We make a big fuss in vision therapy that the power of most activities lies not in the material tools of the procedure, but in the awareness developed about how one’s visual system is functioning – and how to influence it. The patient’s self-discovery then becomes part of a therapist’s conceptual toolkit, a catalogue of sorts to be shared with others who get stuck while traveling the therapeutic path in their own special way.
As a classic example, consider the peripheral awareness chart. Whether Lora’s card or a similar array of letters, the chart is an entree to developing the skill of looking straight ahead while simultaneously processing what is happening in the full volume of space that surrounds you. The magic isn’t in the chart or its letters; it’s in the looking and the feeling. After practicing this skill under controlled conditions, the patient has to then transfer it into the real world while seated in the classroom, walking a mall, or if older – when driving. This type of self-awareness, or self-acutalization can be very challenging for a therapist to guide. What if a patient “isn’t getting it”? How do we shape these “aha moments”?
Sometimes, if we’re fortunate enough, we set the stage for self-discovery and take advantage of the patient’s natural intelligence. This was the case with Liam, a sophisticated 10 year-old born in Hong Kong with characteristic intellectual modesty and the linguistic flair of a Brit. I don’t know that his family’s globetrotting contributed to his intermittent exotropia of the divergence excess kind, but as I was seeing him for his final progress evaluation yesterday prior to completing office-based therapy I wanted to make sure that he was secure doing the maintenance activities agreed upon while he was on holiday.
Although computer programs are nice, and Liam had mastered his HTS, they provide little balance required in the flexibility between near and far efficient binocular localization and control – particularly when there is no distance projection possible. To achieve and practice this balance, one of our favorite portable activities is Life Savers, toggling between orthopic and chiascopic fusion. I asked Liam which way felt easier to control where his eyes where looking, ahead of the plane or behind the plane? He noted that looking nearer was easier than looking far, and I asked him whether he was using a pointer stick to help guide his eyes when looking closer or further. “That never really worked for me” he replied. Liam patiently explained that it was simple to converge his eyes, but to diverge effectively and maintain the stereo effect on base-in he found it helpful to do this:
Just then I was thinking about how clever one of our staff was to suggest to Liam that he waves his hand to the side to prompt a kinesthetic from of peripheral awareness while trying to diverge effectively. But then he blew me away when I asked him if he recalled who suggested that, and he answered very casually: “I thought of it myself”. What?!?! Ingenious !?!? Liam then explained that he came up with the idea after reading Jeff Cooper’s paper on Panoramic Viewing and Divergence Excess. Of course I just made that up to see if you were paying attention, but the part about Liam’s self-discovery was entirely true. I asked him if he minded me taking his picture while demonstrating what he was doing, and although his mother was perfectly fine granting permission, Liam demurred. He has a maturity and sensitivity well beyond his years, so I respected his wishes in leaving his face out of the photo. I’m not even sure I’ll remember Liam’s face years from now, but I will always remember his mind.
At our weekly case conference yesterday, all of the therapists nodded with smiles on their faces when we discussed Liam – and I related what had happened. We agreed that this could be inspirational for other 10 year-olds struggling to come up with their own sense of visual balance and control. Liam’s story of self-discovery is now a part of our therapy lexicon.