I’m the Data

Today Jillian and Robin Benoit visited with students at SUNY Optometry via Skype.  Together they told Jillian’s story…… how it was discovered that she had severe amblyopia; how an ophthalmologist treated her amblyopia; how her vision problems persisted even when the ophthalmologists said there was nothing more that could be done to help her; and ultimately how optometric vision therapy changed her life.

There were a few moments in their presentation today that I found particularly thought-provoking:

1.  Vision therapy changed, not only Jillian’s life, but the lives of her family and friends.  If Jillian had never learned to read music and play the clarinet, she and her family would not have traveled to see her play with her school band.  They never would have experienced the myriad of opportunities associated with writing and marketing, not 1 book, but soon to be 2 books!  And they will never have to wonder, what if I had taken her to see an optometrist when she was a baby.

2.  Jillian received an email from an ophthalmologist who seemed intent on using the never-changing defensive strategy to bash optometric vision therapy:  where is the evidence, where is the data to prove that vision therapy works.  Jillian took on the ophthalmologist by telling him, “I’m the data!  VT is for people and the people can tell if it works.”  Bravo, Jillian!

Jillian, I would like to give you another perspective on “show me the evidence, show me the data.”  The results of the Amblyopia Treatment Study 2-A were published in the journal Ophthalmology in 2003.  In that study, children between 3 and 7 years of age with severe amblyopia were randomized to 2 treatment groups: full-time or 6 hours/day of patching.  The results: visual acuity in the amblyopic eye improved a similar amount in both groups.  The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hr group and 4.7 lines in the full-time group.

Despite this evidence that was published in an ophthalmological journal, Jillian was patched for 11 hours/day for 3 years.  What good is the evidence if you don’t put it into practice!

Thanks Jillian  and Robin Benoit for encouraging my students to be Superheroes.  You are developmental optometry’s Rock Stars…… Rock On!  

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Learning From My Special Needs Patients

Today’s guest blogger is Jessica Stevenson.  Jessi graduated from Capital University with Presidential Honors in Biology and Chemistry in 1998. She is the Clinical Director of Vision Therapy at Professional VisionCare, where she has been integral in the developmental of treatment programs for autism, traumatic brain injuries, and athletes for the past 14 years.  In 2001, she became a Certified Optometric Vision Therapist (COVT).  Jessi lives in Westerville with her husband Preston and her children, Lincoln and Lola.  This originally appeared in Visions, the newsletter of COVD.  

I am so grateful for the opportunity to work with the special needs community.  Here is what they have taught me:

Lesson #1—Listen and look at everything. Keep your ears, eyes, heart and mind open at all times. Watch how the parent interacts with the child for cues on your own interaction. For example, if mom uses short, specific directions, then your poetic (yet long-winded and abstract) ways to describe activities can be distracting.

Lesson #2—Always use person first language. The word “autistic” focuses on the disorder and not the child. “Child with autism” is a verbal reminder you are caring for a child, not a disorder. Parents will notice and appreciate this shift in your language.

Lesson #3—Make modification your new mantra. During a standard vision therapy session, I plan 3 activities. With a child with special needs, I plan dozens. Be willing to try lots of things, if something works, stick with it. If it doesn’t work, don’t take it personally, just move on and try something different. Be flexible even with your equipment. A child with Down Syndrome once refused to wear red and green glasses. Her mom transferred the lenses to a pair of Dora sunglasses and the child loved them. When working with a child with tactile issues, try holding red and green acetate in front of his/her face instead of fighting to get the child to wear the red/green glasses. This idea turned a “challenging case” to an “underwater explorer” as the colored acetates transformed his world.  Imagine the creatures we discovered!

Lesson #4—Parents aren’t allowed to apologize for their child’s behavior and don’t apologize to other patients (within reason). So often, these parents are burdened by explaining their child’s behaviors and justifying them. Taking away this obstacle allows therapy to flow more smoothly and goals to be reached faster.

Lesson #5—Play. Be silly. Play some more.

Lesson #6—Be humble. No matter how smart you are, none of us can claim to be an expert about the patient in front of us. The parent can. Let them. Ask for input, listen to their ideas. When a parent tells you about a procedure, disease, side effect or characteristic that you don’t know about, don’t claim to know if you don’t. Early in her practice, my mentor Dr. Carole Burns, FCOVD, had a mom ask, “What do you know about autism?” Dr. Burns truthfully responded “not much.” This excited the mom because she knew Dr. Burns wouldn’t have preconceived notions or prejudices about her child. Dr. Burns is now sought out in the autism community, but still looks at every child as a unique individual and a chance to learn.

Lesson #7—Be aware of triggers that could cause a behavior or be distracting. When a new patient with special needs schedules an examination in our office, we invite the parents for a walk through before the appointment. We ask them to evaluate smells, sights, noises and overall atmosphere of the office. We invite the child into the exam rooms to touch the equipment with the emphasis that nothing is made to hurt them.

Lesson #8—When communicating with a child with special needs, realize your inability to understand them is not because they are unable to communicate. I learned this lesson with Brandon who was age 4 and non-verbal. While working on parquetry blocks in which two triangles were connecting at the points, Brandon “signed” what I believed to be butterfly. I assured him it was a butterfly, but he needed to build the blocks. Brandon continued signing. I continued prompting him to build the figure. This continued for several minutes, with Brandon’s signs getting more animated. Finally a fellow therapist informed me he was trying to say bird. With that, Brandon jumped up to hug her and then quickly built the blocks. I have learned that whether it is a speech impediment, a toddler’s rambling, or a non-verbal communication, it is my responsibility to figure out the puzzle.

Lesson #9—Count your blessings. Whether I am struggling to get my two children into bed, to eat their peas, or to not use each other as punching bags, I am often struck by how much stronger I would have to be to have a child with special needs. It is then that I am most grateful, not only for my children’s health, but for parents who trust me to work with their children and learn these amazing lessons. I have truly been given a gift and I will never forget that, no matter how many years I am in this profession.

 

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The Space Between

Today’s guest blogger is Dr. Robin Price. Dr. Price practices in Pleasant Grove, Utah.  He and his associate, Dr. Jarrod Davies, are the only Board Certified Fellows of COVD in Utah!  In fact, Dr. Price just completed a term on the Board of Directors of COVD.  He enjoys working with patients of all ages to help them overcome their visual problems but especially children with learning problems. 

A Google search for “The Space Between” brings up a song written by the Dave Matthews band. “The Space Between” I am referring to is a chapter in Fixing My Gaze: A Scientist’s Journey Into Seeing in Three Dimensions. In this book, Susan Barry, a neuroscientist and professor of neurobiology, describes how she went from perceiving space as rather flat and two-dimensional to developing the ability to see in 3-D.

“Space was very contracted and compacted. So if I looked at a tree, the leaves or the branches would appear to overlap one in front of another. But I didn’t actually see the pockets of space between the actual branches. So the world was actually smaller and more contracted before my vision changed.”

After working with a developmental optometrist in a program of office-based vision therapy, Dr. Barry developed stereopsis, or 3-D vision. A critical part of appreciating stereopsis is seeing the space between objects.  She describes seeing a snowfall for the first time in 3-D as follows:

One winter day, I was racing from the classroom to the deli for a quick lunch. After taking only a few steps from the classroom building, I stopped short. The snow was falling lazily around me in large, wet flakes. I could see the space between each flake, and all the flakes together produced a beautiful three-dimensional dance. In the past, the snow would have appeared to fall in a flat sheet in one plane slightly in front of me. I would have felt like I was looking in on the snowfall. But now, I felt myself within the snowfall, among the snowflakes. Lunch forgotten, I watched the snow fall for several minutes, and, as I watched, I was overcome with a deep sense of joy. A snowfall can be quite beautiful—especially when you see it for the first time.

You can listen to Dr. Barry describe her new visual experiences here:

http://bigthink.com/ideas/43690

Dr. Barry was recently profiled by the PBS program The Secret Life of Scientists & Engineers. You can watch her here:

http://www.pbs.org/wgbh/nova/secretlife/scientists/susan-barry/

I had the privilege of attending a seminar in Atlanta, Georgia a few years ago with Dr. Barry. As part of the seminar, I stood side by side with Dr. Barry as we were viewing the Spirangle vectogram projected onto a wall. We both had 3-D glasses on, but our experiences were very different. Dr. Barry was saying how certain letters were popping out from the wall and others were in a space behind the plane of the wall. I, however, could see some letters popping out slightly, but none appeared to be behind the wall to me. Dr. Barry could see the space between; I could not. I have always had “normal” vision, but Dr. Barry’s appreciation of depth was greater than mine. Since then I have worked to appreciate the space between objects, and my depth perception has improved.

Now, we recently returned from the annual meeting of the College of Optometrists in Vision Development (COVD). It was a wonderful gathering of developmental optometrists and vision therapists from all over the world. It was wonderful to be together with such a large group of dedicated professionals who understand the neurology of binocular vision and how to help patients like Susan Barry. But now we’ve returned home to our lives and practices, and often feel isolated in our science. It will be another year until we gather again. So my question is: How are you going to take advantage of the “space between” to promote developmental optometry and optometric vision therapy? Will you take the messages from the meeting back to your patients? Will you put in place the principles you learned to educate the public? Will you keep in touch with your colleagues from the College of Optometrists in Vision Development to continue learning throughout the year? Can you appreciate the “space between”?

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The Need (part 2)

Dr. Eric Borsting and colleagues are still investigating the diagnosis, treatment and consequences of convergence insufficiency.  The most current research from the Convergence Insufficiency Treatment Trial (CITT) which was presented at COVD’s annual meeting considers the behavioral and emotional problems associated with convergence insufficiency (CI).

Fifty-three children with symptomatic CI were enrolled in the study.  For each child, the parents completed the Child Behavior Checklist (CBCL) and the teachers completed the Connors 3 ADHD Index.  The children were then enrolled in office-based vision therapy programs, and 44 of them completed 16 weeks of treatment.  The parents and teachers then completed the surveys again.

When scores at baseline (pre-therapy) were compared to normative data, the children with CI had more symptoms on both surveys.  On the Connors 3 ADHD Index, the symptoms most frequently reported by teachers were inattentiveness, distractability and giving up easily.  On the CBCL, the symptoms most frequently reported by parents were somatic, such as headaches and eye discomfort.  Children with CI exhibited more symptoms and behaviors associated with ADHD than children with no visual problems.  Following vision therapy, the children showed significant improvement on both scales.  Treatment of convergence insufficiency resulted in a reduction in the behavioral and emotional problems reported by both parents and teachers.

Here’s the take-home message:  if your child has been diagnosed with ADHD or exhibits many of the behaviors associated with ADHD, your child needs a comprehensive vision examination.  If vision deficits are revealed, then vision therapy might be the most appropriate treatment option.  This study is another contribution to evidence documenting the power of vision therapy in the treatment of learning-related vision problems.

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We Can Get Better at Everything

Dr. Sue Barry was recently interviewed by NPR for their NOVA web series called “The Secret Life of Scientists and Engineers.”  Her experiences with vision therapy and learning to see in 3-D were life-changing.  Neuroplasticity is the mechanism through which we CAN get better at everything.  Anyone. Any age.

Watch Dr. Sue Barry: The Secret Life of Scientists

Read more about neuroplasticity here and here.

 

Then watch Dr. Barry tell a joke.

 

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The Splash – From Ripples to Waves

Check out this video highlighting a child that has been helped with vision therapy.  In the feature story, the child says he went from C’s and D’s to A’s and B’s in a matter of months.  To me it is another great example of how these developmental life altering vision problems can impact school performance and beyond.

This child’s developmental optometrist is Dr. Carol Scott.  She is the reason I am a developmental optometrist today.  During my first year of optometry school, Dr. Scott came and lectured about children she was working with.  She talked with passion about how so many of these smart, intelligent children were struggling in school due to treatable vision problems.  She talked about the profound impact treating these vision problems had on these children – in many instances, completely altering the trajectory of their lives.  Unfortunately, in our society,  if you cannot read well and therefore cannot perform well in school, so many doors quickly close to your future.  I knew during that lecture that this was the part of my profession I wanted to practice for the rest of my life.

In thinking about that moment, it is amazing how Dr. Carol’s seemingly small act of lecturing to a group of first year optometry students had such a profound impact on my life.  Before attending her lecture, I had considered vision therapy to be one of the last things I wanted to do in my future practice.  Now as a developmental optometrist I see the lives of children change everyday.

And so it is with vision therapy.  The way we will reach the many people who can benefit from developmental optometry  will be the accumulation of many little ripples.  The ever-growing number of lives affected and the ever-mounting body of evidence supporting vision therapy are becoming the waves that will bring our brand of optometry to the mainland.

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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.

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The Science: Performance-Related Symptoms

Convergence insufficiency (CI) is a common visual disorder that is characterized by great difficulty maintaining binocular eye alignment when looking at something close up (such as a book or a writing assignment).  This landmark study, funded by the National Eye Institute, provides strong evidence that office-based vision therapy is the most effective treatment for CI.  Treatment success can and should be measured 2 ways: objectively (looking at changes in measurements used in the diagnosis of CI) and subjectively (looking at changes in symptomology associated with CI).

The Convergence Insufficiency Symptom Survey (CISS) was developed to quantify the frequency and severity of symptoms reported by patients with CI.  The 15 symptoms on the CISS can be divided into 2 categories: performance- related and eye-related.  There are 6 performance-related symptoms evaluating visual efficiency when reading and/or performing near work:

• Loss of place
• Loss of concentration
• Having to re-read
• Reading slowly
• Trouble remembering what you read
• Getting sleepy when reading

The 9 eye-related symptoms include blur, headaches, double vision, tired, sore, uncomfortable eyes, words that move and jump, and pulling sensations around the eyes.

This study evaluated the symptomology of children with Convergence Insufficiency before and after optometric vision therapy.   Before vision therapy, the six most frequently reported symptoms were the six performance -related items. Fifty percent of all the children in the study responded “fairly often or always” when asked if they lose their place when reading.  Similarly, 45% of the children reported loss of concentration and having to re-read; 40% read slowly; 38% have trouble remembering what they read; and 37% get sleepy when they read.

Children with parent-reported ADHD (attention-deficit hyperactivity disorder) had significantly higher symptom scores on the CISS and the higher score was almost entirely attributed to an increase in the frequency and severity of these performance-related symptoms.

The good news is that ALL the children who responded to treatment reported a decrease in ALL their symptoms.  And while this study did not look at academic performance, the authors do note this relationship when they state: “the treatment of symptomatic CI may have a positive impact on reading performance and attention.”

What is the take home message?  If your child has a convergence insufficiency, it is important to consider both eye-related and performance-related symptoms.  Your child may not be complaining of blurred or double vision, but they still might have performance-related symptoms.  Loss of place, re-reading, poor reading comprehension, slow reading, sleepiness, poor concentration….. am I describing your child’s symptoms?  Have you considered a vision problem as a possible explanation?

Read more about convergence insufficiency here.

Reading more about vision and ADHD here.

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Success Stories for Children’s Vision and Learning Month

Children’s Vision and Learning Month is coming to a close today.  Have you seen the success stories that were posted on Facebook?  So inspiring!

Developmental optometrists are helping children succeed by treating their learning related vision problems.  Here are just a few of them:

Ryed  from Kansas

Nick from Pennsylvania

Kyle   from Massachusetts

Morgan  from Michigan

Ytzel  from Oklahoma

Autistic children from Barbados in Michigan

Jacob  from  Utah

August may be over, but these success stories are being written every day all over the world.  Give your children the gift of a comprehensive vision examination as they head back to school.  Start writing your child’s success story today!

Find a doctor here.

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The Splash – Persistent Parents

Our guest blogger this month, Carrie Hall,  is one of the very talented vision therapists at my practice. She brings a unique perspective to the blog since she works with patients every week often times for many months.  Because of this,  she often gets to know the patients and their families on a very personal level and truly gets to know the struggles, trials, and triumphs patients go through.  At the conclusion of COVD’s National Vision and Learning month, I think her perspective into one of our patients is a perfect addition to what has been a great highlight of many inspiring vision therapy success stories.

As a vision therapist, I often see a theme among the parents that I encounter. Though they are of various ages, personalities, beliefs and styles, they often share one certain characteristic that sets them apart as vision therapy parents. They are incredibly persistent. They have been told many times in their lives that their children may not be capable of certain things. Perhaps by a doctor intending to give them a realistic expectation of the future, or perhaps by a teacher who is frustrated by a lack of success in their child. Whatever the source, I encounter parent after parent who has been informed that their child will not be capable of a certain level of ability, be it athletic,  academic, or just general life skill development.

Lynn was one such parent. Her daughter Shelby was simply not blooming in school like her older sister had. Reading was inexplicably difficult for this 8 year-old. Always a fight, often involving tears, Shelby simply would not take to reading. Lynn was baffled. Shelby was obviously bright and determined, a spunky and enthusiastic girl. It just didn’t add up. The pieces did not fit. Her eye doctors confirmed that Shelby’s vision was fine. She had 20/20 acuity, so the only reason why she shouldn’t be learning to read was if she simply wasn’t as smart as Lynn thought.
Perhaps some parents are more inclined to take the words of professionals at face value than others. Perhaps some parents simply refuse to be satisfied with an underwhelming determination of their children’s potential. Whatever is the mitigating factor, Lynn could not and would not be satisfied with this evaluation of her daughter. She persisted in her search. When she eventually found Washington Vision Therapy Center whose symptom checklist of vision-related learning problems read like a specific description of Shelby’s struggles, Lynn knew she had found her answer. When confronted with the financial strain that therapy would mean for her family, her persistence did not waiver. She would make whatever sacrifices were necessary: she would ensure her daughter’s chances for success in school and life no matter what.
Maybe persistence is a genetic trait as well. I certainly saw the same attributes in little Shelby that her mother demonstrated. Months after beginning therapy, after countless lifesaver cards and hart charts, Shelby was burnt out with it all. Who can blame her though? When the goal of all the work is just to get better at doing homework, it hardly seems a fair thing to ask of a girl of 8 who would rather be playing outside than getting better at reading any day of the week.
But like I said, maybe persistence is a genetic trait. Or perhaps it’s more nurture than nature. Whatever the case, Shelby persevered. Not only did she make it through therapy, she did great at it. She learned to be able to coordinate the use her two eyes like the best of them by the time it was all said and done. She and her mother developed a balanced working relationship in regards to this specific area in order to attack vision therapy head-on and accomplish every last bit of what Dr. Winters wanted to see from her clinically. Neither one of them would quit. Lynn pushed Shelby, and Shelby pushed right back in order to finish well. That little girl was the definition of persistence.
It’s the characteristic that marks out the parents, and the patients as well, for success. They are all up against diagnoses and school evaluations that make the future look bleak. They have been told repeatedly that they can’t, that they won’t. But they refuse to listen. Little fighters, they are, coming in and out of our offices defying the odds stacked up against them.
The other day, Shelby came up to her mother after doing some reading and said, “You know Mom, I think I like this reading thing.”  She is now at grade level in reading.  That is the payoff for any persistent mother.  Lynn has continue to fight to get Shelby’s story of hard work and persistence out to the public and she is now being featured on COVD for National Children’s Vision and Learning month. http://www.cisionwire.com/college-of-optometrists-in-vision-development/r/mom-of-struggling-reader-finds-help-and-speaks-out-for-college-of-optometrists-in-vision-development,c9283372 Imagine that. A homeshooling mom from Yakima, Washington who believed her child’s struggles with reading were more than a resistant attitude or just that her daughter wasn’t smart enough. Persistence is a powerful thing.

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