Perceptual Malnutrition

Dr. Tole Greenstein received the Skeffington Award in 1973.  This discussion is based on his writings for the Optometric Extension Program from 1967-8.  The resultant monograph is entitled Optometric Child Vision Care and Guidance. 

When young children learn how to manipulate objects with their hands, they must learn how to REACH for the object, and then GRASP onto the object.  This allows the child to MANIPULATE the object and learn what it feels like and perhaps decide if it is familiar or not.  Then the child must RELEASE the object in order to be ready to reach for something else and initiate this cycle once again.  REACH-GRASP-MANIPULATE-RELEASE.

As children progress developmentally, they learn this same process utilizing the visual system.  The child will reach for an object with the eyes instead of the hands; then grasp the object with the eyes in order to explore the object and determine what it is and what it means; then release the visual “lock” on this object in order to get ready to reach and grasp the next object worthy of “seeing.”

Many children with vision problems have great difficulty with this cycle of VISUAL Reach-Grasp-Manipulate-Release, especially the “grasp” part.  They may be able to find an object with their eyes, but they have significant difficulty keeping their eyes on the target long enough to manipulate the object and figure out what the object is, what it means and how they might want to interact with it.  Without grasping and manipulating, their visual processing is reduced to Reach-Release-Reach-Release.

This visual problem will be evident during very simple procedures to evaluate the quality of eye movements.  The child will be asked to perform saccadic eye movements, which are jump eye movements from one object to another.  These children cannot wait until they are instructed to jump to the other target; they cannot grasp the object.  As soon as they reach the first target, they release and grasp on the 2^nd target; then they release again and jump back to the 1^st target; all this despite instructions to try to keep looking at the 1^st target until told to look at the 2^nd target.  These children will make several round trips without ever visually grasping long enough to manipulate the object.  When asked to fixate a small object, such as a small bell, and keep the eyes on the bell as it is moved into different positions, they have similar deficits.  These children cannot maintain their grasp on the bell; they will release their grasp and look at something else: Reach-Release-Reach-Release.

What is the result of this inability to visually grasp and manipulate?  Dr. Tole Greenstein described this as PERCEPTUAL MALNUTRITION.  These children do a good amount of “looking,” but very little “seeing.” Without the grasp and manipulation, these children have very little useful information; very little visual “food” to feed their visual processing and thinking.  How would a child with PERCEPTUAL MALNUTRITION behave in a classroom?  When reading across a line of words in a book, they may never learn to identify the words.  Every time they see words that are repeated on the same page, they are unable to use past experiences.  Words strung together in a sentence have no meaning.  Pieces have no relationship to a whole.  Maps, graphs and diagrams are incomprehensible.  What about the playground? How can these children react to a moving target if they can’t keep their eyes on the ball?

These children are often diagnosed with an oculomotor dysfunction, which describes their inability to perform age appropriately on the eye movement tests.  Dr. Greenstein wrote, “it is important to talk about what the findings indicate that his life-world response in a given task would be.”  The diagnosis of oculomotor dysfunction is meaningless unless you discuss the consequences.  The resultant perceptual malnutrition and the inability to perform in and out of a classroom are of great consequence.  Dr. Greenstein described vision therapy as a program of learning, teaching these children how to control their environment instead of allowing the environment to control them.  The benefits of vision therapy will be different for every child.  If you think your child may be suffering from PERCEPTUAL MALNUTRITION, find a developmental optometrist and start writing your child’s success story.

 

Read more about eye movements here and here.

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Children With Special Needs: A Collaborative Approach to Vision Care

In a recently published article, Dr. Marie Bodack describes a program at the Herbert Birch Childhood Center in NYC in which 273 children with special needs received eye examinations.  These children, between the ages of 3 and 5 years, had been diagnosed with developmental delays and were enrolled in early intervention programs. Diagnoses included Down Syndrome, cerebral palsy and autism.  The occupational therapists at the school were instrumental in bringing optometric care to the Birch School because they felt that many of the students had undiagnosed vision problems.  Through an affiliation with SUNY State College of Optometry, optometric care was provided to the children during their school day.

The provision of eye care to these children was very collaborative and very flexible.  The children were accompanied to the eye examination by either their occupational, physical or speech therapist.  The therapists’ presence was very comforting to many of the children, and often they were able to assist during the examination process.  The therapists often made suggestions on how to modify procedures in order to obtain responses or helped prepare the children for the examination experience.  They were also instrumental in facilitating communications between doctor, parents and teachers.  If a child was having a “bad day,” or follow-up care was needed, a 2^nd appointment was scheduled.

Research has shown that children with special needs have a higher incidence of vision problems, and this population was no exception.  More than 10% of the children required glasses; 6% had strabismus, and 3.7% had amblyopia.  An additional 2.5% were referred for additional evaluation for potential ocular health problems.  ALL children with special needs should have comprehensive vision examinations ASAP!  Dr. Bodack’s research has reaffirmed this.

Many children with special needs are unable to express their discomfort or explain their symptoms.  Their comorbidities often require large investments of time and money to manage.  The examination of pre-school children with special needs is often difficult.  Therefore, they do not receive the comprehensive vision care that they desperately need, and their vision problems remain undiagnosed.   This project is an example of what can be accomplished when the services are brought to these children instead of waiting for them to seek care.  The interdisciplinary environment facilitated the diagnosis and management of vision problems at an early age.  Most importantly, communication between optometrist, therapists and teachers created a better understanding of each child’s visual functioning and how to help that child reach his or her full potential.

Read Dr. Bodack’s description of the characteristics of strabismus here.

Read more about autism and vision here.

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The Cure

Kudos to Antonio Chirumbolo and the many students at optometrystudents.com for this interview with my friend and colleague, Dr. Ken Ciuffreda.  This interview provides many “jumping off”  points for discussions about vision therapy,   traumatic brain injury and research.  In fact, something in that interview sent me down to the library to find an article that was published in 1958.

Fourteen minutes into the interview, Dr. Ciuffreda refers to the 1961 study by Dr. William Ludlam on “The Orthoptic Treatment of Strabismus: A Study of 149 Non-Operated Unselected Concomitant Strabismus Patients Completing Orthoptic Training at the Optometric Center of New York.” In this study of the effectiveness of vision therapy (orthoptics) for the treatment of strabismus, 76% of the patients achieved a “functional cure.”

That rang a bell somewhere in the optometric filing cabinet inside my brain, and I went in search of “Flom’s Criteria.”  Published in 1958 in the American Journal of Optometry, Dr. Merton Flom discusses “The Prognosis in Strabismus.”   He begins that discussion by distinguishing between a functional cure and a cosmetic cure.  After all, how can you determine the prognosis for a certain treatment unless you know what it is you hope to achieve with that treatment.

A functional cure of strabismus restores normal binocular vision to the patient: clear, comfortable single vision at all distances, stereopsis (depth perception), and the ability to maintain binocular vision 95% of the time when moving the eyes through the world in 3 dimensions.  The patient may require lenses and even small amounts of prismatic correction to achieve this functional cure.

Dr. Sue Barry, who achieved a functional cure for her strabismus at age 50 through a vision therapy program, describes her experience:  “For the first time, I could see the volumes of space between different tree branches, and I liked immersing myself in those inviting pockets of space. As I walk about, leaves, pine needles, and flowers, – even light fixtures and ceiling pipes – seem to float on a medium more substantial than air. Snow no longer appears to fall in one plane slightly in front of me. Now, the snowflakes envelope me, floating by in layers and layers of depth. It’s been seven years since I gained stereovision, but ordinary views like these still fill me with a deep sense of wonder and joy.”

The prognosis for a functional cure is dependent upon many factors:  does the eye turn in or out, all the time or intermittently, is there amblyopia or other adaptations to the eye turn, is the magnitude of the eye turn large or small, how motivated is the patient to achieve a functional cure? In some cases, the prognosis for a functional cure is poor, or vision therapy has been unsuccessful.  Then the discussion changes to considering a cosmetic cure.

A cosmetic cure occurs when the strabismus is no longer noticeable.  A functional cure invariably includes a cosmetic cure, but a cosmetic cure does not assure a functional cure.  A cosmetic cure is the goal of strabismus surgery, and more often than not, this can be achieved.  However, without improved function (a functional cure), the cosmetic cure may not last.  The eye turn may return at some point, and a second surgery may be recommended.

When considering the options to “cure” your strabismus, first consider what type of cure you hope to achieve.  Which options are more likely to help you and what is the prognosis for achieving that goal?

Dr. Flom summed it up quite well…..

“When the prognosis is based on good judgement and is tempered with an evaluation of the patient as a human being, it becomes an invaluable aid in recommending the kind of treatment for a strabismus.”

Read more about strabismus here.

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Optometry & Vision Development (OVD): Now Online!

Optometry & Vision Development (OVD)

Aurora, OH – The most recent issue of Optometry & Vision Development (OVD), the official journal of the College of Optometrists in Vision Development has research and other articles that may surprise the general population. Did you know that a simple pair of glasses can significantly improve your quality of life? Researcher, Dr. Janis Winters of the Illinois College of Optometry/Illinois Eye Institute, in her paper, Vision Related Quality of Life among Urban Low-Income Black Seniors Participating in an Eye Care Program: Effect after New Spectacle, has shown that poor, elderly, under-represented minorities show a significant and positive change in the individual’s perception of their overall quality of life. When the National Eye Institute Visual Function Questionnaire was given to the participants before and after spectacle wear a significant difference was found with wearing the glasses. The general health, general vision, ocular pain, and distance activities, as well as near activities, social functioning, color vision, peripheral vision, and mental health subscales compared to first administration of the survey were also significantly different when the spectacles were worn. This paper strongly supports how an individual’s quality of life can improve just by wearing glasses. It is unfortunate that so many cannot afford or do not have access to optometric eye and vision care.

In this same issue of OVD an article by Dr. Marie Bodack, Eye and Vision Assessment of Children with Special Needs in an Interdisciplinary School Setting, found that during a three year period of the 273 children with special needs who received eye examinations (about 1/3 of the children had been diagnosed with autism), 3.7% had amblyopia (lazy eye), 6% presented with an eye turn, and 11% had refractive errors (nearsightedness, farsightedness, astigmatism) requiring correction. Approximately 2.5% were also referred for additional care because of ocular health problems. This paper supports the need for all with special needs to have comprehensive eye care by an optometrist.

And finally, Dr. Dominick M. Maino, OVD editor, wrote in his editorial, 3D in the Classroom: See Well, Learn Well, that the American Optometric Association’s (AOA), The 3Ds of 3D Viewing is great advice for the consumer. If you experience the 3Ds of 3D viewing (Discomfort, Dizziness and lack of Depth, when viewing 3D movies, television, video-games and 3D educational content), you should incorporate 2 more Ds – See your Doctor of Optometry, especially one who is a Fellow of the College of Optometrists in Vision Development (COVD). Dr. Maino also emphasized the AOA’s recognition of the vision problems that cause the difficulties often associated with 3D viewing as a major public health issue. Although the research is just now beginning to be conducted in this area, it appears that problems with focusing, eye teaming and eye movement ability all play a role in the discomfort, dizziness and lack of depth experienced by those viewing simulated 3D. These binocular vision dysfunctions often affect not only how we enjoy our free time, but also how well we perform in school. The good news is that if you have these problems, those who belong to the College of Optometrists in Vision Development have vision rehabilitation/therapy programs available so that you can enjoy all that 3D has to offer.

This issue of OVD also has practice management articles, as well as photographs and information about COVD’s annual meeting recently held in Las Vegas.

About Optometry & Vision Development

Optometry & Vision Development (OVD) is a peer-reviewed open access journal indexed in the online Directory of Open Access Journals. The full text of these articles is available free from www.covd.org. OVD is an official publication of the College of Optometrists in Vision Development. Any questions may be addressed to the editor, Dominick M. Maino, OD, MEd, FAAO, FCOVD-A at dmaino@ico.edu or 312-949-7282.

About COVD

The College of Optometrists in Vision Development (COVD) is an international, non-profit optometric membership organization that provides education, evaluation, and board certification programs in behavioral and developmental vision care, optometric vision therapy, and visual rehabilitation. The organization is comprised of doctors of optometry, vision therapists, and other vision specialists. For more information on learning-related vision problems, optometric vision therapy, and COVD please visit www.covd.org or call 888.268.3770. 

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100,000 Saccades per Day

Saccades are eye movements from one object of regard to another.  These “jump” eye movements allow us to fixate objects with the fovea, which is the part of the retina that we use to discriminate details and determine, “what is this.” Reading across a line of printed words requires a series of saccades and fixations. First we make a saccades to bring our eyes to the first word in the sentence, then we fixate to allow our brains to process what we are seeing, then we make another saccade to a point a little further along in the sentence and once again fixate to allow our brains to process the visual information.  Saccade-fixate-saccade-fixate.  This pattern continues for as long as it takes to complete the reading .  But saccades aren’t only about reading.  They are the basis for using vision in everyday life.  Every time we want to “look” at something, we have to make a saccade to bring that something onto our fovea.  Saccade-fixate-saccade-fixate.  This happy dance continues all day long.  On average, we make 100,000 saccades per day.

What if you had difficulty with saccadic eye movements?  What if it took you a little longer to make that saccade?  Or you were inaccurate and your eyes landed in the wrong place? Or this put additional stress on your binocular system because you had difficulty coordinating the eyes during saccades?  And now imagine making these errors 100,000 times a day.  The happy dance is no longer very happy.  Welcome to the world of the learning disabled child.

At the annual meeting of COVD, Dr. Zoi Kapoula presented a distillation of her years of work studying saccadic eye movements.  This included the evaluation of the saccadic eye movements of a group of dyslexic children during “real text reading;” recording eye movements as their eyes moved in a sequence of fixations across the text.  The dyslexic children made more saccades, more regressions (moving their eyes backward along the line of text instead of forward), and it took them longer.  In addition, they had more difficulty keeping their eyes properly aligned during the reading task.  This resulted in greater stress on their binocular systems in an attempt to prevent the words from going double.  Dr. Kapoula concluded that these inefficiencies might complicate letter or word recognition processes and “supports the suggestion that besides impaired phonological processes, a visual/oculomotor deficit exists in dyslexics that might perturb the fusional process. “  That’s the double whammy.  Poor eye movements not only make it difficult to read, but make it more difficult to maintain binocular vision while reading which also makes it hard to read.  It’s the proverbial downward spiral.

But there is hope.  Research has shown that vision therapy can be effective at improving both eye movement and binocular skills.  These improvements in visual skills can translate to better academic performance.  It’s time to get your child’s visual “happy dance” back on track.

Percy has great dance moves and eye moves!

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The Science – Vision problem or ADHD?

I have just spent sometime venturing through the blogosphere of mothers with children with ADHD.  I was so impressed with these brave women that write about their experiences, triumphs, and challenges in raising their children with ADHD.  Many of their accounts truly broke my heart.  This is an excerpt from Penny Williams blog “A Mom’s View of ADHD” where she describes her experience of trying to find a good fit for educating her son with ADHD:

“I live in search mode these days, ever since my son Luke, age nine, was diagnosed with ADHD in 2008. I am searching for the medication, therapy, classroom accommodation, product that will make his life with learning disabilities a little easier. I guess you could say I’m searching for the magic bullet, but I don’t think that’s really accurate anymore. It was true the first year or two — I was looking for an “answer,” something to erase his ADHD symptoms. Then I realized that that “something” doesn’t exist. I didn’t think I was looking for a cure for ADHD because I knew that’s not possible, but that’s exactly what I was searching for nonetheless.

My focus in my search now is different, more refined. I am searching for tools to help him compensate for his differences, for environments where he can learn and prosper, parenting methods best suited to his needs, treatments that teach him the skills necessary to have a happy, successful life despite ADHD (and dysgraphia, SPD, Executive Functioning Deficits, and a gifted intelligence). This search is intense and stressful for me, his parent. There’s a lot of {self-inflicted} pressure to be diligent to find all opportunities and to make choices that will only have positive outcomes. In the area of making appropriate choices that lead to positive outcomes, I have failed miserably this year.Luke has struggled in school since the day he walked into kindergarten. Yes, the very first day. While it should improve each year with treatment, maturity, growing self-awareness and a diligent advocacy for accommodations and resources in school, it has not improved for Luke. I feel like we have been standing in the same place for three years, paralyzed, while the world continues to move on all around us. In our minds, we’re moving and working, but we’re getting nowhere.

That feeling of helplessness became overwhelming to me earlier this year. I fought hard with the school but mostly we just received lip service. I watched Luke struggle to fit in an environment that was clearly the opposite of what he needed. I knew he needed more help. I had to find that for him. ”

I think Penny encapsulates the very real struggle that many parents go through that have children with ADHD.  As a developmental optometrist I work everyday with children that have been diagnosed with ADHD.  I see in their parents’ eyes the same sentiments shared by Penny.  While I do not claim to have a magic bullet, I do have tools that have helped many of of my patients that have vision problems that can often mimic or complicate ADHD.

Dr. David Damari, Developmental Optometrist and Fellow of the College of Optometrists in Vision Development wrote a great research article, “Visual Disorders Misdiagnosed as ADHD,” that gives several great case studies of patients with ADHD  who had developmental vision problems. He speaks in the article of how similar the symptoms are for children with common developmental vision problems and those of children with ADHD.  He also describes in detail case studies of children that were misdiagnosed with ADHD and instead suffered from vision problems that affected their ability to perform well in school, learn, read, and maintain their attention.  He also references other research that shows the correlation between ADHD and Convergence Insufficiency, one of the leading developmental vision problems in children.

Probably, though most compelling are the stories from parents whose children were misdiagnosed with ADHD.  Here is a story from the parent of a child from the website, “Vision Therapy Success Stories”:

“Recently, “Sarah” came into the office just to talk to Dr. X. She was so excited .she was no longer struggling with reading and schoolwork and couldn’t wait to thank him. She is no longer taking Ritalin and is doing well in school.

Prior to seeing Dr. X, Sarah struggled to do the work required of her in high school. She found reading burdensome, was unable to finish her homework in a reasonable amount of time, and was unable to keep up with all her assignments. She was feeling frustrated and discouraged. Sarah had been put on Ritalin in order to help her focus on her work, but she continued to struggle.”

Bottom line, if your child is stuggling with attention in school, check to be sure there is not a vision problem.  To find a Developmental Optometrist near you that can diagnose and treat these types of vision problems, please follow this link.

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