Frequently Asked Questions

Many parents ask me to make a series of formal recommendations to teachers to help their child, once I have identified a visual development problem that is affecting their child’s ability to learn. I resist this for several reasons. First and foremost is that the professional educator is the best person to make decisions that directly impact the instructional approach to the child. I am not trained as an educator. Secondly, so many of the visual development problems that I encounter respond quickly to treatment. Often by the time a compensatory procedure or supportive activity is implemented, it may already need to be modified.

With these caveats, I do feel that the following might be found helpful in a combined approach to aid us both in helping the children we serve. This will be presented in a Frequently Asked Questions (FAQ) format, which has become so prevalent on the internet these days.

NOTE: For any given child only a portion of this FAQ may be applicable. However, I feel that by sharing this general knowledge with you, the professional educator, it may empower you to help your students in new ways.

Electrodiagnostics

Electrodiagnostics is a type of testing that allows us to get a better view of how well the connections from the eye to the brain are working. In cases of amblyopia and strabismus, head injury, brain injury and in conditions where a person is non-verbal or has trouble responding to health care providers, as in the case of infants, electrodiagnostic testing can give insights into the degree a signal is getting from the eyes to the brain.

Electrodes are placed on the head. NOTE: These are paste on electrodes that do not require the hair to be cut, nor are any needles used. In some instances ear lobe clips are used as well, which also do not penetrate the skin and as such they do not hurt. The patient sits in front of a stimulator, generally a television screen with changing checkerboard patterns on them of different sizes. The signal from the electrodes goes into the computer and we measure the response of the primary visual cortex to the changing checkerboard patterns.

We look at several things. The first is how much signal we get from the brain that is time-locked to the checkerboard patterns. The more signal we get the better AND we are looking to get about the same amount of signal from each eye. We also look to see if we get a bigger signal from both eyes together than with either eye alone. Most people know that they see better with both eyes open. This "binocular summation" gives us insight into how well this two-eyed type of seeing is present in our patient.

We also look at the latency of the response; which is how long does the signal take to get to the brain. If it takes too long or is long on one side, this may be an indication that some other disease process is taking place that may need to be addressed by other health care providers.

Below are questions that are of a technical nature. They are here for those interested in this aspect of these testing protocols.

Notes to Professional Educators

Many parents ask me to make a series of formal recommendations to teachers to help their child, once I have identified a visual development problem that is affecting their child’s ability to learn. I resist this for several reasons. First and foremost is that the professional educator is the best person to make decisions that directly impact the instructional approach to the child. I am not trained as an educator. Secondly, so many of the visual development problems that I encounter respond quickly to treatment. Often by the time a compensatory procedure or supportive activity is implemented, it may already need to be modified.

With these caveats, I do feel that the following might be found helpful in a combined approach to aid us both in helping the children we serve. This will be presented in a Frequently Asked Questions (FAQ) format, which has become so prevalent on the internet these days.

NOTE: For any given child only a portion of this FAQ may be applicable. However, I feel that by sharing this general knowledge with you, the professional educator, it may empower you to help your students in new ways.

Optometry Services

An optometric practice isn't just one single thing and therefore it is hard to describe all the kinds of care that we offer. One thing that is interesting to me, is that over the years how often people that come to me a specific type of care, end up thinking that I'm just a specialist for people with that kind of condition. Well into their care or towards the end of a treatment program for a loved one of theirs, they may ask me if I see other people for other reasons. The one I love is when they ask if I see "normal people who just need glasses or contact lenses"! My answer is always of course. I say, "I specialize in seeing members of the human race."

Behavioral optometric care is about identifying my patients unmet needs and then seeing, if in the bag of tools I have if any of those could help the person in front of me better met those needs. If so, then we are in business, with me being able to help and the person in front of me having their life changed for the good.

Another pet peeve I have is people who come in with labels or volumes of reports from others as if knowing what others have labeled them as will help guide me in my testing. When I first meet a person, regardless of their history, regardless of the life path that has brought them to me, regardless of what others have labeled them as or what they have tried with them, my job is to look at the person in front of me anew and to get to know them, what they want to do in life and to find out if by helping them use their visual process in a different way, if their life can be changed.

Since the world seems to like categories, here are just a few of the kinds of services we offer:

Visual Therapy

The most exciting treatment alternative available to the behavioral optometrist is vision therapy (VT). This is a treatment program in which the optometrist provides the patient the opportunity to learn and develop those abilities that either were not present or were poorly developed in the patient's overall profile of visual abilities. Vision therapy is a step-by-step, development-based series of activities and procedures that the patient practices over time. The therapy is designed to facilitate the development of a more efficient and comprehensive visual process.

Electrodiagnostics

The following are some theoretical sample form four made up subjects.  This show only the amplitudes of the electrical signal measured at V1 (visual cortex).  All measurements are in micro-volts.  

 

Eye Subject 1 Subject 2 Subject 3 Subject 4
Right 18 18 18 18
Left 18 9 9 9
Both 23 18 12 22

 

Subject 1 shows the normal binocular summation with the signal from both eyes being significantly bigger than the signal from either eye alone, and both eyes signals are the same.

<p> Subject 2 shows decreased amplitude in the left eye as compared to the right (9 μV compared to 18 μV) with the binocular signal the same as the non-amblyopic eye.  Here no binocular summation is occurring but neither is the amblyopic channel causing a decrease in the signal from the non-amblyopic channel.  

<p> Subject 3 shows decreased amplitude in one eye that is actually interfering with the signal from the non-amblyopic eye and indicates a problem NOW that will lead to more of a problem over time.  This is seen by the binocular amplitude actually being less than the right eye amplitude alone.  This implies that the reduced left eye flow is actually causing “noise-on-the-line” when both eyes are open causing a reduction in the binocular amplitude to less than that of the right eye. Most people will not stay in this condition for a long time as it can be quite bothersome.

<p> Subject 4 shows decreased amplitude in one eye but that eye's flow is being used and there is a bigger binocular signal than with the non-amblyopic eye alone.  This is rare but it does happen.


<p> The following slides are real data from a real patient shared by Paul Lederer, OD from Arlington HeightsIL Time increases from left to right and the amount of electrical potential are measured in the deflection up and down of the lines. 

The right eye here shows a classic normal pattern.  The right eye recordings show a small dip down before rising to their peaks.  The peaks, marked with the small vertical line at the highest point of each line, occur at the normal time of around 100 milliseconds.  The left eye has the dip down at about the right time but the lines keep rising to a smaller degree at a later time (more to the right).  Here the peaks are easily 40-50 milliseconds later than they should be and the total amount of signal from the lowest point to the highest point is smaller than for the right eye.

 

 

This second diagram shows two binocular recordings group together at the top with the right eye recording below that and the amblyopic left eye being the lowest one.  You can see that the shape of the right and binocular recordings are very similar in pattern and timing of the highest peak.  In the left eye recording here there is very little of the dip down before the slow rise to a later time.  Here the late shift is smaller than in the example just prior to this.

 

 

 

Here there are two right eye recordings grouped at the top, with two left eye recordings in the middle with the two binocular recordings at the bottom.  Now all of the recordings have the same pattern but with differing amplitudes.  The right eye by itself has a larger amplitude than the left eye.  However, the timing of the peaks is nearly the same (115-116 milliseconds for the right eye to 122-123 milliseconds for the left eye).  It can easily be seen that the binocular recording has the largest amplitude yet and the timing of the large peak is between the timing of the peak times of the right and left eyes respectively at 119-120 milliseconds.   The following table has the averages of the six recordings from above.

 

Eye Amplitude Latency
Right 15.4 115.5
Left 12.0 122.5
Both 17.8 119.5

 

Here even though the amplitude of the left eye is below that of the right it is obviously contributing to the binocular signal because the binocular pattern is larger than the right eye amplitude alone.  This is a powerful demonstration of the ability of optometric treatment to change signal transmission from the eye to the primary visual cortex and to normalize a system that appeared to be beyond care.

 

VEP/VER can be used with any patient. It yields the greatest insights when working with amblyopia, strabismus, non-malingering syndrome, and with some non-verbal patients. The loss of visual acuity associated with these conditions can mimic other conditions that may be secondary to neurological problems. Some have used the devices to monitor changes in binocularity before and after treatment, and to do a form of refraction in some cases. The VEP/VER can be helpful in determining if the loss of visual acuity is functional or developmental, and therefore more treatable, or if the loss is secondary to neurological damage.

The main extra piece of information that the VEP/VER adds to ones diagnostic battery is a test of the neurology of the primary flow from the eye back to the primary visual cortex (V1). It is good to know as soon as possible whether or not there may be any frank neurological involvement that would preclude a positive outcome. One would very much like to know if there is an active problem that requires care from other disciplines. The VEP/VER does not answer all of these questions unequivocally, but it does add significantly to the clinical picture of these types of cases. It only takes one good recording to tell us the neurology is intact and the potential for improved vision exists.

Over time this procedure, has been called by different names. The word “evoked” is part of the name since active and controlled stimuli are used to drive the visual system. Because we care about how detail is being moved through the system the stimuli are various size checkerboards of different spatial frequencies. It is the changing patterns that drive or “evoke” the response.

Those who use the word “potential” are generally referring to the changes in the electrical firing levels in the primary visual cortex. Those who use the word “response” are simply looking at the entire pattern of the graph as the response the primary visual cortex is making secondary to the triggering of the stimuli. The two terms are essentially interchangeable.

A visual evoked potential is a diagnostic test that works based on picking up the electrical signals produced in the primary visual cortex time locked to a stimulus seen by the patient. It is essentially an EEG of the visual system. Electrodes are placed on the skull in such a way so as to allow the recording of the electrical potential changes, hence the name, in response to the stimulation. Many different types of stimulation can be used. One typical use has been by neurology in the diagnosis of demyelinating disease such as multiple sclerosis. By using a bright flash of light and seeing when the signal arrives at the primary visual cortex (V1) they can see if there is a slowing down of signal. If there is a slow down it is generally secondary to loss of myelin.

For our purposes, we care more about how detail from edges of various spatial frequency targets is being moved through the system and how the flows from the two channels are interacting with each other. The typical stimuli we use are varying size checkerboards that alternate, with white boxes changing to black and black boxes changing to white across the entire board several times per second.

Notes to Professional Educators

The Toolbox Analogy

Imagine that we have delivered to a plot of land all of the necessary raw materials needed to build a house. Piles of wood, nails, screws, drywall, cinder blocks, plumbing supplies, electrical supplies, cabinets, doors, windows, roofing materials, etc. are all present in abundance. The child brings to that work site each day their toolbox. The tools in that toolbox have been acquired over the years based on the life experiences that child has had. Some children enter the worksite with a rather complete set of tools to cover most needs, while others have only the essentials or may in fact be missing even a core or fundamental tool. Fundamental or required tools might be considered to be a hammer, a saw, a screwdriver or a tape measure.

In general, schools assume two things. The first is that most children enter with the set of tools that will carry them through their academic career and that the fundamental set of tools that a child brings to school is fairly set or immutable. The child is placed into a series of courses such as Carpentry 101, Plumbing 101, and Electrical Systems 101. In Carpentry 101 they may begin with the simple tasks of measuring and marking lumber to be cut to length, how to start, drive, and set a nail, and making a cross-cut saw cut safely, accurately, and square. To a child coming to the workplace with a basic framing hammer, a handheld crosscut saw, and a Stanley 25 foot tape-measure these beginning classes may come rather easily. To a child missing one or more of these basic tools, failure to achieve basic "educational" goals may become evident rather early on.

Generally in the education system a child comes to the attention of their teacher before testing for a problem is initiated. To qualify for services their performance must have fallen to a certain measurable amount.

Many resourceful and smart children who are missing fundamental tools may find ways to get the job done although they are not using the proper tool. They might find a rock to use as a hammer or they might use a monkey wrench to hammer in the nails. The job gets done but it takes longer, the job isn't done as well and there may be some wear and tear on the child that would not have been present had the child used the proper tool for the job. However, the child, due to a lack of the appropriate developmental experiences is/was lacking the tool. This degree of compensating can often serve to mask the discovery of a missing fundamental tool for quite a while in a resourceful child.

Once the teacher realizes the child is having a problem, the school system will initiate a series of tests to identify the problems. Psychological educational testing often correctly identifies the general category of the problems, such as carpentry or plumbing but may fail to recognize that the lack of a tool may be the problem. Here is where a false assumption dooms the child to an intervention program that will actually work to embed the problem even more. How?

A hammerless child is labeled as "hammerless" or "hammer compromised." The system then looks for special education materials that have been shown to be able to be mastered by those without hammers. The idea has been that the child who does not have a hammer should not be penalized for not having a hammer and we should not ask them to do things that require hammers. Therefore a program has been conceived and produced in, for and by the school, which addresses hammerless children's needs.

The hammerless child will be given activities, which will not require them to use a hammer. Either they will now use screws and screw guns for everything or they will switch to learning to assemble prefab home kits. The child will advance through the rest of their courses but a fundamental tool and basic skill necessary to nearly any home building project will be missing, the ability to use a hammer. The false assumption was that once hammerless, forever hammerless.

The education system is not in the business of tools. They are in the business of tool usage. "Missing tool? Oh well you'll just have to learn to accept your hammerless condition and arrange things differently so that you don't encounter hammering demands in school life." Real life then becomes another matter.

The key factor in behavioral vision care is that our assumption is that the presence of a missing tool is only evidence of not having had the appropriate meaningful experience to have developed or acquired that tool. We are in the business of identifying the missing tools and then putting together treatment protocol. The purpose of which is to provide the child with the necessary meaningful experiences to acquire the tool.

In essence, we take the child shopping. We know that hardware stores exist. We know the fundamental classes of tools. We know the order which people generally acquire tools. One would not start their saw collection with learning how to use a coping saw or a compound miter saw. One starts with a handheld crosscut saw and learns by cutting basic lumber to length. A rip saw may follow. Then a circular saw, jig saw, table saw, band saw, coping saw etc. each experience being built on the prior knowledge base all which came from the handheld crosscut saw. This process of tool acquisition and attaining fundamental competence in the use of the skill is the domain of optometric behavioral vision care. We turn over to the school system a child who now possesses the correct array of tools to perform the tasks required of them. When the school system moves on to fundamentals of balloon framing houses or the proper method of trussing up a floor the child will have the tools necessary to execute the demands of the class, understand the concepts, and to use the proper tools for the proper job.

Behavioral vision care optometrists do not teach carpentry, plumbing, or wiring. Behavioral vision care optometrists do not teach reading, writing or mathematics. Behavioral vision care optometrists do identify missing tools and take the child shopping to acquire and gain competency with the new tools. Then, and only then, will the school system find a child who is ready to be taught using conventional methods and who will achieve in a variety of educational settings and following a variety of teaching methods.

Our program includes a once-weekly in-office 50-minute session of treatment with 15-20 minutes of home practice on the days that the child does not come to the office. Of course some more home practice may be helpful but we find that the 15-20 minutes assigned is adequate. We don’t see a need to use your valuable class time to address these concerns for an individual child.

Now if you should want to look for group activities, particularly in the early grades (K-3) to do with your children, I can highly recommend the book, "Thinking Goes to School" by Furth and Wachs. This is published by Oxford Press and is available at www.oep.org. This book details an educational curriculum and program for the early grades based on the Piagetian principles of learning.

If the only problem a child presents with is a pencil grip and writing posture, we will often make a referral for occupational therapy. However, many children that require visual therapy also present with pencil grip and writing posture problems. If the parent wants us to address this we will deal with the sensory motor aspects of holding a pencil and sitting at a table early in the therapy. Towards the end of therapy we then address how to apply these new sensory motor skills to handwriting. In most instances the sensory motor skills need to be practiced at a fundamental level for several months before they can be applied directly to handwriting.

Many children with binocular problems (problems coordinating the use of both eyes together) are constantly shifting postures (squirming in their seats, etc.) in hope of either (1) reducing tension in the body coming from excess effort going into trying to keep the eyes working together or (2) hoping (subconsciously of course), to find a posture that physically blocks one of the eyes thereby greatly reducing the amount of effort needed to work.

As the child’s binocular problems are addressed the need to keep changing postures or to block an eye is reduced or eliminated. Thus, the range of postures assumed and the frequency of changes of posture are both reduced without directly attempting to work on posture. These changes are often noted to occur in the same time frame as the fixation and tracking changes.

Difficulties in copying from the blackboard come in two flavors. The first is problems secondary to clarity problems. A child who is nearsighted sitting in the back of the room without glasses or contact lenses may not be able to see the letters and differentiate them well and therefore may make lots of mistakes or copy the wrong thing entirely. Generally no amount of treatment will address this. Some form of eyewear, glasses or contacts, are needed to address this problem.

The second and more common problem affecting copying from the blackboard is the problem with fixation and tracking already noted. The child may be incapable of remembering where they were as they shift from one place to another. So when they return to the blackboard after writing down the last portion seen, they may be unable to relocate where they were. This ability to leave a mental marker from the last fixation point is taught in therapy and often comes in between the 8th and 10th week of treatment and certainly should be present by the 16th week. So problems related to fixation and tracking respond to treatment rather quickly. In the meantime it might be helpful to give a child with this type of problem a copy of their assignments so that they can have it at their desk and they are not penalized for making copying mistakes.

Many children with learning related visual problems fall apart when put in timed situations. The added pressure of having to work fast may be the straw that breaks the camel’s back, causing many of these children to "melt down". During the first 8-10 weeks we are working to build fundamental visual abilities. From that point on, although more skill building and elaboration are being done, we shift emphasis to being able to multitask and to perform under pressure.

This aspect of treatment is aided by the use of a stop watch. A number of activities are timed and emphasis on some activities is shifted away from perfection to speed. Some errors are accepted in order to get the child moving. Once moving, then the emphasis shifts back to increased accuracy and then back to faster speeds. These cycles are built into many of the visual therapy activities all the way to using guided reading in the last 8-10 weeks of treatment. Here a moving window flies over text to be read about 20-30 words per minute faster than the speed at which the child is currently reading. These sessions of being pulled over text a bit faster than is comfortable pay great dividends. It also reduces the number of regressions in text (going back to the left within a line of text to reread a section) because the window only moves forward and does not allow for regressions to be of any help when reading.

So the bottom line here is that many of these children have trouble with completing work on time and when time pressures are added they may crumble. However, vision therapy specifically targets this and most children make very quick changes here. Generally from 4-6 months into treatment timing issues are no longer a concern.

Some children show this right away, but this is not to be expected. Typically the first change in the ability to sustain visual attention on near tasks begins around the 8th to 10th session of their treatment. Certainly by the 16th session or about four months into treatment I would expect the child to be attending much better than before, assuming of course that this was a problem before.

Generally this is not necessary although some children benefit from this if you stay fairly stationary in the front of your room. This is because with fewer children between you and the child there are less possible distractions for the child. As well, the volume of your voice and the size of your movements and gestures are larger, which helps the child in question attend better. If for any reason there is an optical reason that is causing a decrease in visual acuity, most frequently lenses will be prescribed to improve visual acuity to at least the 20/40 level, which should allow a child to see anything of import from any place in your classroom.

Reading is a complex process that is dependent on many visual abilities as well as a host of other skills. Much of the early emphasis in the visual therapy programs is aimed at the fundamental visual abilities. These foundational skills are necessary to build on, but often do not have an immediate effect on improving reading performance. Early on, the major effects might be that the child can stay on task for a longer period of time before tiring.

A major developmental hurdle, already discussed, is learning to move the eyes only when shifting visual attention from one place in space to another. Once this has been achieved we often see renewed interest in near tasks that involve sustained use of vision for deriving meaning. The fact that the child can now do this kind of task often helps them feel better about themselves, and early changes in reading may not be directly from the actual visual therapy, but indirectly from the changes in the child’s self-image and feeling that they are not dumb, that a real problem had been found and that it is being addressed.

As the therapy progresses we often see a pick up in the fluency of reading at their current instructional level. Mechanically we see the child begin to take in a larger perceptual chunk, resulting in them not needing to stop so many times with their eyes per unit of text. Because less effort is needed to keep their place, to keep the print clear, and to plan where to go next, as well as keeping both eyes directed accurately so that their inputs are complementary, more of the child is left to learn from the experience.

Over time we see a consolidation of gains at a level of reading material followed by a non-linear jump to a new demand level. When that happens there is a short period of time when the mechanics seem to make a downturn. This is because it takes more thought, reflection and some conscious effort to decode new words and to find the appropriate meaning in more complex contexts at the new level. Over time this too becomes consolidated, with a commensurate period of time of improvement in the mechanics again. This continues cyclically during the course of treatment as well as continuing for many months after treatment has been completed. This can also be seen in normally developing readers at the appropriate developmental time.

To recap, we first often see improvements that are more secondary to attitude differences than to actual treatment effects. Once the "eye movement free of the rest of the body" target has been achieved there is often a new ability to sustain near centered visual attention, which can be seen in renewed interest in close work. Then begins a cycle of change; beginning with improved mechanics at the current demand level and followed by a jump in the demand level that can be understood. During the early part of the jump to the new level the mechanics typically suffer for a finite period of time.

The time-frame for seeing change will vary with the degree of the problem, the age of the child, the intensity and regularity with which the home practice sessions are done , and many other factors. Generally, by the eighth week of visual therapy changes are beginning to be noticed by all. At first, these may only be that the child is staying on task a bit longer or doesn’t have to be restarted on homework assignments so many times. Often the child is beginning to notice things in their environment, many of which may have been there all the time but are just being recognized.

A major visual development step is the ability to track and fixate with eyes only. In cases where this was not present, I see this emerging by the 8-week progress evaluation. The visual therapy begins in free space with real physical objects and moves to working in the two-dimensional plane of paper or a blackboard at about this time. Since visual development follows this course one of the early signs of change is often in sports. The child with emerging spatial competency is more aware of where they are in space in relation to others and to objects and as a result of this they interact with these things more accurately and more consistently.

In some instances your student is under a great deal of stress trying to perform sustained near-centered visual tasks such as reading. Besides the difficulty of the actual work you are assigning, one of the factors contributing to this stress may be an inability to focus their visual system at near. As we shift focus of our eyes from distance to near we have to supply about 2.50 diopters of accommodation ("focusing power"), a bit more so at the closer working distances that are representative of most children. Stress-relieving lenses are glasses designed to take some of the load off of the accommodative system. On average, these lenses reduce the amount the eye has to change focus by about 40%. This has the dual effect of helping the child stay on task for a longer period of time before their visual concentration begins to deteriorate as well as allowing them to stay further away from their close work, thus reducing the on-going demand on the accommodative mechanism.

During the course of treatment the role of the lenses often changes. Whereas at first they helped to maintain a good working distance and helped the child concentrate better, later on they take on more of a role in the prevention of the development of nearsightedness. You may have noticed that more of your excellent students are nearsighted and wear glasses or contact lenses to see clearly at distance. There are links between doing large amounts of sustained close work in people who are goal-oriented and detail-oriented and the development of nearsightedness or myopia. You may have also noticed fewer of those children with learning problems wearing glasses. Once the vision therapy has helped the child acquire the visual abilities necessary to learn and once they begin applying themselves in school they become at-risk to development of nearsightedness. The stress-relieving lenses help to prevent this.

Visual therapy is a step-by-step developmental program designed to provide patients with the necessary meaningful experiences to acquire full use of their visual process. Visual therapy is based on Piagetian principles of learning, in which a series of graded problems are presented to a child under very controlled circumstances and then practiced for reinforcement.

Therapy in my office is done on a one-on-one basis for 50 minutes. Each session consists of four to five activities which are done for 8-10 minutes each. Then two to three of them are assigned for home practice. The most difficult aspect of being a therapist, as well as being a teacher, is to know exactly how demanding a particular activity should be. Too intense and the child may go into a "flight" pattern and avoid the activity or go passive and not fully engage in the activity. Too little intensity, where a child is asked to do something that they can already do, is a formula that simply wastes everyone’s time, effort and energy. My therapists are trained to adjust the demands of the activities to maximize the speed of improvement, but not at the cost of putting the child under too much stress.

A key aspect of therapy is the involvement of the parents as home therapists. We require from 15-20 minutes of practice or drill a day under the direct supervision of a home helper, who is most often the child’s parent.

The primary method of treating a visual development problem is to arrange conditions to provide the person with the necessary meaningful experiences to acquire these needed skills and abilities. The method whereby this is done is called vision therapy.

During the early phase we will be building foundation skills and abilities, which may not translate immediately into observable changes in the classroom. I view the course of a therapy program to consist of three phases. The first third of the therapy program helps the child acquire the fundamental visual skills and abilities. During the first third most symptoms such as headaches or blurred distance sight after doing close work are reduced or eliminated.

The middle third elaborates on those skills and abilities, so that when different life demands are encountered that may be similar but actually require slightly different skill sets, the child has the ability to shift from one application to another with ease.

The final third of treatment has two major purposes. The first is to automate the newly acquired skills and abilities so that the new skills are simply called on when needed without any conscious thought. The second is to help the child generalize the new skills so that as life throws new challenges, they can immediately call on what they have learned and make the necessary adjustments, again almost without conscious awareness of having done so.

The answer to this question certainly depends on a number of variables, including what groups of children we are talking about and at which aspects of visual development we are looking. A study was done by the New York State Department of Education in conjunction with the New York State Optometric Association, in which they did testing on random samples of children in all socioecomic groups throughout New York State. It was found that around 23% of the general school population had visual development problems that were affecting learning in a significant way.

In this study, when you looked only at those children identified under public law 94-142 as needing extra help in school, the percentage climbed to 93%. In a study done in Baltimore with juvenile delinquents at the Hickey School in the late 1980’s, I found the number of these 14-18-year-old boys with visual development problems to be in the mid-90’s percentage wise. In another study in the late 1990’s in several Baltimore City public schools, it was found that over 80 percent of the children had primary visual development problems. Without the visual problems being addressed, simply reducing class size, getting better text books, finding better teachers, or changing the pay system to a merit system will not result in significant gains. The visual problems need to be addressed so that the children can then benefit from their education.

There is no simple answer to this vital question. Parts of it will be found in many areas and blaming one exclusively will not lead to a resolution of the problem for large numbers of children. The following is a list of some of the potential culprits and a bit about what types of problems they may be causing.

o Not enough self-directed movement while young: In our modern fast-paced society, families seem to always be on the go. So we transfer our young child from the baby carrier to the car seat to the stroller and we move them around for much of the day, rather then having them exploring the world around them with their own visually directed mobility.

o Attention demands too short: So many of today’s television shows geared for children are so fast-paced that they seem to flit from one thing to another almost like an MTV video, barely giving the child the opportunity to learn to sustain attention. Thus, they seem to come to school needing a "USA Today" version of school.

o Too many pictures supplied rather than constructed by the child: When a child gets to listen to a reader who orates in an interesting manner, using descriptive prose, the child gets the chance to learn to make, modify and recall visualizations and visual imagery, which will become the basis for spelling and reading later in life. When a child is given a steady diet of graphics and cartoons they become passive viewers of "interesting" content but they don’t get the opportunity to develop the necessary mental imagery skills.

We learn to use the visual process over time. Visual abilities develop as a result of life experiences that children have prior to entering school. We are a product of the environment we grow up in. Many of the skills and abilities we have began with meaningful life experiences as children. Visual skills and abilities are learned primarily through movement and interaction with our three-dimensional world. Novelty is critical for the emergence of a diverse set of skills and abilities.

A child with a limited set of experiences should not be expected to acquire skill merely as a result of surviving a certain number of years on this earth. Time alone does not cause development. Good development is the result of the appropriate meaningful experiences occurring at opportune times in a person’s life. Physiological maturity alone is not sufficient to guarantee proper development.

We cannot expect children who have never heard classical music to identify an oboe or a trumpet by their distinctive sounds. To do so they need the life experience of listening to these instruments in isolation and having someone properly identify the instruments for them. This needs to be repeated more than once to become a lasting skill.

Learning how to fixate on an object, shift visual attention from one point in the visual array to another, precisely align both eyes with ease for sustained periods of time, and shift attention from distance to near and back again are all developed skills. A child who has not had appropriate life experiences in meaningful ways may come to school without these requisite skills.

A behavioral optometric evaluation can be compared to taking an inventory of these visual abilities and skills and finding which are present and which may not yet have emerged. The lack of the emergence of these visual abilities no more represents a physical or physiological or mental deficit than it does in the music example above. In this situation, no one would diagnose a neurological music processing brain center in need of medication. There would be recognition that the life experiences necessary had not been encountered. (Of course there are isolated instances of such problems but these are few and far between.) The vast majority of what we see in clinical practice are visual development problems.

The visual process is the ability to derive meaning and direct action as triggered by light. The behavioral optometric use of the word vision or visual is very different than is seen by the majority of eye-care professionals and the public. Most people, when they think of what they do visually, think only of the clarity with which they see. They think of a trip to the eye doctor as a time to be reassured that their eyes are healthy and to allow for optical corrections in the form of glasses and/or contact lenses to be identified, prescribed and dispensed.

As a behavioral optometrist I do all this, but I also look at much more! From moment to moment we have things we are doing and things we want to accomplish. To do this we scan our environment with all of our senses, but the visual process leads this search and is responsible for building the spatial map of where we are in space, where our body parts are one relative to another and where the object or objects we are looking at, listening to or feeling are relative to us and relative to other things.

We then use this updated construction of reality to direct our actions. As seen from the perspective of a behavioral optometrist, when a clumsy movement or an inaccurate movement is made, it generally is not the fault of the motor system but is the fault of the guidance and control system, and is seen as a visual problem.

It has been said that most visual problems are problems of omission. This means that the information needed to properly identify and locate objects in space was there but it wasn’t taken in and used by the person. Due to a lack of inclusion of the necessary information, an error in the instructions sent to the motor systems results.

To do this well requires several fundamental visual abilities which include:

o The ability to move one’s eyes free of the rest of the body.

o The ability to easily shift fixation from one place to another.

o The ability to accurately point both eyes to the same place in space without excess effort and with a stable alignment. Unstable alignment often leads to the complaint of words moving on the page or momentary jumbling of the letters, or misalignment of numbers in math problems.

o The ability to sustain near-centered visual attention.

Optometry Services

 The number one condition that we address in my practice are children who are having difficulties learning and achieving their potential in school and the primary cause of their problems is a visual development problem. The prevalence of these conditions is 20-23% of the general population and as many as 93% of those identified under public law 94-142 as requiring extra help in school.

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Children with LRVP's have visual development problems in three general areas. 78% have a tracking orocular motor dysfunction which is affecting their ability to keep their place or to move their eyes from place to place across the page. By the age of six and a half a child should be able to track or follow a moving target in front of them without moving their head. This developmental milestone of learning to separate the movement of the eyes from the movement of the head and upper body is essential in learning to read and write. Fortunately this is one of the easiest visual developmental problems to diagnose and to treat. Clinically we see a child who loses his or her place, moves their head when reading, uses a finger to help keep their place, and is often a child who is clumsy.

63% of the children have problems using their two eyes together. The general condition is called a binocular dysfunction with convergence insufficiency being the most prevalent specific diagnosis we see in practice. Children with this problem often have short attention spans, fatigue rapidly, the quality of their work declines rapidly over time, and they may rub their eyes and complain of headaches.

58% of the children have problems focusing their eyes and harnessing their visual attention skills/abilities for long enough to get their work done in a timely manner. This problem is called an accommodative insufficiency or it may be an accommodative infacility.

Obviously many children have combinations of these three problems: tracking, teaming or focusing. I am quite proud of our very high success rate in helping these children.

 

Dr. Harris is proud to be participating in the InfantSEE™ Vision Assessment program that is part of the American Optometric Association and supported by Johnson & Johnson Inc. If you have a child between the ages of 6 and 12 months, who has yet to have their vision assessed, call now for your free appointment. Many vision conditions can be identified very easily, and long-term serious consequences may be averted. Many parents think that because their child cannot respond to verbal questioning that we cannot assess their eyes and their vision development. This is a myth. We have a whole series of tools that allow us to get an excellent view of the optics of the eyes, the health of the eyes, and to see if your child is developing the visual tracking and eye teaming necessary to develop normally. Pediatrician Dr. Arnold Gesell said, "Vision development is child development viewed optometrically." Often we can assess a child's visual and intellectual development better than many other disciplines because of the powerful tools we have and the primacy of vision and the visual process. Former President Jimmy Carter is the national spokesperson for this program. Two of his 11 grandchildren had undetected amblyopia and he wanted to make sure that no children in this country would end up in the same situation. He challenged the profession to take care of the children, and the American Optometric Association listened and created this program. Dr. Harris served as the InfantSEE™ State Leader promoting amongst his peers a program he supports 100%. He also served as an instructor for the other optometrists, putting on courses in Maryland and other states to help them learn how to examine these infants. The vision assessment lasts about 30 minutes and should be scheduled in the morning during a time your baby is normally awake. Please change your baby prior to the visit. Often the child, particularly those very young ones, are most alert during feeding. If possible, try to hold off nursing or giving them their bottle until your actual visit. Also, if possible please try to leave siblings home. For more information vision the InfantSEE™ website. More information is available at Baby Center.com.

Dr. Harris and the entire team of the Baltimore Vision Fitness Center offers to all school-age children (enrolled in Kindergarten to grade 12) access to a free visual screening for potential learning related visual problems (LRVP). Vision or visual developmental problems often masquerade as ADD, ADHD, or other related learning disabilities, when in fact, the primary problem is a visual development problem. Most of these visual problems go undetected because the vast majority of these children have 20/20 sight: they can see small detail and do not require glasses for clarity. However, they may have a primary problem with looking for sustained periods of time (visual attention), with moving their eyes accurately from place-to-place to follow along with reading or with a lesson (tracking problem), or they have a subtle problem with coordinating the use of their two eyes together, causing momentary shifting of images or causing an apparent movement of the words on a page (eye teaming problem - binocularity). None of these problems can be observed by just looking at your child. To find out, call now (1-410-252-5777) or email us to request a time for a free LRVP visual screening for your child. The screening will take about 45 minutes and is done by our capable staff. At the end of the screening, a staff person will sit down with you and let you know if evidence of a problem that requires further investigation by Dr. Harris exists. You are under no obligation to schedule this follow-up evaluation, and if you like, a list of other behavioral vision specialists will be given to you for on-going care. For additional information on undetected learning related vision problems, please go to the websites for PAVE (Parent Active for Vision Education) and to the Children with Special Needs web sites. Please also be advised that this visual screening is for children that have not yet had a vision development problem identified. If you already know about or suspect that there may be a childhood visual problem such as a turned eye, or an eye that is not seeing well, or if you know that there is any problem of overall child development such as autism, pervasive developmental disorder, Asperger's Syndrome, ADD, ADHD or if they are currently taking any systemic medications, then they should be scheduled for a full 90-minute Vision Therapy Workup appointment, which will be charged at the usual and customary fee. Send us an email if you would like us to contact you about scheduling a vision screening for your child.

The Purpose - or Why do I do the Exam? The clarity of your sight is only one of our many concerns. The visual evaluation will also reveal how well your eyes work together as a team. Evaluations of depth perception, eye movement skills, ability to focus easily from near to far and back again, focus endurance for near-centered tasks, color vision, and visual fields are among the many tests of visual performance which we implement. During the visual evaluation, we carefully evaluate the health of your eyes, inside and out, for such problems as cataracts, glaucoma, circulatory problems, hypertension, diabetes, etc. We are part of a wide network of health professionals and will direct any patient in need to the most appropriate source as quickly as possible should we detect any abnormality. However, additional special testing of visual performance is available right here in our office. Contrast sensitivity testing for those subtle visual defects, which can so profoundly affect visual performance, and electro-diagnostic analysis, to rule out neurological problems as a causative factor in eye turns or lazy eye conditions, can be done without leaving the office. Our modern world demands more from our vision than ever before. In fact, 80 percent of all school learning tasks require close-up vision. Adults in our technological society constantly use their near vision at work and at home. Computers especially strain our visual systems, and both adults and children are using them more and more. A thorough vision evaluation and follow-up care on a regular basis are very important for early detection and treatment of eye health problems and for prevention of vision problems created or aggravated by today's academic and vocational demands. Your vision should be evaluated EVERY YEAR or more frequently if symptoms of vision problems occur. Children should have a complete behavioral screening at the ages of six months and three years. They should then have complete visual evaluation on a yearly basis with the first evaluation occurring the summer prior to entry into kindergarten. The Mechanics of the Exam/Evaluation The initial visual evaluation is an exciting time for me. It is a real thrill to meet so many different people who have the need for my services. Many have seen others who have failed to help make a difference. Many have been down several different avenues searching for help and ended up making little or no progress. I love playing the role of Sherlock Holmes and discovering the mystery before me and coming up with alternatives of care to help you alter the path your life is on. Most of you will see me for a full 90 minutes the first time we are together. Generally that time is broken up in the following way. I will spend 15-20 minutes getting to know you and to find out what unmet needs you have that I might be able to help you with. These may vary from not being able to sustain attention on near-centered tasks, to getting headaches when reading or working on computers, to seeing double or seeing the words move on a page of print, to simply wanting to be better at sports or to recover basic skills of daily living following a stroke or head injury. Patients are often struck by my down-to-earth fun-loving spirit. A comprehensive visual evaluation should be fun, in spite of being put through many challenges that will help me see how various aspects of your visual process is working. After the case history we shift to the examination chair. We rapidly will move through a series of tests with lights and a moving steel ball, and lenses, and charts, and Polaroids and color charts and many other things. After as many years as I have been doing this it feels choreographed and you may marvel at how quickly we move from one thing to another. During this part I get a good sense of how you track moving objects and how you move from one place to another while shifting visual attention. I also get a sense of how accurate you are at pointing each of your eyes at precise locations in space. Many people have never learned how to be very accurate with the placement of both eyes at the same time and this can cause all kinds of loss of efficiency as the brain attempts to decide which channel to trust, rather than having the benefit of a well-merged dual view of the world. I then move in a testing device called a phoropter, which has many different lenses and allows me to analyze the optics of your eyes precisely while also giving me the chance to put your visual process through a series of visually stressful probes to find the range and ease that you can extend the use of your two eyes through. Once this is done we typically move over to a table top where I will do several performance tests. It is one thing to look at the optics of the system and to see the ranges through which you can keep both eyes aligned for example, but it is another thing entirely to see how quickly you can call off numbers from a paper or follow intertwined lines in a maze. I may have you read or copy text or write some spelling words, to see how you use your visual system in the real world. For some the final test uses infra-red technology to record your eye movements to a computer system so I can analyze the data and understand the mechanics of how you use your eyes to read. All of the testing usually can be completed in 50-60 minutes. The balance of our time is spent in me explaining to you and those who have come with you to your appointment, in terms you can understand, what my understanding is of your visual process. We will discuss the various potential etiologies that brought you to this point of your life and then I will give you the three alternatives of vision care and help you understand the potential outcomes of each of these alternatives. Many times problems can be addressed by using lenses alone. If so, this is great as it means we may not need to engage in vision therapy. However, some problems can only be overcome by vision therapy and if you have one of them I'll come right out and let you know that this is your best option. With your permission I will make a digital recording of our conversation and I will make it available to you and to whomever you wish to share it with via the internet later that same day or the very next day. Many people have found this refreshing that they will be able to go back through our dialogue later and not feel so overwhelmed with all the new information that is so important to learn. My goal is to find a path that helps you improve your visual abilities so that you can meet the demands that life throws your way. I look forward to meeting you and those whom you bring with you to the office.

The name of these visits that occur after each group of eight therapy sessions is a bit misleading. As patients progress through their vision therapy both they and my staff are getting direct feedback as to the level of progress being made. We use a curriculum model of providing vision therapy. This refers to the fact that based on the kinds of unmet visual needs you present with I will have either selected an appropriate curriculum (sequence of activities in a proscribed order) program from our standard selections or customized a curriculum for your special needs. Based on the length estimate I gave you at the first visit we have a shared expectation of how long it will take to work through your curriculum. Each week we can see if you have mastered the prior weeks assignments and are ready to move on or if you require additional time to master these activities. As you move through the curriculum you will get a sense of accomplishment and will know you are making progress. As well, you will note many things in your life that are changing, as your needs are beginning to be met. For example it is not unusual for people who have come in with headaches when doing sustained near concentrated tasks to have those headaches be gone by the first 8-week progress evaluation. So if you and my staff and I know you are making progress why do we need to get together once every 8 weeks? The primary purpose is for me to take some independent objective measures to be sure that the curriculum we have chosen to work on is still most appropriate. Another aspect of the testing is to make sure that any lenses that you have are indeed correct. Many times lenses are given to help treat the underlying problem but as the therapy progresses their role changes from treatment to helping to reduce visual stress. In some cases the actual prescription will need to be changed and at others the form of the lens (ex: single vision lens to a bifocal) may need to occur. Finally, as your life demands change you may identify additional needs that we may be able to address which might require me to alter the curriculum we have set up for you. All this occurs during the progress examination. After you have completed your vision therapy, I generally see you at one, three and six months to make sure that all gains are holding and again that you have the correct lenses on. Vision therapy plants a seed. And through continued use, it generally continues to grow and develop well after we have finished office-centered therapy. Many people continue to make excellent gains during this post-therapy period.

Visual therapy is a step-by-step developmental program designed to provide patients with the necessary meaningful experiences to acquire full use of their visual process. Visual therapy is based on Piagetian principles of learning, in which a series of graded problems are presented to a child under very controlled circumstances and then practiced for reinforcement.

Therapy in my office is done on a one-on-one basis for 50 minutes. Each session consists of four to five activities which are done for 8-10 minutes each. Then two to three of them are assigned for home practice. The most difficult aspect of being a therapist, as well as being a teacher, is to know exactly how demanding a particular activity should be. Too intense and the child may go into a "flight" pattern and avoid the activity or go passive and not fully engage in the activity. Too little intensity, where a child is asked to do something that they can already do, is a formula that simply wastes everyone’s time, effort and energy. My therapists are trained to adjust the demands of the activities to maximize the speed of improvement, but not at the cost of putting the child under too much stress.

A key aspect of therapy is the involvement of the parents as home therapists. We require from 15-20 minutes of practice or drill a day under the direct supervision of a home helper, who is most often the child’s parent.

Visual Development

The answer to this question certainly depends on a number of variables, including what groups of children we are talking about and at which aspects of visual development we are looking. A study was done by the New York State Department of Education in conjunction with the New York State Optometric Association, in which they did testing on random samples of children in all socioecomic groups throughout New York State. It was found that around 23% of the general school population had visual development problems that were affecting learning in a significant way.

In this study, when you looked only at those children identified under public law 94-142 as needing extra help in school, the percentage climbed to 93%. In a study done in Baltimore with juvenile delinquents at the Hickey School in the late 1980’s, I found the number of these 14-18-year-old boys with visual development problems to be in the mid-90’s percentage wise. In another study in the late 1990’s in several Baltimore City public schools, it was found that over 80 percent of the children had primary visual development problems. Without the visual problems being addressed, simply reducing class size, getting better text books, finding better teachers, or changing the pay system to a merit system will not result in significant gains. The visual problems need to be addressed so that the children can then benefit from their education.

There is no simple answer to this vital question. Parts of it will be found in many areas and blaming one exclusively will not lead to a resolution of the problem for large numbers of children. The following is a list of some of the potential culprits and a bit about what types of problems they may be causing.

o Not enough self-directed movement while young: In our modern fast-paced society, families seem to always be on the go. So we transfer our young child from the baby carrier to the car seat to the stroller and we move them around for much of the day, rather then having them exploring the world around them with their own visually directed mobility.

o Attention demands too short: So many of today’s television shows geared for children are so fast-paced that they seem to flit from one thing to another almost like an MTV video, barely giving the child the opportunity to learn to sustain attention. Thus, they seem to come to school needing a "USA Today" version of school.

o Too many pictures supplied rather than constructed by the child: When a child gets to listen to a reader who orates in an interesting manner, using descriptive prose, the child gets the chance to learn to make, modify and recall visualizations and visual imagery, which will become the basis for spelling and reading later in life. When a child is given a steady diet of graphics and cartoons they become passive viewers of "interesting" content but they don’t get the opportunity to develop the necessary mental imagery skills.

We learn to use the visual process over time. Visual abilities develop as a result of life experiences that children have prior to entering school. We are a product of the environment we grow up in. Many of the skills and abilities we have began with meaningful life experiences as children. Visual skills and abilities are learned primarily through movement and interaction with our three-dimensional world. Novelty is critical for the emergence of a diverse set of skills and abilities.

A child with a limited set of experiences should not be expected to acquire skill merely as a result of surviving a certain number of years on this earth. Time alone does not cause development. Good development is the result of the appropriate meaningful experiences occurring at opportune times in a person’s life. Physiological maturity alone is not sufficient to guarantee proper development.

We cannot expect children who have never heard classical music to identify an oboe or a trumpet by their distinctive sounds. To do so they need the life experience of listening to these instruments in isolation and having someone properly identify the instruments for them. This needs to be repeated more than once to become a lasting skill.

Learning how to fixate on an object, shift visual attention from one point in the visual array to another, precisely align both eyes with ease for sustained periods of time, and shift attention from distance to near and back again are all developed skills. A child who has not had appropriate life experiences in meaningful ways may come to school without these requisite skills.

A behavioral optometric evaluation can be compared to taking an inventory of these visual abilities and skills and finding which are present and which may not yet have emerged. The lack of the emergence of these visual abilities no more represents a physical or physiological or mental deficit than it does in the music example above. In this situation, no one would diagnose a neurological music processing brain center in need of medication. There would be recognition that the life experiences necessary had not been encountered. (Of course there are isolated instances of such problems but these are few and far between.) The vast majority of what we see in clinical practice are visual development problems.

The visual process is the ability to derive meaning and direct action as triggered by light. The behavioral optometric use of the word vision or visual is very different than is seen by the majority of eye-care professionals and the public. Most people, when they think of what they do visually, think only of the clarity with which they see. They think of a trip to the eye doctor as a time to be reassured that their eyes are healthy and to allow for optical corrections in the form of glasses and/or contact lenses to be identified, prescribed and dispensed.

As a behavioral optometrist I do all this, but I also look at much more! From moment to moment we have things we are doing and things we want to accomplish. To do this we scan our environment with all of our senses, but the visual process leads this search and is responsible for building the spatial map of where we are in space, where our body parts are one relative to another and where the object or objects we are looking at, listening to or feeling are relative to us and relative to other things.

We then use this updated construction of reality to direct our actions. As seen from the perspective of a behavioral optometrist, when a clumsy movement or an inaccurate movement is made, it generally is not the fault of the motor system but is the fault of the guidance and control system, and is seen as a visual problem.

It has been said that most visual problems are problems of omission. This means that the information needed to properly identify and locate objects in space was there but it wasn’t taken in and used by the person. Due to a lack of inclusion of the necessary information, an error in the instructions sent to the motor systems results.

To do this well requires several fundamental visual abilities which include:

o The ability to move one’s eyes free of the rest of the body.

o The ability to easily shift fixation from one place to another.

o The ability to accurately point both eyes to the same place in space without excess effort and with a stable alignment. Unstable alignment often leads to the complaint of words moving on the page or momentary jumbling of the letters, or misalignment of numbers in math problems.

o The ability to sustain near-centered visual attention.

Visual Therapy

The name of these visits that occur after each group of eight therapy sessions is a bit misleading. As patients progress through their vision therapy both they and my staff are getting direct feedback as to the level of progress being made. We use a curriculum model of providing vision therapy. This refers to the fact that based on the kinds of unmet visual needs you present with I will have either selected an appropriate curriculum (sequence of activities in a proscribed order) program from our standard selections or customized a curriculum for your special needs. Based on the length estimate I gave you at the first visit we have a shared expectation of how long it will take to work through your curriculum. Each week we can see if you have mastered the prior weeks assignments and are ready to move on or if you require additional time to master these activities. As you move through the curriculum you will get a sense of accomplishment and will know you are making progress. As well, you will note many things in your life that are changing, as your needs are beginning to be met. For example it is not unusual for people who have come in with headaches when doing sustained near concentrated tasks to have those headaches be gone by the first 8-week progress evaluation. So if you and my staff and I know you are making progress why do we need to get together once every 8 weeks? The primary purpose is for me to take some independent objective measures to be sure that the curriculum we have chosen to work on is still most appropriate. Another aspect of the testing is to make sure that any lenses that you have are indeed correct. Many times lenses are given to help treat the underlying problem but as the therapy progresses their role changes from treatment to helping to reduce visual stress. In some cases the actual prescription will need to be changed and at others the form of the lens (ex: single vision lens to a bifocal) may need to occur. Finally, as your life demands change you may identify additional needs that we may be able to address which might require me to alter the curriculum we have set up for you. All this occurs during the progress examination. After you have completed your vision therapy, I generally see you at one, three and six months to make sure that all gains are holding and again that you have the correct lenses on. Vision therapy plants a seed. And through continued use, it generally continues to grow and develop well after we have finished office-centered therapy. Many people continue to make excellent gains during this post-therapy period.

Some vision problems cannot be treated adequately with just glasses or contact lenses, and are best resolved through a program of vision therapy. Over 45% of the space in our office is devoted to this unique service. Our vision therapists are all well trained professionals who function to implement individually prescribed vision therapy programs, usually scheduled in-office on a weekly basis.

Vision therapy utilizes various procedures to aid eye-mind-body coordination. This enables people to use their vision more effectively. Typical improvements noted as a result of a vision therapy program are clearer vision, improved memory, increased interest in reading, along with better comprehension, endurance and speed. Vision therapy also helps focusing problems, tired eyes, headaches, fatigue following visual tasks, light sensitivity, and aids depth perception, night vision and peripheral vision. It is the most effective treatment for eye turns and for “lazy” eye. The multi-sensory vision therapy that we use improves integration of vision with gross and fine motor abilities, speech and hearing, and rhythm and timing abilities.

A patient may enter into vision therapy to cure a number of different types of visual difficulties or to simply enhance their visual performance in some way. Some of the reasons our patients choose vision therapy are:

  • Control and treatment of near point stress
  • Learning related visual problems
  • Eye turns, strabismus
  • Lazy eye, amblyopia
  • Sports vision enhancement
  • Reduction of job related visual problems
  • Improvement of near point concentration
  • Improvement in visual efficiency

Our program includes a once-weekly in-office 50-minute session of treatment with 15-20 minutes of home practice on the days that the child does not come to the office. Of course some more home practice may be helpful but we find that the 15-20 minutes assigned is adequate. We don’t see a need to use your valuable class time to address these concerns for an individual child.

Now if you should want to look for group activities, particularly in the early grades (K-3) to do with your children, I can highly recommend the book, "Thinking Goes to School" by Furth and Wachs. This is published by Oxford Press and is available at www.oep.org. This book details an educational curriculum and program for the early grades based on the Piagetian principles of learning.

If the only problem a child presents with is a pencil grip and writing posture, we will often make a referral for occupational therapy. However, many children that require visual therapy also present with pencil grip and writing posture problems. If the parent wants us to address this we will deal with the sensory motor aspects of holding a pencil and sitting at a table early in the therapy. Towards the end of therapy we then address how to apply these new sensory motor skills to handwriting. In most instances the sensory motor skills need to be practiced at a fundamental level for several months before they can be applied directly to handwriting.

Many children with binocular problems (problems coordinating the use of both eyes together) are constantly shifting postures (squirming in their seats, etc.) in hope of either (1) reducing tension in the body coming from excess effort going into trying to keep the eyes working together or (2) hoping (subconsciously of course), to find a posture that physically blocks one of the eyes thereby greatly reducing the amount of effort needed to work.

As the child’s binocular problems are addressed the need to keep changing postures or to block an eye is reduced or eliminated. Thus, the range of postures assumed and the frequency of changes of posture are both reduced without directly attempting to work on posture. These changes are often noted to occur in the same time frame as the fixation and tracking changes.

Many children with learning related visual problems fall apart when put in timed situations. The added pressure of having to work fast may be the straw that breaks the camel’s back, causing many of these children to "melt down". During the first 8-10 weeks we are working to build fundamental visual abilities. From that point on, although more skill building and elaboration are being done, we shift emphasis to being able to multitask and to perform under pressure.

This aspect of treatment is aided by the use of a stop watch. A number of activities are timed and emphasis on some activities is shifted away from perfection to speed. Some errors are accepted in order to get the child moving. Once moving, then the emphasis shifts back to increased accuracy and then back to faster speeds. These cycles are built into many of the visual therapy activities all the way to using guided reading in the last 8-10 weeks of treatment. Here a moving window flies over text to be read about 20-30 words per minute faster than the speed at which the child is currently reading. These sessions of being pulled over text a bit faster than is comfortable pay great dividends. It also reduces the number of regressions in text (going back to the left within a line of text to reread a section) because the window only moves forward and does not allow for regressions to be of any help when reading.

So the bottom line here is that many of these children have trouble with completing work on time and when time pressures are added they may crumble. However, vision therapy specifically targets this and most children make very quick changes here. Generally from 4-6 months into treatment timing issues are no longer a concern.

Some children show this right away, but this is not to be expected. Typically the first change in the ability to sustain visual attention on near tasks begins around the 8th to 10th session of their treatment. Certainly by the 16th session or about four months into treatment I would expect the child to be attending much better than before, assuming of course that this was a problem before.

Reading is a complex process that is dependent on many visual abilities as well as a host of other skills. Much of the early emphasis in the visual therapy programs is aimed at the fundamental visual abilities. These foundational skills are necessary to build on, but often do not have an immediate effect on improving reading performance. Early on, the major effects might be that the child can stay on task for a longer period of time before tiring.

A major developmental hurdle, already discussed, is learning to move the eyes only when shifting visual attention from one place in space to another. Once this has been achieved we often see renewed interest in near tasks that involve sustained use of vision for deriving meaning. The fact that the child can now do this kind of task often helps them feel better about themselves, and early changes in reading may not be directly from the actual visual therapy, but indirectly from the changes in the child’s self-image and feeling that they are not dumb, that a real problem had been found and that it is being addressed.

As the therapy progresses we often see a pick up in the fluency of reading at their current instructional level. Mechanically we see the child begin to take in a larger perceptual chunk, resulting in them not needing to stop so many times with their eyes per unit of text. Because less effort is needed to keep their place, to keep the print clear, and to plan where to go next, as well as keeping both eyes directed accurately so that their inputs are complementary, more of the child is left to learn from the experience.

Over time we see a consolidation of gains at a level of reading material followed by a non-linear jump to a new demand level. When that happens there is a short period of time when the mechanics seem to make a downturn. This is because it takes more thought, reflection and some conscious effort to decode new words and to find the appropriate meaning in more complex contexts at the new level. Over time this too becomes consolidated, with a commensurate period of time of improvement in the mechanics again. This continues cyclically during the course of treatment as well as continuing for many months after treatment has been completed. This can also be seen in normally developing readers at the appropriate developmental time.

To recap, we first often see improvements that are more secondary to attitude differences than to actual treatment effects. Once the "eye movement free of the rest of the body" target has been achieved there is often a new ability to sustain near centered visual attention, which can be seen in renewed interest in close work. Then begins a cycle of change; beginning with improved mechanics at the current demand level and followed by a jump in the demand level that can be understood. During the early part of the jump to the new level the mechanics typically suffer for a finite period of time.

The time-frame for seeing change will vary with the degree of the problem, the age of the child, the intensity and regularity with which the home practice sessions are done , and many other factors. Generally, by the eighth week of visual therapy changes are beginning to be noticed by all. At first, these may only be that the child is staying on task a bit longer or doesn’t have to be restarted on homework assignments so many times. Often the child is beginning to notice things in their environment, many of which may have been there all the time but are just being recognized.

A major visual development step is the ability to track and fixate with eyes only. In cases where this was not present, I see this emerging by the 8-week progress evaluation. The visual therapy begins in free space with real physical objects and moves to working in the two-dimensional plane of paper or a blackboard at about this time. Since visual development follows this course one of the early signs of change is often in sports. The child with emerging spatial competency is more aware of where they are in space in relation to others and to objects and as a result of this they interact with these things more accurately and more consistently.

Visual therapy is a step-by-step developmental program designed to provide patients with the necessary meaningful experiences to acquire full use of their visual process. Visual therapy is based on Piagetian principles of learning, in which a series of graded problems are presented to a child under very controlled circumstances and then practiced for reinforcement.

Therapy in my office is done on a one-on-one basis for 50 minutes. Each session consists of four to five activities which are done for 8-10 minutes each. Then two to three of them are assigned for home practice. The most difficult aspect of being a therapist, as well as being a teacher, is to know exactly how demanding a particular activity should be. Too intense and the child may go into a "flight" pattern and avoid the activity or go passive and not fully engage in the activity. Too little intensity, where a child is asked to do something that they can already do, is a formula that simply wastes everyone’s time, effort and energy. My therapists are trained to adjust the demands of the activities to maximize the speed of improvement, but not at the cost of putting the child under too much stress.

A key aspect of therapy is the involvement of the parents as home therapists. We require from 15-20 minutes of practice or drill a day under the direct supervision of a home helper, who is most often the child’s parent.

The primary method of treating a visual development problem is to arrange conditions to provide the person with the necessary meaningful experiences to acquire these needed skills and abilities. The method whereby this is done is called vision therapy.

During the early phase we will be building foundation skills and abilities, which may not translate immediately into observable changes in the classroom. I view the course of a therapy program to consist of three phases. The first third of the therapy program helps the child acquire the fundamental visual skills and abilities. During the first third most symptoms such as headaches or blurred distance sight after doing close work are reduced or eliminated.

The middle third elaborates on those skills and abilities, so that when different life demands are encountered that may be similar but actually require slightly different skill sets, the child has the ability to shift from one application to another with ease.

The final third of treatment has two major purposes. The first is to automate the newly acquired skills and abilities so that the new skills are simply called on when needed without any conscious thought. The second is to help the child generalize the new skills so that as life throws new challenges, they can immediately call on what they have learned and make the necessary adjustments, again almost without conscious awareness of having done so.

We learn to use the visual process over time. Visual abilities develop as a result of life experiences that children have prior to entering school. We are a product of the environment we grow up in. Many of the skills and abilities we have began with meaningful life experiences as children. Visual skills and abilities are learned primarily through movement and interaction with our three-dimensional world. Novelty is critical for the emergence of a diverse set of skills and abilities.

A child with a limited set of experiences should not be expected to acquire skill merely as a result of surviving a certain number of years on this earth. Time alone does not cause development. Good development is the result of the appropriate meaningful experiences occurring at opportune times in a person’s life. Physiological maturity alone is not sufficient to guarantee proper development.

We cannot expect children who have never heard classical music to identify an oboe or a trumpet by their distinctive sounds. To do so they need the life experience of listening to these instruments in isolation and having someone properly identify the instruments for them. This needs to be repeated more than once to become a lasting skill.

Learning how to fixate on an object, shift visual attention from one point in the visual array to another, precisely align both eyes with ease for sustained periods of time, and shift attention from distance to near and back again are all developed skills. A child who has not had appropriate life experiences in meaningful ways may come to school without these requisite skills.

A behavioral optometric evaluation can be compared to taking an inventory of these visual abilities and skills and finding which are present and which may not yet have emerged. The lack of the emergence of these visual abilities no more represents a physical or physiological or mental deficit than it does in the music example above. In this situation, no one would diagnose a neurological music processing brain center in need of medication. There would be recognition that the life experiences necessary had not been encountered. (Of course there are isolated instances of such problems but these are few and far between.) The vast majority of what we see in clinical practice are visual development problems.

The visual process is the ability to derive meaning and direct action as triggered by light. The behavioral optometric use of the word vision or visual is very different than is seen by the majority of eye-care professionals and the public. Most people, when they think of what they do visually, think only of the clarity with which they see. They think of a trip to the eye doctor as a time to be reassured that their eyes are healthy and to allow for optical corrections in the form of glasses and/or contact lenses to be identified, prescribed and dispensed.

As a behavioral optometrist I do all this, but I also look at much more! From moment to moment we have things we are doing and things we want to accomplish. To do this we scan our environment with all of our senses, but the visual process leads this search and is responsible for building the spatial map of where we are in space, where our body parts are one relative to another and where the object or objects we are looking at, listening to or feeling are relative to us and relative to other things.

We then use this updated construction of reality to direct our actions. As seen from the perspective of a behavioral optometrist, when a clumsy movement or an inaccurate movement is made, it generally is not the fault of the motor system but is the fault of the guidance and control system, and is seen as a visual problem.

It has been said that most visual problems are problems of omission. This means that the information needed to properly identify and locate objects in space was there but it wasn’t taken in and used by the person. Due to a lack of inclusion of the necessary information, an error in the instructions sent to the motor systems results.

To do this well requires several fundamental visual abilities which include:

o The ability to move one’s eyes free of the rest of the body.

o The ability to easily shift fixation from one place to another.

o The ability to accurately point both eyes to the same place in space without excess effort and with a stable alignment. Unstable alignment often leads to the complaint of words moving on the page or momentary jumbling of the letters, or misalignment of numbers in math problems.

o The ability to sustain near-centered visual attention.