Go Fly a Kite!

Today’s guest blogger is Dr. Christine Allison.  Dr. Allison is an Associate Professor at the Illinois College of Optometry, where she is the Director of the Binocular Vision/Pediatric Residency Program.  Dr. Allison currently serves on COVD’s Board of Directors.

One of the most common questions I hear from parents is, “How can I prevent my children from needing glasses?” or “How can I prevent their eyes from getting worse?”  This is a question that haunts vision researchers on a daily basis.  There is no question that populations worldwide are seeing an increase in nearsightedness.  Many studies have looked at the increased use of near work such as increased reading, computer use, and texting to be the blame for this problem.  While these activities definitely increase the need for the focusing system to be working overtime, a clear link for the development of nearsightedness to these activities has yet to be established.

The question of genetics has also been looked at in many studies.  A recent study of Sinapore Chinese preschool children published in the British Journal of Ophthalmology showed agreement with many other studies that children with two nearsighted parents have a much greater risk of being nearsighted than those with one or no nearsighted parents.   Also, children with even one nearsighted parent have a much greater risk of needing glasses than those children whose parents are not nearsighted.  Thus there seems to be a definite genetic component to the question of “Will my child need glasses?”

Recently though, some exciting new studies have come out that show that children who spend more time on outdoor activities have less nearsightedness than those who spend more time indoors.  Time spent outdoors on leisure activities such as playing in the backyard or at a park, or taking a walk around the neighborhood were compared to sporting activities both outdoors and indoors.  It was found that time outdoors, rather than specifically playing sports, was the factor that was the most important in preventing the development and progression of nearsightedness in school-aged children.  The reason for this is not clear yet, but many researchers believe that the increased light levels outdoors versus indoors are an important factor.  The significantly increased levels of light intensity when a child is outdoors may cause a decrease in a chemical in the brain that causes eye growth (nearsighted eyes are longer), or the smaller pupil size when outdoors may cause a larger depth of field and thus less blur (which could stimulate nearsightedness to develop).

Thus, we now have good reason to send our children outdoors more!  Not only will the increased time outdoors give them a chance to increase their physical activity to prevent childhood obesity, it may also work to prevent them from needing glasses!  So, it is time to tell our patients and their children “To go fly a kite!” and mean it!

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Dr. Martin Kane & Multiple Intelligences

In 1971, Dr. Martin Kane was the first optometrist to receive COVD’s prestigious Skeffington Award for Excellence in Optometric Writing.  In addition to writing many traditional “journal articles,” Dr. Kane took full advantage of his position as editor of the Journal of Optometric Vision Development (now Optometry and Vision Development) to write many editorials.  One theme that ran through many of his editorials is the need for “grass roots” efforts to promote COVD’s philosophy of vision care.  Actions that ultimately result in positive changes begin when individuals “make themselves available to facilitate conditions that will lead to improved patient benefits.” At our recent annual meeting in Rio Grande, Puerto Rico, I realized how much COVD’s doctors, vision therapists and students are out in their communities, “making themselves available.”   You may have seen them performing vision screenings in pre-schools, providing services at Rehabilitation Centers, examining babies at no charge as part of the InfantSEE program, educating parents, school nurses and teachers, conducting clinical research in their offices, etc.  COVD’s members are investing time and energy in a myriad of ways to address societies unmet needs. I think Dr. Kane would be very proud of COVD’s members today.

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Dr. Kane co-authored an article entitled “The Impact of Visual Training on Intelligence” that was published in the Journal of Optometric Vision Development in 1988.  The article considers the concept of multiple intelligences proposed by Gardner in his book, “Frames of Mind: The Theory of Multiple Intelligences” which was published in 1983.  The authors begin by presenting a definition of intelligence.  Intelligence is the skill or efficiency to internalize data, integrate it into an image (idea), and apply alternate strategies in using this image for solving new problems. When examining a patient with learning related issues, the optometrist will often review reports from a clinical psychologist in search of “IQ (Intelligence Quotient) scores.”  Usually these IQ scores measure 2 types of intelligence:  verbal skills, or the ability to manage information via oral communication, and performance skills, or the ability to manage information presented visually.  This approach is very limiting because it neglects “those intelligences which are critical to effective behavior.”  According to Gardener’s model, there are many different types of intelligence.

• Linguistic intelligence is the ability to understand and produce language to solve problems.
• Visual-spatial intelligence is the ability to apply visual imagery to interpret, remember, reconstruct, and understand our spatial world, and to remember what we see.
• Bodily-kinesthetic intelligence is the skilled control of body movements and the ability to continually refine body parts to solve problems that require movement.
• Musical intelligence is the powerful and compelling reaction to sound, that provides us with the ability to appreciate, understand and produce sound/music.
• Intrapersonal intelligence is the knowledge of the internal aspects of self and the ability to access one’s feelings and emotions.
• Interpsersonal intelligence is the capacity to notice distinctions among others—their moods, desires, motivations and intentions—and to adjust, adapt and blend harmoniously with people.

Intelligence is not only multi-faceted, but extremely dynamic and malleable. Given the right opportunities, patients can utilize past experiences and prior learning to solve new and more complex problems.  Visual training can create those opportunities.  For each type of intelligence, the authors describe various ways visual training activities can be selected or utilized to enhance those abilities.  Some examples: when patients describe the strategies they are accessing to solve a particular problem, they are enhancing their linguistic intelligence;  asking patients to perform activities involving balance boards and trampolines encourages the development of bodily-kinesthetic intelligence; the relationship between a patient and vision therapist supports the enhancement of interpsersonal intelligence.

Many of my young patients are brought to the eye doctor to “rule out” a vision problem because they are experiencing reading difficulties.  Upon questioning, more often than not, it becomes evident that their difficulties extend beyond the ability to read and understand words.  When vision problems are, in fact, “ruled in” and these children are enrolled in a vision therapy program, often these children blossom and grow in ways that neither I nor their parents expected.  By reaching into these multiple intelligences, vision therapy enhances their abilities to process information, communicate ideas, interact with others, and make decisions.  Dr. Kane’s article has helped me understand why and how vision therapy can be a turning point in a child’s life.

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The Skeffington Award

At our annual meeting each year, a distinguished Fellow of COVD is recognized with the Skeffington Award.  This award is given to an individual who has made outstanding contributions to optometric literature in the areas of vision therapy and vision development.  The award in named after A.M. Skeffington, an optometrist who is considered by many to be the “father of behavioral optometry.” Skeffington described vision as a process involving the entire person.  His model depicts vision as emerging from the interaction and integration of four circles: antigravity, identification, centering and speech-auditory.   This expands the concept of vision way beyond the retina and challenges the clinician to consider output and actions that are part of human behavior such as movement, navigation, language, and comprehension.  From the 1930s through the 60s, Skeffington traveled across the country to meet with optometrists and leaders of other disciplines in search of questions as well as answers. He was committed to making optometry better by looking at the world from many different perspectives and sharing his ideas in many different formats, including his writings.  It is this spirit of moving the profession forward to enhance patient care that is honored with the Skeffington Award.

Virtually all of the writings of these great optometric thinkers still resonate today.  As a clinician and an optometric educator, hardly a week goes by when I do not run across one of their publications.  I have decided to assign myself the task of revisiting their writings and sharing my educational journey with the readers of this blog.  I hope many of you will expand on my writings on these writers.  In fact, I may ask some of you to help me consider what we have to learn from these 39 great optometrists.

A list of the recipients can be found in this article in the latest issue of Optometry and Vision Development.

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Divergence Excess

Today’s guest blogger is Dr. Kimberly Walker. Dr. Walker practices in New Jersey.  She is also a part-time member of the faculty at SUNY State College of Optometry.  She often travels to different schools in NYC providing eye examinations for young children.

I read a great journal article on the train into work this morning.  The paper is “Treatment Approaches to: Divergence Excess Intermittent Exotropia” and was written by the amazing behavioral optometrist, Dr. Nathan Flax.   Here is a copy of the article.   Flax discusses how this type of Exotropia (eye turned out) is treated differently than any other exotropia. While I have found this approach to treatment to be successful, I have also found myself struggling to clearly explain this treatment method to patients and parents who at first my see this approach as counterintuitive.

Most parents notice when one eye is turned out significantly especially at distance. The Divergence Excess Exotropia is quite easy to see in these kids, because usually the magnitude of the eye turn is quite large.  When their eye floats out when they look up, it really goes OUT!  As a parent,  this large eye turn can be quite disconcerting! While the eye turn or exotropia itself is quite obvious, what is not so obvious is the cause and the treatment.  Many times when a parent sees an eye turn, they talk to the pediatrician and then they are sent to a pediatric ophthalmologist.  In this scenario, the parent is usually given 2 treatment options: surgery or no treatment lets see if he or she “grows out of it”.  The sad part is many of these parents are never told about the 3^rd option:  Vision Therapy.

Now, it is difficult to explain to a parent of a child with Divergence Excess Exotropia that not only does their child need vision therapy for the eye turn at distance, but they also need to wear reading glasses or a bifocal! The parent often time has trouble understanding that the key to Divergence Excess is that the eye turn at distance is really a response to near visual strain. What the eyes have to do to maintain single clear vision at near causes them to have an eye turn when they look out at distance. WHAT? I know confusing…. But I also try to explain it like this (while not technical at all) think of how a runner looks after they finish a marathon, their body is so exhausted, they practically fall to the ground.  When this child tries to read or do work at near, it is like “running a marathon” with their eyes… basically too much hard work. Then they look up and their eyes are so relieved… “Yahoo, time to relax”… and the eyes get floppy and wander off to the side. Reading glasses help the children relax their “eye focus” while doing near work. Once their eyes are not working so hard at near, this will help them to stay aligned at distance.  While this is not a technical account of what is going on in Divergence Excess Exotropia, it seems to help the parents of my patients understand my treatment approach and increases compliance.  Now we just need these patients to be referred to us first. Then we won’t be doing as much vision therapy with children with post-surgical eye turns and double vision!

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