Monroe “Puggy” Farmer – Part 4

In Part 3 I showed why the patient with amblyopia has visual deficits beyond visual acuity.  For many years behavioral optometrists referred to vision as a learned process, and some teachers such as Susan Schocket readily grasp the significance of this to education.  Given that vision scientists have defined amblyopia as a developmental disorder of spatial vision, it simply isn’t good enough to judge a “cure” for the condition based on sharper sight that enables identifying smaller letters on or near the 20/20 line of an eye chart.

If we practice what we preach, then the most effective way to treat amblyopia should be the same way we approach developmental disorders.  The approach at we take clinically to delays in visual development are not to emphasize more traditional “eyeball stuff” like focusing and eye tracking.  It’s to emphasize visual processing or perception and cognition (a tip of the cap here to the incomparable therapy team of Linda & Bob Sanet).  And sure enough, vision science now supports that the key component of improvement in amblyopia therapy comes through perceptual learning.  The year was 2006 when Dr. Jeff Cooper joined me for a Symposium at the American Academy of Optometry on the applications of computers to vision therapy.  I served as the editor for a series of papers for OEP on the subject, one key set written by Dr. Bill Ludlam on the Optimum System for amblyopia therapy, and the other by Dr. Cooper.  I asked Jeff to send me his slides in advance for the Symposium, and when I opened his email I called him in a panic because one of the key slides looked like machine language.

I was soon to learn that this was only one of 12 programs that were part of the new Amblyopia iNet Program.  As soon as we began to use it, the program’s utility in aiding perceptual learning was immediately evident.  So much so, that we began using the program for children who had learning issues even in the absence of amblyopia.

- Leonard J. Press, O.D., FCOVD, FAAO

 

Is It Possible to Have A Learning Disabled Eye? Monroe “Puggy” Farmer – Part 3

We left you in Part 2 with Tonya finally getting some relief from double vision when reading, or trying to use binocular instruments, when a primary care Optometry resident at her University determined that she could benefit from some vertical prism.  But her struggles were far from over.  Tonya related during our in-office seminar to the SUNY Residents yesterday that on the Visagraph she still tests as having only a grade level equivalent reading performance of a 4th grader.

So let’s review a key concept from neuroscience that will help Tonya understand her visual function better, and in turn will illuminate how she treats patients when she embarks on her own practice of Optometry in West Virginia.  Amblyopia is a developmental visual disorder of cortical origin.  It has much less to do with the eye than it does with the brain.  As such, it is better termed a developmentally delayed or learning disabled eye, rather than “lazy eye” – as amblyopia is known in the vernacular.   But the fact that the public and even many professionals persist in referring to amblyopia as lazy eye signals that our concept of amblyopia is as outdated as the notion of referring to a learning disabled student as simply lazy.  There is much more to improving amblyopia than patching or penalizing the stronger eye to force the weak or lazy eye to become more industrious.  Just as we ultimately want to mainstream the student with learning disabilities or developmental delays as much as possible, the same imperative should be present for the individual with a developmentally disabled eye.

The key to aiding individuals like Tonya to process information when the connections between one of her eyes and the brain is relatively disabled has been termed perceptual learning.  Note that this label was coined not by behavioral optometrists, but by vision scientists and researchers publishing largely in ophthalmologic journals.  And while it may be surprising to ophthalmologists (and pediatricians) that amblyopia has an impact on reading, it is difficult to feign surprise when these connections appear in one’s  own literature.  Tonya knows, after our Residents’ seminar yesterday, why she has continued to struggle with reading.  In Part 4, we’ll finish helping Tonya build on the start she got in “remedial seeing” with Puggy in West Virginia and the Primary Care Resident at her College of Optometry.

- Leonard J. Press, O.D., FCOVD, FAAO

Vision therapy for the special needs patient…you be the judge

A few days ago a Dad of one our special patients raised a question of  concern  that centered around his son being able to have access to some of the new computer-based teaching applications being introduced into his school.  You see, his 10-year-old son Christopher has cerebral palsy and  like many children with cerebral palsy,  Christopher has developmental vision delays associated with his neurological condition. 

 The question posed by Christopher’s dad was, “Should my son be able to take advantage of the new high-tech computer-based, interactive technologies that are becoming available at Christopher’s school?”  This question stemmed from discussions at his school and assumptions about children  with neurological based conditions like CP. In this case a concern was voiced at the school that Christopher’s Individualized Education Program (IEP) might disallow him having access to the newly available interactive computer based education systems being utilized in the classroom.   Imagine this is your special child and while all the other kids are enjoying access to the “new educational gadgets”,  your child  is going to be relegated to “playing with blocks.” 

Yes,  prior to his vision therapy treatment Christopher would have  had trouble  with even the most basic visual demands in the classroom. Yet even though  Christopher has cerebral palsy,  there is still plasticity in his visual brain that has enabled him to positively respond to neuro-optometric vision rehabilitation. His treatment has targeted the plasticity of  his brain with office-based vision therapy through a variety of activities that incorporate awareness, feedback and sensory integration.

To help demonstrate the point, in this Movie Clip take a look at our patient Christopher. First you will see Christopher 10 months ago showing him struggle to visually track and follow a simple cube on a stick in a very basic chair-side assessment of his eye movement. Second in the clip you will see  an introduction by Dr. Fortenbacher and Dr. Tuan (MCO Extern) demonstrating an example of one the latest  advanced vision therapy applications using the Sanet Vision Integrator.  Then you will see Christopher in action (on the SVI) showing progress in his visual skill development with an interactive visually challenging high-tech vision therapy procedure. 

You be the judge…should Christopher be given the opportunity to try to work with the new computer-based educational applications as part of his IEP?

Dan L. Fortenbacher, O.D. FCOVD

Ethan and His Infant Vision Laboratory

InfantSEE is a wonderful public health service sponsored by the American Optomertic Association involving formal assessment of an infant’s eyes and developing visual system.  An example of one of its assessment procedures is the Random Dot E test, and I blogged elsewhere (okay, bragged might be more apt) about my grandson Ethan responding to the RDE administered to him at six months of age by his father, Dr. Daniel J. Press.  Back in the day, as with Piaget,  observing my own children helped to educate me about infant vision development, coupled with trips to the MIT Infant Vision Lab to watch Held, Mohindra, and Gwiazda, and later working with the likes of  Forrest/FirtzGerald/Duckman/Gruning at SUNY among others, and of course studying the works of the marvelous developmental specialist Dr. Arnold Gesell and his collaboration with Drs. Frances Ilg and Gerry Getman (Vision: Its Development in Infant and Child)

In follow-up to sharing Ethan’s Random Dot E detection prowess, I’d like to share with you another aspect of infant vision development, this time something that you can observe more casually, outside the context of formal assessment.  It’s part of what I call Ethan’s Infant Vision Laboratory.  It’s fun renewed for me to see him reach for objects to hold on to, judging cautiously if it will support him or not, and peering around corners to conduct his own visual cliff experiments.

In these photos I’ll take you through Ethan’s thought process, and you can visualize the bubble caption that might go with each picture.  It’s the classic infant/toddler high chair high jinks experiment that’s part science and part entertainment.  You could say that he’s visually exploring gravity, which he most certainly is, and that the more I pick up the Cheerios that he drops on the floor, the more inclined he is to continue doing it to see who wins the endurance contest.  Most certainly there are ways to contain the experiment, such as this mom’s ingenious Cheerio Containment Bucket, but sometimes it’s just too much fun as a grandparent to indulge 10 month-old Ethan in his open-ended Infant Vision Laboratory.

- Leonard J. Press, O.D., FCOVD, FAAO

Twice-Exceptional

 

What comes to mind when you read the phrase, bully pulpit?  Some interpret it as a pejorative term, signifying the abuse of a platform, but the term was originally coined by President Teddy Roosevelt for using his office opportunistically for a very noble cause.  The irony in this comes to mind for one of our vision therapists, Jennifer Ehrentraut, for whom speaking out about New Jersey’s new anti-bullying law has become a passion.

Though the law has garnered statewide attention, it is a national issue.  In fact, it is an international issue, and a timeless one that has been a social factor for as long as societies have existed.  For Jen this is personal.  She is, by nature, soft-spoken and unassuming.  Yet her compassion makes her a natural fit to work hotlines for kids to call when they need someone to talk to.

I made the point the other day that our vision therapy staff is a talented group for whom thinking and stepping outside the box is an everyday occurrence, and this can be said for the practices of many of my colleagues.  We’re very proud of Jen for her courage in speaking out, and for telling all who’ll listen that this is a natural extension of her day-to-day work as an optomeric vision therapist helping people who in many instances have been patronized, marginalized, or trivialized by our educational and health-care systems.

Bright Not Broken is an exceptional book about exceptional children.  Twice-exceptional, or 2e, is the term used to describe many gifted children and Tyler Clementi, Jen’s cousin, was certainly gifted.  Many of these children don’t “fit in” and almost by definition due to their social traits they are susceptible to bullying and victimization while in school (p. 66). Unfortunately, with cyberbullying, the abuse to which these individuals are subjected does not necessarily end during the school day.  As the subtitle of the book indicates, these bright kids are stuck.   Aside from the specific tools that we give them clinically, we help these individuals through our compassion.  We’ve discussed this before in terms of critical empathy and mindfulness as crucial attributes of an effective therapist.  In this regard the effective therapist might be considered as twice-exceptional.  To the extent this is true, she serves as a role model for the gifted children she works with.  And children are discerning enough to know the real thing when they see it.

- Leonard J. Press, O.D., FCOVD, FAAO

 

 

Delayed Visual Maturation: A Visual Inattention Problem

I’ve been fortunate now, on two consecutive days, to get a heads up from sharp New Jersey primary care O.D. colleagues who keep an eye out for articles of common interest.  Yesterday it was new evidence based support for amblyopia therapy.

Today Dr. Charlie Fitzpatrick sent the link to an article from Expert Review in Ophthalmology on delayed visual maturation (DVM) as a problem in visual inattention.  In a nutshell, the article describes what those of us in Pediatric Optometry have dealt with as cortical blindness or cortical visual impairment (CVI). There is no apparent reason why these infants don’t respond visually.  That is, they generally respond normally to retinal tests such as ERG, subcortical tests such as OKN, and visual cortical measures such as VEP.  The distinction might be made that DVM is a form of CVI that resolves over time.

This article notes that the defining characteristic of DVM is an inability to fixate and follow a target.  The authors do a nice job subdividing DVM into four categories:

Type 1 DVM: Visual fixation, attention, and tracking eventually develop, but these infants are at higher risk for learning disabilities and attention disorders.

Type II DVM: Resolution of visual delay is often slower and more incomplete than in Type I.  There is often seizure activity associated with cognitive disorders, and visual responses often improve as seizures are treated.  Hypoxia to the extrageniculostriate visual system is often involved.

Type III DVM: Infants in this category have associated congenital nystagmus and albinism.  Their vision starts to improve later, and to a lesser degree.

Type IV DVM: Infants in this classification include severe ocular disorders such as retinal dystrophies, optic nerve hypoplasia, and macular coloboma.

There are several interesting implications from this review:

1) DVM is a symptom common to a variety of neurologic abnormalities in which efferent and afferent visual pathways are largely intact.  The symptom itself is a problem of visual inattention that exists on a continuum in terms the time course of delayed development, and the degree to which visual attention is ultimately developed.

2) Top-down visual attention derives from multiple areas outside of the visual cortex, consisting primarily of an anterior and posterior network.  The anterior network includes he frontal and supplemental eye fields of the frontal cortex, as well globus pallidus, caudate, putamen, parts of the thalamus.  The posterior system consists of parietal cortex, superior colliculus, and pulvinar.  It is likely that visual inattention involves delayed maturation of, or damage to this network.

3) We are used to thinking of the concept of visual neglect in terms of acquired brain injury that results in inattention to a select region of the visual field.  A better understanding of DVM as total visual neglect, and its resolution, in those cases where fixation and following ultimately develops, may provide a better understanding of visual inattention with other populations.

An ophthalmologist who functions more like a developmental/behavioral optometrist, Lea Hyvarinen, has material that complements this article.  Here is a nice lecture she gave in San Francisco in 2003 on the assessment of CVI, and Dr. Hyvarinen has also presented on the trans-disciplinary nature of assessment.  A conference in which she participated last year highlighted these complexities.  Of particular interest will be her blog, Dr. Lea & Children’s Vision.

- Leonard J. Press, O.D., FCOVD, FAAO

 

Oh Yes, Doctor, I Forgot To Mention That …

I’ll cut to the chase on Surbhi’s case, a sweet five year old, and tell you that she was one “DTE”, or Difficult to Examine child.  Surbhi’s family used to live in the U.S., but relocated to the Philippines due to dad’s job.  Mother found me through a nystagmus support group, and scheduled an appointment to coincide with a visit back in the States.

Surbhi habitually rotates her head, usually to the right side but sometimes leftward.  She has a constant esotropia of the right eye, approximately 45 prism diopters, so it’s a big strabismus, and has asymmetric OKN.  Her mother reported that Surbhi’s nystagmus was worse when she was younger, and has decreased.  She has glasses prescribed for myopia (-4.50 sph OU).  Her visual acuity was 20/80 with the left eye and 20/200 with the right eye.  Her mother had been instructed to patch her left eye and when she did, Surbhi rotated and tilted her head significantly more than when both eyes were open.

Surbhi loves to read, but fatigues very quickly.  Her glasses have been broken, and mother reports that Surbhi seems to prefer not wearing them when she is engaged in near activities.  I scoped an additional -1.00 which improved her slightly to 20/70 isolated letters at distance.  Her doctors both in the U.S. and the Philippines had advised that there was no treatment other than patching or surgery.

Having no prior records, I dilated Surbhi and was in for a surprise.  Looking at her fundus was like playing a video game, with her fixation all over the place, but the signs of ROP in the right eye were unmistakable.  I took the retinal photo that you see above, joystick skills coming in handy again at hitting a moving target, and showed mother the photo.  “Was Surbhi a premie who got supplemental oxygen?”  I asked.  “Oh, yes, I forogot to mention that”,  her mother noted a bit sheepishly.  “They told me that something was different about the back of the right eye compared to the left eye, but that she was difficult to examine and they would have to do it under anesthesia.  But I never got around to it.”

I advised Surbhi’s mother that strabismus surgery would have to be weighed carefully, and that the dragging of her fovea in the right eye plays a significant role in her viewing pattern when both eyes are open as well as when the left eye is patched.  Strabismus surgery may actually create more problems than it solves.  Surbhi may also have nystagmus blockage esotropia, since by history the increase in her angle occurred with the reported decrease in nystagmus.   Her near visual performance may be enhanced when when she removes her glasses because it provides her with magnification.  I’m working on locating a doctor in the Philippines or Hong Kong who can combine all the components of developmental vision to help Surbhi maximize her visual potential.

- Leonard J. Press, O.D., FCOVD, FAA

Practical Wisdom – Part 4: Pattern Recognition

In every situation that we encounter, we find both similarities and differences to situations we have encountered before.  Is it the similarity or the difference that will prove to be important?  And in helping us make decisions, which similarities and differences will weight more heavily? This is more than just learning from experience.  To be wise, say Schwartz and Sharpe, requires cognitive and perceptual machinery that picks up on similarities without being blind to differences.  When we recognize patterns, our ability to see similarities and differences often exceeds our ability to describe them in words.  “She looks just like her sister”, we say.  We don’t really mean just like; yet we’d be hard-pressed to say exactly how they look alike and what makes them look different.

The fact that many of the patterns we recognize are not easily described by language reminds us that rules are often stated as linguistic entities.  But if we over-rely on rules we desensitize ourselves to information and understanding that we have that cannot (easily) be put into words.  Paradoxically, those children who excel at pattern recognition with “fuzzy boundaries” are the ones who don’t do as well in a learning environment with rigid boundaries such as school, yet are the ones who often excel in social and business situations where nuanced judgments trump rigid rules.  They may be the ones who receive good grades from sensitive teachers who recognize their strengths, yet do poorly on standardized tests with black and white boundaries.  Oft times through vision therapy we can arrange conditions so that children can attain a better balance between these disparate elements of pattern recognition.  Even if the outcome of vision therapy doesn’t have an immediate impact on a child’s grades because of their educational circumstances, we find find ourselves saying to parents that these children will do well once they survive school.

Think about something ostensibly simple like parquetry blocks.  We know the standard way of doing them, proceeding in “concrete” stages in workbooks where the entire outline of the block are presented, toward levels where the inner lines are missing and the patient must visualize the boundaries.  We then proceed to reproducing the pattern in more “abstract’ fashion, where the patient reproduces the pattern off the page, and then ultimately with the mental manipulation of rotating the pattern through quarter turns.  Or what it would look like if they viewed the pattern from underneath.

Essentially what we’re “training” with Parquetry Blocks is a progression from basic to advanced pattern recognition.  At the outset it may be a big victory for a patient to match a shape.  As we fine tune visual discrimination, the patient is able to make comparisons and use that to plan visual space by narrowing down the possibilities before arbitrarily taking a block and attempting to put it into the pattern.

Yet in a powerful sense we’re also helping the individual develop a sense of empathy, aren’t we.  Particularly when we ask the patient to visualize what the pattern would look like if they were sitting opposite to their current position (rotated 180 degrees), we’re literally asking them to adopt the visual point of view of someone else.  You can sometimes facilitate this by sitting opposite to the patient, rather than alongside them.

This has broad implications in the learning environment.  The interrelationship of objects in pure pattern recognition subjects such as geometry.  The ability to visualize what an author had in mind.  What is the teacher asking or looking for in a math word problem where language interacts with vision?

Nor should we shortchange  the life skill applications of empathic pattern recognition.  Take road rage for instance.  Its origin is often the inability to quickly recognize, or even reflect on why a person would literally look at the same circumstance from a different visual angle, point of view, or visual judgment.  To be sure, there are many factors involved in road rage.  But the inability or unwillingness to put yourself in another person’s visual perspective is a huge factor.  In the next part, we’ll take a look at some of the neural architecture of pattern recognition.

- Leonard J. Press, O.D., FCOVD, FAAO

Update on Vision and Autism Spectrum Disorder

As far as I know, the first published article on Vision and Autism in a refereed journal was authored by Dr. John Streff, and incorporated the application of yoked prisms.  The article is reprinted in the current issue of OVD which is a tribute to Dr. John Streff.

There is a major review of Vision in ASD in a 2009 issue of Vision Research that will be well worth your time to read.

Vision therapy should be part and parcel of early intervention services.  Here is an article that alludes to this.

An informative interview with one of the optometric pioneers in the treat of ASD, Dr. Melvin Kaplan, is available here.

Dr. Jeffrey Getzell is featured in an article on vision and autism that can be found here.

- Leonard J. Press, O.D., FCOVD, FAAO

Vision and “The Dys-es”

Dyspraxia doesn’t attract as much attention as a clinical entity in our practices in the U.S. as dyslexia does, but it has garnered  significant attention in the U.K.  In short, dyspraxia is difficulty with motor control.  We tend to think of it more in terms of motor skills involving posture, balance and larger muscle movement.  This is in contrast with dysgraphia, which is held to involve fine motor skills as in handwriting.  In the U.S., many professionals refer to dysgraphia as DCD or developmental coordination disorder.

Keith Holland, a highly regarded optometric colleague of ours in England, has a nice intro video on a website called dysTalk that overviews “the dys-es” of dyslexia, dyspraxia, dysgraphia, and dyscalculia.

Mark Menezes, an optometrist in the U.K. who I don’t know personally, has a concise discussion about vision training and dyspraxia.   He notes that VT can be synergistic with OT in certain cases of dyspraxia.  Here is a nice monograph from a pediatric therapy group in Pennsylvania on sensory integration as related to praxis, with subtypes of dyspraxia.  You’ll note the nice attention give to the role of vision in the motor process.

Lisa Kurtz, MEd, OTR/L, FAOTA is an occupational therapist who has written several nice paperbacks that draw attention to the role of developmental and behavioral optometry to the full spectrum of “the dys-es”.  In her book on Understanding Motor Skills in Children with Dyspraxia, ADHD, Autism, and Other Learning Disabilities, she notes (pp. 25-27) the crucial role of functional visual skills in motor coordination and development, and the importance of seeking a developmental-behavioral optometrist with specialized training in this area.  Here is the summary of an excellent case report illustrative of improvements in performance following optometric vision therapy for a child with dyspraxia.

Geoff Platt, a Ph.D. in the U.K., has written a concise and informative book about dyspraxia.  In an overview of professionals who are involved in the evaluation of children with developmental motor concerns, he cites Developmental or behavioural optometrist, and suggests that a qualified practitioner is one who has completed postgraduate examination by the American Academy of Optometry or the College of Optometrists in Vision Development.  Parenthetically, the increased emphasis in developmental optometry on the role of primitive reflexes relates directly to vision and dyspraxia.  Nice to see authorities in fields outside ours guiding the public toward a greater understanding of our role in “the dys-es”.

- Leonard J. Press, O.D., FCOVD, FAAO