Podcast with Lindsey Biel Touts Developmental Optometry

You may be aware that I collaborated on a book Against the Odds, with Dana Latter – a mom from the U.K.   Dana hosts a free podcast called Sensory Change.

Dana Latter Sensory Change

Dana’s most recent podcast features the pediatric occupational therapist Lindsey Biel, OTR/L, who is a wonderful friend to developmental optometry.  I previously blogged about her first book, Raising a Sensory Smart Child, as well as her follow up book, Sensory Processing Challenges, both of which inform the public about a variety of visual issues and encourages parents to consult with developmental optometrists.

Lindsey Biel

Dana’s podcast with Lindsey is 38 minutes in length.  At the 11:35 mark she introduces visual issues, elaborating on how they go well beyond the need for glasses related to eyesight issues.  She notes that potential problems with vision extends to issues such as fusion between the two eyes, tracking accurately when reading to keep print stable, following moving objects, keeping the visual field stable while moving, figure-ground, contrast sensitivity, and light sensitivity.

At the 29:30 mark, Lindsey says: “In terms of visual processing, you must get to a developmental optometrist, who can assess your child’s vision and visual processing skills.  Your resource for that is covd.org, you plug in your zip code, and you’ll get a list of developmental optometrists close to you.  That stands for the College of Optometrists in Vision Development.  So you want to make sure there’s nothing going on with the visual system.  At least 50% of the kids that I evaluate and work with have an undiagnosed vision problem that can be corrected … Now you may think that well, my pediatrician checks out my child’s vision and hearing whenever we go.  These are screenings.  These are not evaluations.  So it’s very important to have children’s vision actually evaluated.”

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Other podcasts that Dana has conducted that relate directly to vision are the ones with Geoff Shayler and Susanna Zayarsky, and there are several others that will likely be of interest including the one on quantum reflex integration.  Be sure to subscribe to the Sensory Change podcast!

 

 

 

Subclinical Ocular Torticollis: A Tilt in Perspective

The subclinical stage of any entity is considered to be a presentation that escapes the more commonly applied clinical tests. Of course this is accentuated when not looking for something, as the famous clinical dictum reminds us: we miss more by not looking than by not seeing. A brief piece in the Australian Journal of General Practitioners last year suggested that a tilt in perspective is sometimes needed when looking at the significance of ocular torticollis.

The article cites a case of long-standing superior oblique palsy in a 95 year-old patient, and reviews application of the Parks-Bielschowsky Three Step Method to isolate paretic muscles, yet notes this this test only has a sensitivity of 70%. This lack of sensitivity, owing to the spread of comitance over time, makes the detection of subtle ocular postural skews more challenging. As the article notes, the treatment of choice in some of these instances may be “refractory prisms”. We blogged about this a few years ago regarding a more sensitive sensory variant of the Three Step Test, and more recently reviewed the art of prescribing prism, particularly for subtle imbalances with vertical vectors.

Whenever you see a child with a subtle head tilt in a consistent direction, it is prudent to assume that there is a vertical or cyclovertical imbalance until proven otherwise. The easiest way to confirm that in free space is to use a red maddox rod/Risley prism together with a fixation light.

With the zero line perfectly perpendicular to the nose, when the head is positioned to eliminate the habitual heat tilt, the patient will observe that the line is slanted. The degrees of torque that you need to angle the Maddox rod before the slant is neutralized gives you a feel for the amount of cyclophoria. While this can be done a trial frame with a loose Maddox rod from your trial set so that the exact number of degrees can be measured, I prefer to do it this way in free space for several reasons. One is that the trial frame is clunky and makes controlling head position more difficult, particularly with younger children. Another is that it makes it easier to measure the amount of residual vertical phoria in conjunction when the cyclorotation is neutralized, and vice-versa. Whenever there is a subtle, but clinically significant vertical or cyclovertical imbalance, go back into the history and ask about the parent’s recollection of torticollis being present in infancy. Due to the spotlight that OTs and PTs place on this in early intervention, parents often recollect this. While that won’t likely influence what you prescribe, it can provide a clue about underlying etiology.

The clinical report that I cited above from the Australian Journal of General Practice provided reference to an interesting review on torticollis from the Journal of Child Neurology. It notes that torticollis can be seen at all ages, from newborns to adults, and can be congenital or postnatally acquired. Congenital primary torticollis usually occurs when there is breech presentation, or trauma during birth, impacting the sternocleidomastoid muscle. Acquired torticollis usually occurs as a result of trauma. This is an entity to bear in mind when there is a history of mTBI, and added to the list of subtle but clinically significant conditions that might otherwise escape detection.

The review in the Journal of Child Neurology by Tomczak and Rosman offers a new classification of torticollis based on dynamic qualities and pathogenesis. Torticollis can be classified as either nonparoxysmal (nondynamic) or paroxysmal (dynamic). Ocular torticollis, in which the head tilt and chin or face turn is due primarily to EOM or visual imbalance, and secondarily to adaptive sternocleidomastoid contracture, is classified as nonparoxysmal. An example of paroxysmal would be primary cervical misalignment contributing secondarily to ocular adaptations involving a vertical or cyclovertical vector. The term paroxysmal may be familiar to you from the condition of BPPV, or Benign Paroxysmal Postional Vertigo. Particularly fascinating is that included in Tomczak and Rosman’s classification of paroxysmal torticollis is an etiology of conversion disorder.

To finish on a lighter note, not all head tilts signify primary or secondary ocular torticollis. In some cases a head tilt is adopted consciously or subconsciously without a functional adaptive purpose. But don’t take my word for it. Readers of Best Life Online learn that tilting the head comes in at #22 on the list of 23 subtle ways to make yourself more attractive. And #23 on the list? …. Smile more 🙂

Insights From ISA/AAPOS 2018

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Held in March of this year in Washington, D.C., the 2018 annual meeting of the International Strabismological Association and the American Association for Pediatric Ophthalmology and Strabismus included a variety of lectures, papers, and posters of  interest.

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Here are some highlights (with active hyperlinks preceding each title):

  • The Bielschowsky Lecture – Accommodation and Convergence: Ratios, Linkages, Styles, and Mental Somersaults
  • Paper 3: Impaired Motion Perception in the Fellow Eye of Amblyopic Children is Related to Abnormal Binocular Function
  • Paper 7: Effects of Immersive Virtual Reality Viewing on Young Children: Visuomotor Function, Postural Stability and Visually-Induced Motion Sickness
  • Workshop 17: Reading Difficulties and the Pediatric Ophthalmologist
  • Poster 33: Re-Reading the Same Line in Intermittent Exotropia is Related to the Saccadic Disconjugacy.  (Difficulty of reading is a typical symptom of intermittent exotropia (IXT) and is coupled with re-reading the same line.)
  • Poster 57: Attitudes Concerning Cortical Visual Impairment Among Pediatric Ophthalmologists and Teachers of the Visually Impaired
  • Poster 161: Optic Nerve Morphology in Normal Children: A Validation Study
  • Poster 181: Baltimore Reading and Eye Disease Study (BREDS): Two-Year Results on Compliance with Eyeglass Usage
  • Poster 214: What is Amblyopia? A Primary Care Physician’s Perspective
  • Poster 217: Boston Amblyopia Study 1: Complete Resolution of Subthreshold Amblyopia with Standard Clinical Treatment
  • Poster 218: Boston Amblyopia Study 2: Treatment Outcomes in Patients with Asymmetric, Bilateral Amblyopia
  • Poster 227: Influence of Orthokeratology Lens on Axial length Elongation and Myopic Progression in Childhood Myopia
  • Poster 228: A Three Year Follow-Up Study of Atropine Treatment for Progressive Myopia in Europeans

The Vision Component of Sensory Integration

 

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Having taken time off in 2016 to pursue other ventures, it is re-energizing to review and prepare new material for a seminar regarding the totality of vision.  I’ll be re-booting the seminar on visual processing and therapy on Clearwater Beach on March 6, and on March 13 in Tampa (that one as a live webcast as well).  The seminars are oriented primarily toward OTs, PTs, SLPs, and Educators, and my renewed focus will be on vision within the context of sensory integration.  This draws the most attention related to children on the Autistic Spectrum, and  Patty Lemer’s material has been influential in this regard.

As you know from reading this blog, I’m particularly drawn to advocacy on behalf of our services by notable non-optometric authors such as Sue Barry, Lindsey Biel, Katie Johnson, Fernette and Brock Eide, Robin and Jillian Benoit and Wendy Rosen.  Of course I’m fond of citing optometric authors such as Stan Appelbaum, Laurie Chaikin, and Lynn Hellerstein regarding vision and sensory integration as well, but what makes non-optometric authors appealing as well is that they have no vested interest in promoting the role of optometric intervention.  In that regard what they have to say is particularly resonant to much of the audience attending these PESI seminars.

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I’ll be resurrecting a nice resource you can add to your list of non-optometric advocates for our therapeutic services co-authored by Ellen Notbohm and Veronica Zysk.  Ellen is the mother of two children on the Autistic Spectrum, and Veronica is former ED of the Autism Society of America and former Managing Editor of  Autism Asperger’s Digest.

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The first 55 pages of the book are devoted to sensory integration and, on pages 29 and 30 you’ll find the following under Vision and seeing:

“What do toe walking, headaches, poor handwriting, and weak organizational skills have in common?  They’re all signs of a visual processing problem in a child.  Just as communication involves more than words, vision is more than 20/20 eyesight.  Vision is the learned developmental process of giving meaning to what we see, and it emerges from the integration of sensory input from the eyes and and the body to the brain.  Vision is conceptual and perceptual, and through it we learn to attend to, organize, and understand our world (Lemer 2009).

It is common in individuals on the autism spectrum that vision – not eyesight – is impaired, sometimes in multiple ways.  Warning signs of visual dysfunction include:

  • Has difficulty  making eye contact
  • Tilts head when observing closely
  • Squints, closes an eye, covers one eye or widens eyes
  • Experiences headaches, nausea, and/or dizziness
  • Moves head and/or body or uses finger to track words while reading
  • Frequently loses his place while reading, or can’t find items in his desk, locker, or backpack
  • Is fascinated by lights, spinning objects, shadows, or patterns
  • Looks through hands
  • Flaps hands, flicks objects in front of eyes
  • Looks at objects sideways, closely, or with quick glances
  • Becomes confused at changes in flooring or stairways
  • Toe walks
  • Is excessively clumsy
  • Pushes or rubs eyes repeatedly
  • Bumps into objects or touches walls while moving through space
  • Cannot spot errors in own work; does not notice details in general
  • Has messy or poor handwriting; colors outside boundary lines
  • Has trouble copying material from the chalkboard

If you suspect your child may have visual issues, find a developmental optometrist (enter your zip code at Oepf.org or Covd.org for referrals) and ask for a thorough vision assessment.  These organizations certify and educate optometrists to work with individuals on the autism spectrum.”

 

The Depths of the Brain

I appreciate that the allure of a small local bookseller for some may be the recommendations of its clerks or owners.  Yet for others, myself included, the opportunity to browse provides a sense of self-discovery that can be satisfying in its own right.  I say this bearing in mind that chancing upon hidden treasure is only possible when owners of small bookstores (like Rita Maggio) speculate on a gem such as Helmut Dubiel’s phenomenal memoir, Deep In The Brain, a slim 129 page volume nestled without fanfare between much heftier works.

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The book was originally published in Germany in 2006.  It’s appearance in 2009 awaited the translation by Philip Schmitz as a Europa edition.  Although ostensibly a memoir about living with Parkinson’s Disease, as it is subtitled, this little gem is actually a primer for battling through life’s challenges.  Dubiel, a German sociologist who sojourned in the U.S. for four years through visiting professorships at U.C. Berkeley and NYU between 1998 and 2002, traverses the terrain between what sort of person has the disease and what sort of disease has the person.  What follows are several passages that illuminate the personal nature of a brain/body disease such as Parkinson’s from the patient’s perspective.

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On the paradoxical relief that a diagnosis can bring:

“Theories, models, and concepts are not simply the toys of scientists.  They also play an important role in the everyday lives of laypeople – for example, in the way humans experience their bodies … Once the term Parkinson’s had been introduced into my world the constant fatigue and anxiety attacks could no longer be dismissed as the hypochondriac symptoms of  a severe neurotic.  The diagnosis brought order into an apparently random series of symptoms, just as one creates order in randomly scattered iron filings simply by passing a magnet over them at close range.”

On motor coordination difficulties:

“My vertigo increased and was accompanied by a new kind of difficulty coordinating my eyes..  My pupils began contracting and dilating involuntarily and independently of one another.  From one moment to the next, I was hardly capable of placing one foot in front of the other.  It was as if I were wearing shoes of lead.”

On divulging the full range of signs and symptoms of one’s illness:

“It was precisely the parallelism of physical and psychiatric symptoms that was so confusing.  The more they coalesced into a neurological picture, the more I kept silent about them … it was experiencing the diverse fears, the daily impairment of my lifestyle and the constant inexplicable exhaustion, after performing tasks that had once been a source of joy that permanently darkened my horizon … The fact that serious diseases often use psychophysical breakdowns as a Trojan horse may mislead one into interpreting the underlying disease process in a simple, psychosomatic sense.  To me, the hypothesis of an emotional immune system would appear more fitting.  In addition to an intact physical immune system, every person who is physically and mentally well enough also possesses an emotional immune system  The latter can be so weakened by numerous traumatic stressors that it collapses, resulting in the manifestation of a pathology which was long present in a latent, germinal form.”

On the “X” factor in the “why” chromosome:

“I often find myself thinking what a vast number of coincidences determine our lives.  I’m referring not only to the chromosome lottery at the beginning of life, but rather to the situation where, at the threshold of old age, one asks: which aspects of my biography may be attributed to my own merit or guilt, and which have resulted from pure coincidence … the complexity of insights we reconstruct always lags far behind the complexity of the actual reconstructed events themselves.”

And lastly, on the folly of certainties:

“In the modern age, discourse on physical disability, insanity, and illness is guided by a binary schematic of normal versus abnormal … Over the last few months I have tried – with some success – to secure the positive stocks of my life rather than lament what I am no longer able to have or to do … one of the prerequisites for happiness is in realizing life’s open-endedness and having an inkling that beyond the next mountain range, around the next bend in the road, lies an unknown land …

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The Press Three Step – Part 2

The Parks Three Step was first introduced by Bielschowsky in 1935 to isolate paralytic eye muscles, and is used primarily to localize the responsible muscle in oblique or cyclovertical deviations to pinpoint cranial nerve dysfunction or to plan eye muscle surgery for non-comitant strabismus.  By definition a hypertropia exists on the cover test in primary gaze, and changes as the patient gazes to the left or right, and then tilts left or right.  The first step of the test involves no eye or head movement; the second step involves eye movement; and the third step involves head and neck movement with the eyes counter-rolling in doll’s eye fashion.    It is well-known that the Parks Three Step becomes less accurate in identifying the paretic  muscle over time due to the spread of comitance.  Sensory correlates of the Parks Three Step are usually limited to something like the Hess-Lancaster Screen, most recently computerized by Spectrum Software.

The Hess Test principle is also inherent in the plot of motor fields used in Home Therapy Systems’ Motor Field Test.  The limitation of the Hess Test of course is that eye movements to the nine cardinal positions of gaze are involved but head and neck movements are purposely limited.  It struck me one day that I’d like to combine the motor elements of the Parks Test with the sensory elements of the Hess Test and voila:  Parks + Hess = Press (okay, a little bit of poetic license there) as depicted in Part 1.

The reason I’m placing emphasis on all three planes of neck rotation is that it activates the  COR, or Cervico-Optical Reflex.  The COR is part of the reflex arc providing positional awareness through proprioceptive feedback to the EOM nuclei.

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Though the VOR (Vestibulo-Ocular Reflex) tends to get all the headlines (no pun intended), the gain of the COR and the gain of the VOR are mutually interactive in balancing eye, head, and neck movement to maintain fusion through postural interaction with the extraocular muscles.  The two clinical conditions in which patients typically report cervical or neck discomfort are torticollis and whiplash, but there are subclinical version of this where patients have more subtle discomfort, headaches, dizziness, or vertigo associated abnormalities of the COR.

I am therefore proposing that the Press Three Step serves as clinical biomarker for a lag in the plasticity of the gain of the COR as the patient actively rotates his neck through the three principal planes – horizontal, vertical, and oblique.  In practical terms, we’re looking for diplopia or difficulty fusing in a particular plane in contrast to its polar coordinate.  In other words, if as the patient maintains fixation on the target rotating L with eyes to the R the target doubles, then rotating R with eyes L should result in more comfortable fusion.  The patient’s habitual head posture in these cases is a vector representing the coordinates for best fusion.

Why bother?  On to the applications of therapy and prism in Part 3.

Reminder: Vision is One of your Senses!

Sounds odd, doesn’t it?  Who would need a reminder that vision is one of the key senses among our sensory processes?  After all, we learned this as one of the most basic lessons in elementary science classes.  Yet somehow, when it comes to discussions about sensory processing disorder, or difficulties with sensory integration, vision often is not adequately in the mix.

custom_cement_truck_mixer_16993Occupational therapists are the professionals typically associated with sensory issues and sensory processing disorders.  Select individuals have championed the significance of visual abilities vis-a-vis sensory processing, most notably Lindsey Biel and Carol Kranowitz.  Others include Temple Grandin and Chantal Sicile-Kira.

Recently I came across another champion, Jennifer McIlwee Myers, who wrote an insightful book titled Growing Up with Sensory Issues: Insider Tips from a Woman with Autism.

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Jennifer has some really nice insights that she shares about vision, subsumed under the sense of Seeing:

  1. “The problem of the child who has only recently been found to be severely nearsighted or farsighted.  Some children can almost immediately take advantage of the improved sight that comes with having glasses that give them clear vision, but some kids with SPD have a really hard time adapting to suddenly being able to see so much more than before.”  [Wow!  What great sensitivity from someone who is not a VT-O.D., understanding that just because a particular lens power can make eyesight significantly sharper doesn’t mean it’s a lens that is going to be accepted by a patient – particularly when the individual has SPD and needs to be transitioned into any sensory environment that is significantly different from that to which one is accustomed.  This holds true for sound and touch as well as vision.  How many of us have had patients come to us whose parents have said that Dr. X prescribed glasses that my child won’t wear.  Or, the child comes in wearing the Rx from Dr. X, and is observed to be looking over the top of the glasses.  Oft times tempering the Rx and prescribing something much milder allows the child to adapt from the habitual visual state to something that provide additional clarity or efficiency without being unnecessarily disruptive.]
  2. “If a kid has had years of bad hand-eye coordination because he is terribly farsighted, the process of getting eyes and hands synced up can take time and may require help from an OT or behavioral optometrist.”
  3. “My own brother had severe behavioral problems in nursery school, none of which seemed to make sense …  It took an examination by a behavioral optometrist to find out that he had double vision … My brother underwent vision therapy that made a huge difference.  For a long time, he had to wear special glasses that had partially blacked-out lenses to permanently train his eyes to look forward correctly.  But the initial therapy made a huge difference in his behavior quite quickly.”

Gunter K. von Noorden

Mention the name “Gunter K. von Noorden”, and many optometrists and ophthalmologists of my era will think of his classic textbook, Binocular Vision and Ocular Motility: Theory and Management of Strabismus.  Thanks to CyberSight, the entire book is available online.  von Noorden is 86 years old now, having resigned from his faculty position as professor of ophthalmology at Baylor College of Medicine in 2009 to accept the title of distinguished emeritus professor of ophthalmology.  von Noorden wrote a memoir published in 2007, titled From Berlin To Texas: Forging a Life from the Devastation of Warvon Noorden

I had the opportunity to read it on the flight from NJ to San Diego yesterday, and highly commend the book to you.  There are intricacies regarding von Noorden’s upbringing in Nazi Germany that are unique and revelatory, and for that reason alone the book is worth reading.  It is noteworthy that von Noorden wouldn’t have collaborated with his principal mentor Hermann Burian on their classic strabismus textbook were it not for the influence that Alfred Bielschowsky had on Burian in the first place.  Bielschowsky emigrated to the United States in 1936 to escape mounting discrimination in Germany, and joined the world’s foremost binocular vision clinic at the Dartmouth Eye Institute.  Burian joined him shortly thereafter, but was recruited to Iowa after Bielschowsky died and Dartmouth disintegrated.  It was in Iowa where Burian and von Noorden began their monumental collaboration.

Among the many items that popped out in reading about von Noorden’s odyssey, two in particular caught my eye:

1)  although the former Austrian and naturalized Canadian physician Hans Selye coined the term “stress”, it was one of von Noorden’s teachers, Professor Ferdinand Hoff, who should be credited with influencing Selye on the pervasive nature of stress in health and disease.

2) When Burian was out of town or otherwise unable to conduct what was called in Iowa the “Muscle Clinic”, von Noorden gladly filled in for him.  They both loathed the name, and for good reasons.  In his research, von Noorden became increasingly intrigued by how the visual system in the human brain adapts itself to abnormal stimulation as occurs in strabismus.  There were complex mechanisms in play, and over the years his work extended beyond medicine into neuroanatomy, neurophysiology, psychophysics, electrophysiology, psychology, and even philosophy.

These influences spring to life in many sections of von Noorden’s Binocular Vision textbook, perhaps best summarized when he writes in his introductory chapter:

Certain motor skills of the eyes are learned and improvable, as are all motor skills. The situation may be compared with that of a musician. ‘‘Innate’’ musical talent is necessary, but to be a pianist or violinist the motor skills of fingers and arms must be learned and continually reinforced through practice.

… and perhaps best encapsulated in chapter 9 when he states:

The relative position of the visual axes is determined by the equilibrium or disequilibrium of forces that keep the eyes properly aligned and of forces that disrupt this alignment. Clearly, the fusion mechanism and its anomalies are involved in some manner in producing comitant heterotropias. To understand the etiology of neuromuscular anomalies of the eyes, therefore, one should also gain an insight into other factors that determine the relative position of the visual axes.

First, there are anatomical factors, which consist of orientation, size, and shape of the orbits; size and shape of the globes; volume and viscosity of the retrobulbar tissue; functioning of the eye muscles as determined by their insertion, length, elasticity, and structure; and anatomical arrangement and condition of fasciae, ligaments, and pulleys of the orbit.

Second, there are innervational factors, that is, all the nervous impulses that reach the eyes. These factors include the co-movements of extraocular muscles with intrinsic ocular muscles, psycho-optical reflexes (fixation reflex, fusional impulses), influences of the static apparatus on extraocular muscles and their tonus (endolymph, vestibular system, reflexes from neck muscles), and influences of the several nuclear and supranuclear areas that govern ocular motility.

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Vision Can Be A Sensory Processing Challenge

Congratulations to Lindsey Biel, an occupational therapist whose latest book, Sensory Processing Challenges just came out.  If her name is familiar to you, it may be because we blogged about her a few years ago (see here).  You can get a feel for her material through this informative YouTube video oriented toward sensory processing issues for those on the Autistic Spectrum.

BielLindsey’s new book takes in the full range of sensory processing challenges, and as with her prior book she does a marvelous job guiding the public about vision.  She gives a nice overview of vision as a sensory modality, including functional visual processing, elaborating on binocular vision, stereoscopic vision, ocular motor skills, visual attention and memory, and visual perceptual skills.  In a later section entitled Developmental Optometrists and Other Vision Specialists, Lindsey cites guidelines from the AOA and clearly delineates the role of the developmental optometrist as distinct from the pediatric ophthalmologist.  She identifies the former as an expert in functional and behavioral vision, and the latter as authoritative in surgery and disease.  Lindsey notes: “A good place to find a qualified developmental optometrist is through the College of Optometrists in Vision Development (covd.org).”

Getting In Sync With Optometric Vision Therapy

Vision is acknowledged to be our most important sense for learning, so it would be logical to think that optometric vision therapy has a significant role to play in the field.  We know that to be the case from research and clinical practice, but what do other knowledgeable and informed professionals have to say?  One of the best-selling books about children’s development and learning in recent years has been Carol Kranowitz’s The Out of Sync Child.

For the past 12 years, since the original edition of the book was published, we suggested to parents of children in our practices that they take a close look at its contents.  It paints a very positive and well-balanced look at Optometry and Vision Therapy from the view of an authority in education and human development.  Now there is another source for parents to consult that takes the Out of Sync Child concept to a new level.

Browsing the shelves of the Special Needs section at Barnes & Noble I came across Growing an In-Sync Child, which presents simple, fun activities to help every child develop, learn and grow.  In this delightful paperback, just published a couple of months ago, Carol Kranowitz is joined by co-author Joye Newman.  I was delighted to open the first page and see that Joye acknowledged her “mentor extraordinaire”, Amiel Francke, O.D., who shares his brilliance about vision and its importance in living an In-Sync life.

The influence of Dr. Francke, a well-known colleague of ours who has practiced in the D.C. area for many years, is evident.  The book is chock full of wonderful explanations, such as the difference between 20/20 eyesight and the visual skills necessary for learning and development.  We now have another source to give parents and other professionals who are looking for activities at home or in school to complement or supplement office-based optometric vision therapy (OVT) activities.  Though these procedures don’t substitute for OVT, there is very useful information categorized as beginning, intermediate and advanced perceptual motor therapy procedures.

Another professional who truly understands what behavioral and developmental optometry has to offer is Lindsey Biel, an occupational therapist I first met when she gave a continuing education lecture at the Annual Meeting of the College of Optometrists in Vision Development (COVD).

Lindsey’s book, Raising A Sensory Smart Child, initially published in 2005, won the NAPPA Gold Award and the iParenting media award.  It became available last year in a newly updated and expanded edition with a foreword by Temple Grandin.

In a chapter on dealing with developmental delays, Lindsey does a great job of helping parents understand the indications for seeing an optometrist knowledgeable in vision therapy.  She notes that if your child shows signs of visual problems, such as difficulty reading, headaches and eyestrain, or visual inattention and distractibility, you may be referred to a behavioral optometrist, also called a developmental optometrist.

Lindsey adds that parents should consider taking their child to a behavioral optometrist even if no one has referred them, because an undiagnosed vision problem is a major obstacle for any child.  She also addresses the inadequacy of vision screenings done in school or in a pediatricians office.  I’m proud to say that Lindsey acknowledges input from some of the very best professionals out there, and among them she includes Dr. Fran Reinstein, a developmental optometrist and former student.

Bravo to Carol Kranowitz,  Joye Newman, and Linsdey Biel, three cutting edge child development experts who understand the essential role of optometry and optometric vision therapy in learning.