Harold Koller’s vision for his pediatric ophthalmology colleagues to diagnose visual processing problems, or at least to collaborate with other professionals in the field did not sustain the momentum it had in 2001. The “Why Can’t EYE Learn?” AAP Seminar, which held such promise, was never convened again. Dr. Koller’s last writing about the subject was a review article for Current Opinion in Ophthalmology on Visual Processing and Learning Disorders in 2012.
Several years before he passed away in 2014, Dr. Paul Romano confided to me that he felt there were pediatric ophthalmologists who wanted to collaborate with optometrists regarding visual processing, and he found the optometric model as I and my colleagues articulated it compelling, but would never admit this “in public” because the negativism about vision therapy among his colleagues was too entrenched. An ophthalmologist who came out of the closet in support of vision therapy risked being ostracized by his or her peers. There are occasional glimmers of hope, such as this recent graphic from a piece in Review of Ophthalmology this summer on How to Reach Kids Who Need Your Help.
Perhaps the presentation most prescient at Why Can’t EYE Learn? was delivered by Ricardo C. Carrasco, PhD, OTR/L, FAOTA, entitled: “Visuopraxis: How It Fits within Sensory Integration Theory and Human Occupation”. It was principally a review of the clinical relevance of the work by A. Jean Aryes, a practicing occupational therapist who also earned a Ph.D. in educational psychology from USC and completed a post-doctoral traineeship in Brain Research at UCLA. Because his handout at the seminar was never published, I’d like to leave you with some key excerpts that rekindled my enthusiasm at the time for collaborating with occupational therapy:
“The Ayres’ orientation to visual perception differed in the viewpoint that visual perception was an isolated problem. She postulated that visual perception difficulties often accompanied learning and behavioral problems. Again, her view had its origins in the scientific literature, and she hypothesized that there is a necessary interactive, albeit sequential development of brainstem and cortical processing. This postulate was based on Trevarthen’s hypothesis of a dual mode of vision: focal and ambient. Focal vision perceives stimuli that are near and immediate to the organism; it requires precise attention to details of orientation and form and is a function of the cortex. As the word implies, ambient vision perceives the surrounding environment; its development occurs with postural and locomotion abilities which in contrast to cortical mediation of focus vision, are mediated at the brainstem level.
Through various postural ocular experiences with gravity and environmental space during the development of locomotion, the child develops a spatial map produced by the brainstem. The ability of the cortex to activate focal vision is dependent on the development of this spatial map. It is important therefore, to develop adequate postural ocular reactions for visual form and space perception to develop … Without these experiences, the brainstem is not able to produce the partial map for visual form and space demands to perceive the orientation of letters on a page, or the orientation and position of different shaped blocks as in the Constructional Praxis test of the SIPT (Ayres’ Sensory Integration and Praxis Test). According to Ayres, some expressions of form and space perception, or visuopraxis are dependent on postural ocular reactions.”
Although the following graphic was not supplied by Dr. Carrasco in his handout (it comes from a Ph.D. thesis by Shelley Mulligan at University of Washington), it neatly summarizes praxis issues.
Dr. Carrasco continues:
“Classical sensory integration procedures provide experiences through which a subject is challenged by the bombardment of vestibular, proprioceptive, tactile, and visual input aimed at eliciting an adaptive response. The inner drive of a child is tapped by providing the bombardment at a level that the therapist determines as just the right challenge… In a preferred prone position while on a swing, for example, movement allows for the stimulation of the vestibular apparati, but also of the neck proprioceptors and extraocular muscles to maintain the position of the trunk and neck and to maintain the eyes in a position of function… Additionally, the compensatory movements to right the head and the eyes in concert with the activity, put the neck and extraocular proprioceptors to work in unfamiliar positions and movements. This novelty adds to the repertoire of neuronal models for later use.
Dr. Carrasco concluded his presentation by noting the following:
Use of scooter boards, especially when the child is prone, actively pumping, going up and down a ramp, and catching or throwing a ball incorporate the same demands and results mentioned above. T-stools, or stools with only one leg when used during an eye-hand activity, again bombard the child with simultaneous multisensory input. Similar activities, albeit adapted to an extent, can be implemented at home, in the classroom or in a developmental optometrist or ophthalmologist’s practice.”