Dr. Don Getz — Strabismus and Amblyopia

Developmental optometry has lost another giant.  Dr. Donald Getz has died.  His dear friend and colleague, Dr. Robert Sanet had this to say:  “Don loved many things…. he  especially loved COVD, where he served as President and Master of Ceremonies at the Awards Banquet, and he loved mentoring optometry students.  Don and Lynn opened their home, and Don freely gave enormous amounts of his time and energy to hundreds and hundreds of students who visited him over the years.  Don was a great clinician and a tireless champion of behavioral optometry.  The impact of his generosity, friendship, and knowledge will be carried on through the lives of the patients whose lives were enriched because of his clinical expertise, and through the amazing optometric knowledge he shared with us.”

Dr. Getz received the Skeffington Award in 1988.  I happily re-read his monograph on Strabismus and Amblyopia, which was first published in 1974 by the Optometric Extension Program.  In the acknowledgements, he recognizes his vision therapist, Lora McGraw.  “She did not have the disadvantage of an optometric education, and, consequently, did not know that certain things were impossible.”  Dr. Getz and Lora McGraw were always pushing the envelope and thinking outside the box.

A strabismus is a condition in which the eyes are not aligned. One eye may be turned in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia) relative to the fixating eye.  When the eyes are not aligned, this can cause patients to see double.  Even worse, overlapping images will cause 2 different objects to appear superimposed on the same location in space.   Brains find this “visual confusion” intolerable.  In fact, brains will go to great lengths to avoid double vision and visual confusion.  Having a strabismus will often cause a series of adaptations to avoid double vision, and perhaps permit the visual system to make the most of a bad situation. These adaptations include amblyopia (reduction in visual acuity and other visual functions), suppression (turning off the visual input from the turned eye), eccentric fixation (using an off- center point on the retina to denote straight ahead) and even anomalous correspondence (remapping the processing of spatial coordinates when both eyes are attempting to work together).  It is these adaptations that often make the treatment of a strabismus a difficult task.  These adaptations must be eliminated if a patient is going to learn how to straighten their eyes and keep them straight.

In his book, Strabismus and Amblyopia, Dr. Getz explains the importance of tackling these adaptations and then offers many different activities that can be incorporated into a vision therapy program.  He places great emphasis on the monocular phase of treatment. If monocular skills are not developed and equalized, binocular therapy will be very difficult;   or stated another way, if monocular skills are developed and equalized, binocular therapy will be much easier.

In addition to amblyopia, strabismic eyes have poor spatial localization skills.  The brain has learned to interpret straight ahead while the eye is actually turned.  This process of locating where objects are, and how far away they are, must be relearned, under monocular conditions.  If equal spatial localization exists under monocular conditions, it is almost impossible for the patient to have eccdentric fixation; and if equal spatial localization exists under binocular conditions, it is almost impossible for the patient to have anomalous correspondence.

I have prescribed many of the activities listed in his book as part of a treatment program for amblyopia, but re-reading his book has forced me to reconsider what I am attempting to accomplish.  Dr. Getz has reminded me not to overemphasize the visual acuity of the amblyopic eye.  Instead, attempt to improve and EQUALIZE the performance of each eye during these activities.  The visual acuity will improve along with the improvements in spatial localization and performance.  Even if visual acuity is never equalized, the patient may be capable of binocular function.  Equalizing the behavior and performance of each eye separately should not be overlooked or rushed in the therapy program for a strabismic patient.  The patient will now be ready to match the 2 “ocular circuits” and proceed to the binocular phase of therapy with greater likelihood of success.

Read Full Post »

Building a House With Dr. Amorita Treganza

Amorita Treganza as “Miss Lemon Grove”

Dr. Amorita Treganza received the Skeffington Award  in 1986 .  She was another GIANT in developmental optometry.  She was instrumental in the birth of COVD as the national (and now international) organization of developmental optometry.  In fact she served as COVD’s first president, in 1971.   When I typed her name into Google, I was delighted to find this story about the celebration in Lemon Gove, CA, honoring her life and legacy , 100 years after her birth.  Dr. Treganza continues to be  an inspiration and role model for women pursuing optometry, especially those of us specializing in developmental vision.  Dr. Treganza is the co-author of Optometric Evaluation of Children with Academic Dysfunction, published by the Optometric Extension Program, from 1977-78. 

In her case presentation to parents, Dr. Treganza would often begin by separating the vision problem and the reading problem.  She would use the analogy of building a house.

Vision is the foundation.  Vision provides the platform, the stability and the strong beginning on which the remainder of the house will be built.  Reading is the structure of the house; the framing, walls, ceiling and finishing work.  The visual dysfunction affects reading efficiency.  It eliminates or puts crack in that foundation that is supposed to provide stability and strength.  Learning to read and reading to learn are both more difficult.  Attempts to teach that child to read may add a few boards to the walls of the house, but what might we expect if the foundation is unstable and weak?  The pieces won’t fit together and won’t function properly.  At best it will be disorganized, and at worst, it will be unusable!  In order to treat the academic dysfunction, it is necessary to start at the beginning, by rebuilding the foundation.  This can be accomplished with optometric vision therapy.  Then, it is possible to address the reading problem with the appropriate educational intervention.  The framing, walls, ceiling and finishing touches can be built.  Just as building a house requires a team effort (contractor, plumber, electrician, carpenter, etc) so does treatment of the academic dysfunction.  Optometrists, parents and educators must work together.

–August is National Children’s Vision and Learning Month–

So let’s build some houses, from the ground up.   If your child has academic problems, please schedule a vision examination today! 

Find a developmental optometrist in your area.

Read Full Post »

Dr. Harold Solan — Visual Attention and Reading

Dr. Harold Solan received the Skeffington Award in 1990.  At that point, his body of work was quite impressive.  But he was only getting started!  He continued his research, writing and scholarship for many more years.  In many ways, his post-Skeffington Award work was even more influential.  It is very difficult to choose one “topic” or article to highlight his contributions to developmental optometry.  I suppose I shall have to write more about Dr. Solan’s work. 

Dr. Harold Solan

Attention is often defined as the ability to focus on relevant stimuli as well as a decrease in responsiveness to irrelevant information.  In reading, visual attention increases the ability to read efficiently across a line of text.  Readers must learn to use the oculo-motor system to move their eyes accurately.  First they must focus on the first word on the line, then they must shift their attention to the right as they prepare to move their eyes to the next fixation point, then they must sustain their attention in order to allow for processing of the text.  These three principal elements of attention–focus, shift and sustain—are the link between perception and cognition.  Perception makes the visual information available but not necessarily recognizable.  Cognitive processes allow the reader to use the visual information in order to gain meaning.  In other words, reading comprehension is dependent upon visual attention as expressed by accurate oculo-motor control.  Therefore, vision therapy that is directed at improving focus on relevant stimuli, shifting attentional focus within a complex visual environment, and sustaining attention for an appreciable interval might be expected to improve reading comprehension.

Dr. Solan and colleagues investigated this relationship in a group of 6^th graders with moderate reading disabilities.  These students attended public school in New York City.  On a standardized reading test, their reading comprehension scores averaged 2.2 years below their grade level.  The students’ attention skills were assessed using a standardized testing battery.  Then they received 12 one-hour sessions of vision therapy.  The therapy consisted of specific procedures which were aimed at improving or enhancing focusing, shifting and sustaining visual attention during oculo-motor (eye movement) activities.  After completing the 12 hour therapy program, the students were retested with both the standardized reading and attention tests.  Their scores improved significantly on both measures.  After 12 hours of vision therapy over 5 months, their average reading scores jumped an entire grade level, from the 4^th to 5^th grade level.  This is in sharp contrast to the first 5 years of schooling, when their reading scores improved from a 1^st grade to a 4^th grade level.

Dr. Solan’s research supports the notion “that a link exists between visual attention, oculomotor readiness, and reading comprehension…”  He acknowledged that uncertainties still exist.  For example, the therapy also incorporated memory, speed of processing and executive functions.  How does the engagement of this triad influence cognitive performance and reading comprehension?  Dr. Solan’s research always answered BIG questions but at the same time, left more questions to consider.  That way, he never ran out of ideas for his next research project.  Now, he has left these unanswered questions for others to consider.

Read more about eye movements here.

Read Full Post »

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.

Read Full Post »

Dr. Nathan Flax — Vision and Learning

Dr. Nathan Flax received the Skeffington Award in 1982.  He is an author, educator and advocate, especially when the issue is childrens’ vision.  Dr. Flax is a Professor Emeritus at SUNY State College of Optometry, where he served as Chief of the Vision Therapy Service for many years.  He also maintained a private practice in Garden City, NY (that’s on Long Island).  He has published and lectured extensively on a wide range of topics related to vision development and vision therapy.  Dr. Flax is now  enjoying the life of a retired optometrist in Arizona.

Understanding the relationship between vision and learning begins by acknowledging that both are very complex processes.  Rather than considering vision and learning each as one specific skill, Dr. Flax’s writings on this topic emphasize a task analysis approach. He writes, “It is illogical to assume that all aspects of visual function would relate to all aspects of the learning process.”  By first considering the specific learning task, then the potential contribution of specific visual functions can be analyzed.

When a parent reports, “my child is doing poorly in school” or “he/she has a reading problem,” what does this mean?  The case history is essential to determine the nature and extent of the learning problem.  Only then can the doctor begin to consider which if any visual functions may be implicated.  If the primary problem is reading, then the first distinction that should be made is between learning to read vs. reading to learn.  These two tasks require very different visual skills.

Learning to read is more dependent upon recognition and recall of visual symbols.  The child must be able to understand how a visual symbol represents a sound (auditory-visual integration) in order to sound out words (phonetic analysis).  Visual-motor integration comes into play when the child begins to write the letters of the alphabet and then words and sentences. Understanding the directional aspect of visual stimuli is also critical.  Otherwise, the letters b and d are equivalent and the child will confuse these letters when reading and writing which leads to a “reversals” problem. The visual skills that are more related to the ability to sustain attention are usually less significant.  The teacher usually engages the students in a particular learning activity for a short amount of time before moving to another activity.  Text at both distant and near activities is typically quite large.  Using this task analysis approach, learning to read places less demands on precise accommodation (focusing) and binocularity (eye teaming) but great demand on visual perceptual/processing skills.

Reading to learn places far greater emphasis on the ability to sustain visual attention.  The emphasis shifts to speed and comprehension.  Binocular vision (eye teaming) and accommodative (eye focusing) skills increase in the potential contribution to reading disorders as the reading demand shifts toward the capacity to sustain reading for longer periods of time.  Many children enter school and make great progress in learning to read.  When they enter 3rd or 4th grade, they begin to have difficulties and their grades drop.  As the size of the print decreases and the time spent reading increases, deficient visual skills begin to interfere with academic performance.  Oculomotor (eye movement) accuracy is necessary to read without skipping words or rereading.  Copying from the board accurately also requires oculomotor control and accuracy.  Reading comprehension difficulties may result if eye movements are not fluid enough to facilitate the proper sequencing of information being obtained from the page.  Accommodative (eye focusing) and binocular (eye teaming) disorders both show a strong relationship to time.  The more time required to complete an assignment, the more the child’s efficiency (or willingness to participate) declines.  These children often complain of intermittent blur or even double vision, but sometimes they do not complain because they assume this is normal! They also avoid reading because of the associated discomfort.  If these children remain undetected, they may learn to compensate by reading very slowly in order to gain any degree of comprehension.  They often run into serious difficulty on standardized tests, because they cannot function well with time constraints. They often think of themselves as slow readers and don’t realize that their visual systems are to blame.

This task analysis also helps to understand expectations when therapy is implemented. If the problem is reading to learn, reading performance often improves as soon as the visual skills are enhanced and no longer a roadblock to reading comprehension.  If the problem is learning to read, the child may need instructional support or tutoring.  The child will be able to respond to reading instruction once the visual perceptual skills have been put in place.

This task analysis also helps to understand expectations when therapy is implemented. If the problem is reading to learn, reading performance often improves as soon as the visual skills are enhanced and no longer a roadblock to reading comprehension.  If the problem is learning to read, the child may need instructional support or tutoring, in addition to VT.  The child will be able to respond more favorably to reading instruction once the visual perceptual skills have been put in place.

Dr. Flax has provided the developmental optometrist with this roadmap to help direct appropriate diagnosis and treatment for children with learning related visual problems. The best map is in the book by Scheiman and Rouse, titled Optometric Management of Learning-Related Vision Problems.  Dr. Flax’s  chapter on the Relationship between Vision and Learning – General Issues is well worth reading.

Read Full Post »

Time and Direction

Dr. William Lee was the 2nd recipient of the Skeffington Award, in 1972.  In his book, Each Of Us An Island, he describes “those systems which form the building blocks of the manner in which man performs.”  I have chosen to to focus on his chapter on time and direction.  Time and direction are the building blocks of all perceptions, not just visual perception.

Our sensory systems measure energy, such as sound waves, pressure, gravity, or, in the case of the visual system, light.  In addition to intensity, these measurements include discernment of time and direction: the length of time the stimulus is present and the direction in which the stimulus is traveling when the measurement is made.  All the sensory systems can measure time, but the visual system is the most accurate system for measuring both time and direction.  Think of a blind person trying to navigate in an unfamiliar environment.  They may depend upon a sighted individual or guide dog to help them obtain accurate directional information.

Time and direction are an integral part of perception.  Without direction, there is no beginning or end, only on or off.  Motion or movement is the combination of time and direction.  Understanding movement (either of oneself or other objects) requires the visual processing of time and direction.  Without an ability to use vision to make judgements about time and direction, the individual will have difficulty performing activities that require movement. Imagine that you have an appointment that requires you to be at a certain location at a certain time.  In order to get there, you have to know where you are starting from.  If you do not know where you are, it is impossible to know in what direction to proceed or how long it will take to get there.  Now imagine that you are playing baseball.  How will you know when to swing the bat if you do not know the direction from which the ball is coming and the speed at which it is traveling?  Finally, imagine you are a second grader trying to read a book.  In order to read efficiently, you must make make small eye movements called saccades moving from left to right.  If you cannot coordinate the timing and direction of the saccades, reading becomes very difficult.

Since time is infinite, stretching from the past, throughout the present and into the future, processing time requires breaking this timeline into intervals.  Let us look at a behavior, such as learning to write your name.  The first time you perform this activity, you have no basis for comparison.  The second time you perform this activity, you are able to compare your experience to past experience.  You can also anticipate what resources you will require to perform this again in the future.  Through these intervals of time, or cycles, we are able to learn.  If performance does not improve through these rhythmic intervals of time, then perhaps the individual does not possess the requisite skills.  The other possibility is that the individual is not able to use vision to accurately process time, and performs the right activity, but at the wrong time.  You turn right but at the wrong intersection; you swing the bat, but too late; you move your eyes to the next line of words, but you haven’t read the last few words on the first line.

Now consider performance of complex behaviors that require the coordination of several systems.  Think about the baseball player, but now he is in the outfield.  He sees the batter swing, he hears the sound of the ball hitting the bat, and he has to move in the right direction to catch the ball at the right time.  He has to coordinate all this information arriving at his sensory systems at different points in time and respond by accurately moving in the right direction through an accurately determined time interval.  Difficulties processing time and direction visually will make it impossible to perform this task successfully.  What if the outfielder is an 8th grader?  The information he is receiving is constantly changing due to his fast growth rate.  His past experiences are no longer reliable.  He has to constantly rebuild the coordination of all systems to perform successfully.

Visual processing of time and direction is essential to coordinated performance.  Many learning disabled children have difficulties in this area.  The result is often more accurately described as a “living disability” because these children have difficulty, not only in school, but at home and at play.  What can the developmental optometrist do to help the child who has difficulty with these skills?  Vision therapy will often include activities aimed at improving rhythm.  Providing an external clue to organize sensory inputs will support the motoric response or output.  These activities may involve the use of the metronome, music, flashing lights, hand clapping, swinging balls, and trampolines.  Activities can be done at home to enhance self-directed awareness of time intervals, such as skipping, jump rope, marching, or tapping the foot and clapping the hands to various patterns.  As the ability to process time improves, activities which require directional movement and the integration of the sensory systems can be incorporated into the therapy program.  Improving rhythm will improve the child’s ability to process time and direction.  The result is the ability to do the right thing, at the right time, in the right place.  Success.

Read Full Post »

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.

———————————————————————————————————————-

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.

Read Full Post »

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.

Read Full Post »