not only shapes our abilities and  human performance, but also shapes our emotions.

Visual conditions that result in the dysfunction of binocular vision will typically reduce or impair an individual’s ability to have normal depth perception leaving them to experience a visual world that is flat, without the ability to see “pockets of space”. These vision problems of binocular vision are not rare…

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Scanning

Scanning is used to find an object, a person, or a word. This is usually simple for most adults, but not always (such as men looking into a refrigerator). As is true for many skills that have become automatic, it is easy to overlook the complexity involved and how difficult it is to learn.

fridge


Scanning requires sequential eye movements and fixations. It requires visualizing the desired object and maintaining that image while looking at other objects. This is particularly challenging if the other objects are either distracting or similar to the object in question. When this is the case, the load on working memory increases and it becomes more difficult. If we are looking for our sneakers, that is one level of challenge. If we are looking for tomato soup amongst other soups or a phrase on a page, that is very different. It can be like singing one song while listening to another. If the eye movements are random, the fixations too brief, or if the visualized image fades, we will not succeed. Scanning requires sustained vigilance.

Where’s_Wally_World_Record_(5846729480).jpg


The inability to scan efficiently wastes time and is frustrating. The quality of scanning reflects a person’s organization. They are both disciplined, sequential, and require working memory. Academically, scanning is important when we are copying so we can find our place when looking back-and-forth. It is important when finding information, such as answers to a question in a passage that has been read. If a child needs to start to read a passage over, it will be time-consuming and they will inevitably forget what is was that they were looking for. Scanning requires the integration of top-down processing (keeping the image in working memory and filtering everything else that is seen) and bottom-up processing (directing the eyes with a goal-oriented priority). Scanning is one of the skills developed in optometric vision therapy.

names

Visualization

The Effect of Saccadic Training on Early Reading Fluency

Solutions for your child who struggles in school starts by knowing what to ask your eye doctor

Vision and Learning: A Guide for Parents and Professionals