What Exactly is Vision Therapy and Behavior Optometry all about?

Right now, you may be wondering to yourself, why should I go to a behavioral optometrist? What is the difference between behavioral optometrist and an optometrist that you may see for your every year eye exams? Well, it is my hope that I may better help you understand that distinct difference in the post below. Behavioral optometrists look at how a child perceives the world around him or herself. There are a number of different skills that we use to see the world around us. Having perfect vision (20/20) is just a very small part of that larger picture.

In our day to day life, we use so many more visual skills. If a few of those skills have a deficit, we will have some difficulty in our daily routine. For instance, if we drive, let’s just take a moment and think about what all goes into driving a car in regards to our visual system. There is first active movement of one’s head to look in the blind spot. As such, we need to be aware of how much we need to move our heads to see behind us.

In addition to our feedback that we get with our necks, there are tracking movements when we drive. We have to constantly be looking up at the horizon to see if there are any obstacles on the road that may be a challenge to overcome.

We also need to be aware of how fast we are going, how much fuel we have and other controls by the driver. How do we compensate for that? Well, we do that through something called accommodation or focusing. If we did not focus our eyes, our eyes could not see up close.

With that said, we also have depth cues to tell us how far something is in front of us. If we did not have good depth perception, driving may become much more scary as it would be very difficult to see where things are in space.

So what does all this have to do with my vision or my child’s vision? Well, unless you have a doctor that will actively look at see how your visual skills such as tracking, pursuing, depth perception, focusing, teaming and information comprehension abilities are, you may have vision related inefficiencies that could be negatively effecting your day to day life.

Be sure to check to see if your optometrist is a behavioral optometrist (also known as a developmental optometrist). You may do so on the College of Optometrists in Vision Therapy website at http://www.covd.org/, or directly ask your optometrist.

In the next paragraphs, I am going to talk about a number if disorders that a patient may have. Some of which could be combinations with others.

However, before we go into the description of what each disorder is, I briefly want to talk about what a behavioral optometrist is looking for in a visual system of a patient. First we look at something called the ocular motor system. This will tell us a number of things like how the eye can follow a target (pursue a target). This is done for example with a light or picture for the patient to look at and follow. If a deficit is observed, we certainly will note that. Deficits will typically include an inability for a child to smoothly follow a target with his or her eyes. This is seen with “jerky” eye movements. It is almost as if the patient thinks the target is not moving smoothly and moves fast to compensate when the target is far away to where the patient first though the image was. This can make following or tracking objects very difficult for patients when to do. Also, reading will become extremely difficult, as staying on the same line becomes a big challenge. Many children will have these symptoms around 2nd grade. This is when children start to read to learn instead of learning to read which makes a big difference in the way they look at words.

Another system that we look at is the binocular system. What than means is that we look at the way in which both eyes can come together and help see a clear image. We see problems with this skill in patients that have eye turns or lazy eyes. If this system is not working properly, a patient may complain of double vision. Also, it is very possible that you may not hear anything at all. This is often seen in children because they think what they are seeing is exactly what every other child sees since they have never seen a behavioral optometrist.

Lastly, we look at the focusing system or accommodation system. Now, some of you reading this may know that at around age 45 we all typically will lose this ability to see clearly at near. This is due to something else all together, however, some children and patients in their teens, twenties and thirties may show signs of poor focusing. This is very frustrating, as distance images may appear blurry and near images may also appear blurry.

Our eyes are much like a camera lens in that we are either at an infinity setting for distance or an up close setting for reading, when our focusing system is not performing properly, a patient will be affected.

You may be at a point that you are asking yourself, what can behavorial optometrists find or diagnose? Well, in the next section I am going to talk about some common conditions that behavorial optometrists look for.

Vergence Disorders

Convergence Insufficiency

This is one of the most common vergence disorder of the eye. It occurs in approximately 5% of children in the United States1. What happens in convergence insufficiency is that the eyes can not come in together as efficiently as a team. This will lead to double vision up close. When this occurs, many children will complain that they do not like to read or do things up close and will want to do more distant orientated activities like watching TV or playing sports. An easy way to see if you have trouble with bring your eyes in is you can take a pen and slowly bring it in to your nose. Eventually, it will be very hard to keep looking at the pen when it is right by your nose. At this point, it may become two. If the pen splits into two at 12 inches or greater from the nose, this may be an alarming finding that you may have convergence insufficiency.


Fortunately, convergence insufficiency there is an effective treatment known as vision therapy (See below). Studies and personal testimonies have proved time and time again that vision therapy works. The most recent studies were conducted by the national eye institute.

Other vergence disorders that exist but are less common include divergence Insufficiency, convergence excess and divergence excess. In divergence insufficiency the eyes have a difficulty going apart from a converged position at near. Convergence excess is where the eyes over cross at near that results in uncomfortable vision. Lastly, divergence excess in where the eyes proceed to turn out in a position in far away gaze that causes visual problems. All of these conditions can be treated with vision therapy with a fairly high success rate. Although, the treatment time is typically much higher that convergence insufficiency.

Ocular Motor Dysfunctions

Also, a very common disorder is a deficit in the way in which we are able to follow targets and use our eyes to read and look around in our daily environment. This will be seen with a child losing their place of a page, rereading a sentence because they can’t keep their fixation or a child taking a long time reading.

One interesting concept is that our vision is so much more than the clarity that is presented in the distance, it also all about the way in which we can follow a target or search on a page for certain sets of information.

Ocular motor deficits become much more evident in the pediatric population around the age of 7-8 years as child change from learning to read to reading to learn. As such, many symptoms that present to parents and teachers is a child drop in grades and interest in school.

An alarming concept is that many times the diagnoses of ADHD may present with very similar to the diagnoses of a vision related component like ocular motor dysfunctions. The only way to really see if the child or adult that you question has a vision related component is to have their eyes examined by a behavorial optometrist.

Accommodative Insufficiencies

As we were discussing earlier, our eye has a lens behind the pupil that focuses much like a camera lens. The focusing lens of our eye is controlled by a muscle. If this muscle does not work properly or does not effectively communicate with neurological set up of a patient, a patient will experience fluctuating visual symptoms that will be very frustrating. Sometimes the distance may be blurry, but yet at other times, reading will become very blurry.

The most effected treatment for accommodative problems would be vision therapy. Lenses only change the way light enters the eye and does not teach the ocular muscles as much as comprehensive vision therapy problem would.


Amblyopia

Amblyopia is one of the most important things that eye doctors across the board will try to prevent. This is where the eye will not obtain a crisp correctable vision to 20/20 due to a multitude of causes from unequal prescriptions, eye turns (strabismus), ocular diseases / opacities and others to name a few.

What is happening is that the eye is not receiving proper crisp vision because of some condition in the eye like I previous mentioned. As such, the brain will not develop those cells and this results in a failure of the eye to develop 20/20 vision.

Fortunately, if caught as a child, the outcome is usually positive if the child is enrolled in a vision therapy program. Even if the patient with amblyopia is not a child, progress has been made in many instances. No matters at what age, our eyes constantly convey information to our brain which has certain amounts of plasticity. It is our goal to patch into that plasticity through therapy and increase the patient’s visual function.


Strabismus

Another common condition that some patients present with is an eye turn or strabismus. If an optometrist discovers a strabismus there a few things that we look for. First, is the strabismus present when the patient looks far away, intermediately or up close? Is is always there? How much in magnitude is the turn?

There are three tools that an optometrist can use to fix a strabismic patient. Those tools include vision therapy, lenses and surgery. Surgery is often not considered a primary route of action in many cases hoever it is considered in large eye turns that are always present in all gazes. There are a number of characteristics that are determined before sending a patient to surgery. One thing that surgery does is give a quick fix but cannot compete in the way that vision therapy intergrates the visual system of a patient with their eye control. This is why vision therapy is such a valuable resource for many patients with strabismus.


In closing, there are many other conditions that I have not mentioned. It is my hope that I have shed some light on common ocular conditions that appear in the population that may require vision therapy. If you have any questions, please don’t hesitate to contact me.

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1. National Eye Institute http://www.nei.nih.gov/neitrials/viewStudyWeb.aspx?id=107