Seven year-old James likes an audience and is, shall we say, rather loquacious.  Cute no doubt, he can also be a source of distraction to himself and others in the room.  So instead of clowning around to attract the attention of patients and staff, his mother came up with the idea of creating a paper bag audience.  This way James always felt that he had onlookers.  It was then simply up to Jen to keep James gainfully on task during his vision therapy session.  The best results come when we adapt the therapy environment to the individual child.

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

A great article in the New York Times supports this notion.  There are many implications in the effect of protein deposition in the lens, and how it alters incoming light.  Increasingly we find that vision therapy populations in our practices are no longer just the young.  How often do we consider the influence of early “cataract” development on the performance issues of adult patients other than changes in visual acuity or contrast sensitivity?

The notion of ALD is a more holistic one, particularly considering the influence of the lens in altering circadian rhythms.  It has long intrigued me that the denaturing of the cyrstalline lens with age results in protein deposition of prions – the same beta amyloid protein buildup that occurs in the brain of Alzheimer’s patients.  We are used to making the point that the composition and function of the retina qualifies it as brain tissue.  The new way of  looking at the crystalline lens suggests that it also participates in visual thinking.

As you read the article in the New York Times about the eye’s lens, all kinds of connections may spring to mind including the implications of color effects and the altering of light wavelengths on the retina’s SCN and circadian rhythms.  This extends to considerations about the nature and effects of implanted IOLs for the treatment of ALD.  Yet another reminder of the pervasive nature of vision.

In the Knowledge Center area for parents on vision health information, there is a nice article on myths and misconceptions about vision therapy.  There is another nice article about the relationship between Attention Deficit Disorder (ADD) and vision which has this headline:

ADD or just can’t see? The restless child in the classroom may have a vision problem.

… and begins as follows:

Is your child or student acting restless in class? Making careless mistakes on schoolwork? Not listening to the lecture and rubbing his/her eyes? Don’t reach for the Ritalin quite yet. Instead, you might want to first schedule a visit to the optometrist.

At the end of each of the Knowledge Center pieces there is a link to visionhelp.com.

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

With fluorescein dye, you can see folds in the conjunctiva appearing as little dark waves on the white part of the eye.  The eye above has minimal stain.  Contrast this with the appearance of the eye below, which has considerably more staining and radial as well as lid parallel conjunctival folds.

The lips are covered with a mucous membrane lining similar to the bulbar conjunctiva.  One can have a beautiful looking cornea, but a bone dry sclera that contributes to a sense of ocular fatigue or discomfort and invariably shows conjunctival folds and staining patterns.  Everyone develops modest lid parallel conjunctival folds with age.  It’s like sagging skin or furrows in your brow.  But the dense staining pattern, particularly with radial folds, means the conjunctival lining is excessively evaporated – much as one experiences with chapped lips.

Patients who have excessive dryness around the eye, excema, or rosacea are particularly prone to conjunctival folds.  Topical lubricant in the form of gel, and sometimes ointment, are the analog of Chapstick.  Omega-3-fatty acids in the from of fish oil supplementation can aid dryness from within to combat surface evaporation.  And of course, drinking water to promote hydration aids both conditions from the inside out.

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

My buddy, Dr. James Aversa, does the best Rodney Dangerfield impression around.  He’s also a great example of a primary eyecare doc who “gets  it”.  I love when our front desk buzzes me that Jim’s on the line to discuss a patient.  Like Rodney, Jimmy appreciates a good crowd, and like me he appreciates clinical challenges.

In Puggy Part 4 we talked briefy about amblyopic crowding, and vision science particularly during the past decade has come to realize how significant a model amblyopia is for understanding visual function and rehabilitation.  Like Rodney, at one time the subject of amblyopia got little respect.  After all, the patient still seemed to function perfectly fine with “the good eye”.  No big deal – just patch or otherwise treat the good eye well enough so that it’d be a decent spare tire instead of a toy tire in case anything happened to the good eye.

Zahra Hussain is a vision scientist who did her graduate work at McMaster University in Hamilton, ON (Canada).  Zahra and her colleagues in the UK have just published a great paper in The Journal of Neuroscience: Perceptual Learning Reduces Crowding in Amblyopia and in the Normal Periphery.   You can download it from her list of publications.  McMaster U. is the mastermind of a group called Brain CPR (Cortical Plasticity Revisited).  At their most recent meeting in Montreal in June, they posed the following framing questions:

• What evidence is there for critical periods during development when the organism is more sensitive to environmental input than at other times?

•  What determines the timing of the onset and end of such critical periods?

• What evidence is there for plasticity in the mature organism?
• What is the nature of that plasticity?

• How does it differ from earlier plasticity?

• What do you foresee as the exciting developments in your field in the next 5 years that relate to issues of plasticity?

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

Okay, now for some real fun, have you tried using Draw-A-Stickman to help with visual-motor planning and all the good stuff that goes with it in the context of building a story line?  Yowser, what great fun!  But be careful.  It can be addicting!  Begin here.

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

Interviews can be stressful, and I was impressed with the thought that Tonya had given to why she was applying to our Residency program.  Although no one should be as open as the gentleman above, Tonya was refreshingly forthcoming in noting that she had made application to several other private practice residencies, and two institutional residencies.  But what she told me next almost floored me.  She had decided not to interview at one of the institutions, because of that College of Optometry’s response to her inquiry.  In her cover letter she indicated interest in, among other things, vision-based learning problems and how vision influenced behavior and development.  The reply that she got was that she should seriously consider whether this program was a good fit because, essentially, they “don’t believe in that stuff”.

It was almost inconceivable to me that a College of Optometry faculty member would write that to an applicant.  To be fair to that program, I’ve not yet seen it in writing.  But is it possible?  Absolutely, and I found out why over the weekend.  I participate in an online forum regarding dyslexia.  Last night a dyslexia researcher who trivializes the role of vision cited an article in defense of her position.  It was published in Perspectives on Language and Literacy, a quarterly publication of the International Dyslexia Association, Winter edition 2011, co-authored by an optometrist from — you guessed it — the same College of Optometry that told Tonya they wouldn’t be a good fit for her Residency interests.

Here is what that article concluded:

“Given the evidence in this article and other reviews (American Academy of Pediatrics, 2009; Barrett, 2009), children with academic problems should be referred for vision exams using the same criteria as any other child. Visual acuity is critical for supporting reading, and people need to be able to see print sharply, clearly, and comfortably. However, routine screening for ‘vision-related learning problems’ is not warranted and would not be expected to have a major impact on the reading performance of children and adults with well-defined reading disabilities …. The fact that vision therapies (and therapies based on visual information processing) continue to proliferate despite decades of research reflects in part the degree to which parents are desperate to remediate reading problems.”

One might say it’s disappointing to see a College of Optometry faculty member put her name on an article that regurgitates the anti-VT bias of the American Academy of Pediatrics.  Indeed, as Dr. Fortenbacher and I have pointed out, the Section on Ophthalmology of the AAP doesn’t even follow the guidelines of the CITT study that office-based vision therapy is preferable to home based VT.  Nor, by the way, does this College of Optometry offer any office-based vision therapy, but that is a subject for another day.  On this day I will encourage Tonya to continue her vision quest.  Irrespective of where she does her Residency, I am confident that she will travel far on the path that Dr. Monroe “Puggy” Farmer put her on at age 6.  She is already a step ahead of the faculty member at a College of Optometry who dismissed the AOA’s Clinical Practice Guidelines on Care of the Patient with Learning Related Vision Problems out of hand.  She can think outside the bag.

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

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

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