Getting Your Eyes Checked, Part II

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Suppose you suspect your child just may have some convergence issues.

How is a "developmental" (or "behavioral" or "neuro") optometric exam different from a standard exam?

According to Dr. Linda Azwell, a developmental optometric physician in Orlando, Florida,

Both [a standard and developmental/behavioral optometric exam] will look at the health of the eye and the possible need to have corrective lenses. But a Developmental Eye Exam will also assess how the eyes are working together as a team at distance and especially at near since this can be a source of problems for approximately 20% of the population. The Developmental Exam will measure:

  • The ability of the eyes, separately and together, to change their focus rapidly and smoothly
  • The amount of flexibility the eyes have to make "turn in" or "turn out" adjustments at distance and at near so the eyes are pointed at what the person actually wants to look at
  • Can the eyes actually stay comfortably where the person wants to look at distance and at near without sliding in and out of alignment?
  • Does the person have adequate depth perception and ability to see binocularly?
  • Can the person follow something smoothly with their eyes or are tiny correctional movements always needed?
  • The ability of the eyes to smoothly and accurately move from one point to another: 1) at distance, 2) at near, and 3) from near to distance and back again
  • Do they have good orientation, coordination and laterality?

A Case Study: "I can't read this!"

Two years ago, while I was undergoing therapy, I made sure Dr. Manniko, my behavioral optometrist, knew the kind of work I do with homeschoolers. As a result, he gladly shared with me information and insights–and even experiences–that most patients would never enjoy.
A couple of times, he requested permission from other patients (or, actually, other patients' parents) to let me observe their tests.
So one day I was able to watch a 6-year-old boy take the VisaGraph test (the test that measures individual eye movements–right and left eyes, both–while a person reads a text).

The technician set up the infrared goggles and handed the boy his first-grade reading material.

"I can't read this!" the boy exclaimed as soon as she handed it to him. "I'm only in first grade!"

Dr. Manniko whispered to me: "This is typical with children who have these kinds of visual difficulties: they stall for time."

The technician didn't miss a beat. "Try this one, then," she said. And she handed him a card that simply had single-digit numerals spaced about three or four per line. I don't recall if there were also lines that filled the spaces between the numerals. "I'd like you to read these numbers as if they were in a book. First the number in the upper left. Then the number over here in the middle. Then the number on the right. Then the number on the next line down, over here on the left. And the one in the middle. . . ."

The boy agreed he could handle the assignment.

"Okay," said the technician. "Whenever you're ready."

The boy paused for a moment, then began reading. And I watched the VisaGraph paint a picture on the computer screen of where his eyes were looking.

First number: left eye swung to the left while right eye shifted right. Then they swung the opposite way–left eye to the right and right eye to the left beyond each other! Back and forth, back and forth, maybe three or four times before they settled on the spot where the first numeral was.

"Seven!" cried the boy in triumph. (I am making the number up. I don't remember the specific numbers. I just want you to get a sense of the experience.)

Next number. His head shifted turned to the right. ("Notice he's not moving his eyes to look," whispered Dr. Manniko; "he's moving his head!")

Bounce with the eyes–out and in, wobbling around about four or five times before they settled. "Three!"

And so on and so forth all the way through the 20 or so digits.

"Can you see why your son is having difficulty reading?" Dr. Manniko asked the boy's mother when he had completed his ordeal. "He is working so hard just trying to get his eyes to work together, he has little energy left to do much of anything else. . . . "

Then there was our son, Justin. . . .

A Case Study: Better than 20-20 . . . but at what cost?

Our son, Justin, had been measured by our regular optometrist as having 20-12 eyesight–"better than normal." . . . But he had complained for years of suffering headaches. He always thought it was his eyes. So we would bring him to the optometrist, and the optometrist always said there was nothing wrong with his eyes. Except there was. And it wasn't until I brought him to Dr. Manniko that we found out what it was. . . .

Dr. Manniko ran Justin through the same set of tests that a regular optometrist does, then did something I've never seen before. He reset the phoropter (the machine eye doctors set in front of you and flip lenses around and say, "Is this better, or is this?") . . . –He reset the phoropter to some strange setting, asked Justin if he could read the top line of the chart (which Justin, at that point, could not), and then said, "Great! . . . I want you to sit there and relax and wait until you can see something. Then tell me what you see."

Manniko then turned to me and we began to talk.

It took about three minutes before Justin suddenly called out, "Hey! I can read the first line! It's ‘__' (whatever it was)."

"That's great!" Manniko replied. "When you can see more, tell me."
A few minutes later, Justin said he could read the next line. . . . And he did.

After about 10 minutes, Justin was able to read four of the six lines on the chart. At which point Manniko stopped the test.

What had happened?

Dr. Manniko said that, normally, our eyes are at rest when we are looking at a distance. It takes quite a bit of muscle power to force ourselves to look up close. Justin was, indeed, able to see well, but at the cost of tremendous exertion: "It's like a car that can't go faster than 60 mph even when floored and running downhill. Justin's eyes are that car, and they're trying always to run at 55 mph. A car that can't go faster than 60 mph will achieve the speed, but at tremendous cost–especially if you're always trying to run it at its top capability. Justin's headaches are the result of the constant strain."

Sure enough, with glasses (which he "doesn't need"), his headaches have disappeared.

*

Prismatic Lenses

Dr. Manniko prescribed some prismatic lenses for me. My regular optometrist had said he could write me such a prescription, but he didn't want to. "Though they would help you to see," he said, "prisms are like heroin: totally addictive and, long term, destructive to your eyesight. You'll become dependent on the lenses to do what your eyes are supposed to do for you."

I asked Dr. Manniko about that. "Your optometrist is absolutely right," he said. "Prisms are adaptive technology–just as regular eyeglasses are. They help you do what you want to. . . .

"You can get by without prisms. Just as you can get by without shoes. But you want to do things that your eyes aren't well adapted for. Because of your work, you want to be able to read, and to read at high speed. The prisms will help you achieve your goal.

"Look. Think of your feet. Your feet are weaker because you wear shoes. . . . But shoes let you do what you could not do without them. You could not easily walk outside in your bare feet when it is freezing cold and snowy. You could not easily walk on burning hot tarmac in the summer. Shoes help you do those things. The right shoes can help you run faster than you would if you didn't own them. So do you care that the shoes are also contributing to your feet becoming soft and weak [compared to what they would be if you didn't wear shoes? . . .

"In the same way, John," he continued, "prismatic lenses for your condition will enable your eyes to do what you want and need them to do."

I have used prismatic lenses, now, for almost two years. And I can tell you: they have made a world of difference. I engaged in about three and a half months' worth of therapy as well and that, too, helped me improve my eyes' coordination.

Since therapy, and using my prismatic glasses, I have been able to read for hours at a time without getting sleepy. I have "even" read a 150-page book on an airplane in about two hours–a feat I could have never done prior to therapy and the adaptive technology of my prismatic glasses.

So What's Therapy All About?

The therapy I underwent is rather odd.

There are a few pieces that seem relatively easy to understand. Separate from Dr. Manniko, I purchased an eyesight kit that included a "Fusion String" that is about six feet long and has a red bead attached every six inches down its length (with about 6″ free on each end). You're supposed to attach the string on one end to a wall (I attached it to a door knob) and then hold the other up to the end of your nose. You're then supposed to sight down the string, focusing on each bead in succession. "If you're nearsighted, start with the closest bead and work outward. If you're farsighted, start with the farthest bead and work up toward you."

I have found this Fusion String to be most enlightening. If your eyes are working as they should, you should actually see "two" strings running down to the point where you are focused; they should fuse at that spot, and then continue, crisscrossed, beyond the focus point. I.e., they should form a giant "X" if you're looking at a bead somewhere in the middle, and a "V" (or upside-down "V") if you're looking at either end.

If you see only one string, then one of your eyes is blanking out. If you see a "Y"-like figure–where one of the legs of the "X" is broken off, that means something else. I have found that I often see a "Y."

I used various fusion devices under Dr. Manniko. But the majority of my therapy was nothing like that at all. Mostly, I played games–games like throwing a ball against a bounce-back net; shooting baskets at mini indoor basketball hoops; walking on a balance beam; playing catch with a partner while the two of us are standing on the balance beam; and so forth. I played these games while wearing heavily prismed glasses.

These special therapy glasses ranged from 3 to 12 diopters of prismatic shift. And the prisms could be rotated. So we started playing and of the games I mentioned with the prisms "up"–at the 12 o'clock position. I'd shoot 10 baskets with my right hand, shoot 10 with my left (or engage in 10 back-and-forth throws of a ball . . . or whatever) . . . then shift the prisms "right" (to the 3 o'clock position). Same series of activities in the "right" position. Then "down" (to 6 o’clock). Repeat. Then "left" (9 o’clock). Then "out" (left lens at 9, right at 3). Then "in" (left at 3, right at 9). . . . And finally–since I have an alignment problem where my eyes not only don't converge properly left-to-right (the most common type of difficulty), but also up-and-down–I would do the activities also with the prisms set one down, one up and vice-versa.

Talk about making you feel dizzy! . . . But this kind of exercise helped my eyes converge.

I asked Dr. Manniko about his regimen. He said that the prismatic glasses "merely" speed up the whole process. But the games themselves are really the "secret."

He said that far too many kids lack the kind of practice they really ought to have in focusing near-far and far-near in rapid succession.

"Think of it," he said. "To begin with, a child at two or three should learn to catch a slow-moving balloon. Eventually, he should graduate to a slow, soft ball. And only after plenty of that kind of experience should s/he ever face the kind of situation that a lot of boys face when they are 8 or 9 years old where they are set 90 feet from the pitchers mound and then have a hard ball thrown at them at 40-, 50-, or 60-miles per hour!"

Too many kids today, he said, do little more than stare at computer and video screens (or, for Sonlighters, read books!). And their eyes don't get the wide range of practice they need to perform optimally. . . .

Where to Get Help

In sum, if you or one of your loved ones is experiencing any of the issues I listed at the beginning of today's article–or even if not–I urge you to find a "Developmental" or "Behavioral" (or possibly a "Neuro") optometrist and have that person's vision checked out. At least once. If there are no problems, stick with your regular optometrist. But at least once, see how your and your children's eyes work together.

You can find a doctor locally by going to http://www.covd.org/ ["developmental" optometry; there is a "Locate a Doctor" function on the home page–find a doctor within so many miles of your ZIP code] or http://www.healthy.net/oep/OEPSearch.htm ["behavioral" optometry; click on the "Search" button next to your preferred means of searching]. "Neuro-Optometrists" are pretty similar to developmental and behavioral optometrists, though they specialize in "rehabilitation for acquired brain injury." A Neuro-Optometrist has a good web page that highlights some of the kinds of issues they deal with. (See http://www.agape1.com/neurolog.htm.) To find a neuro-optometric doctor or therapist, go to http://www.nora.cc/locater/index.html.

One last item (mentioned by several people): "Some docs recommend surgery right off the bat. Other treatments are often as good and less invasive."

A Way to Afford "Therapy"

As Dr. Manniko said, the "real secret" to vision therapy is ocular (eye) exercise. To SPEED UP what would otherwise be a much (much!) slower process, the doctor has patients work with certain equipment. . . .

It seems we can purchase a lot of the key pieces for . . . a whole lot less than one therapy session per item. In fact, a bunch of them might each cost the equivalent of half a therapy session.

Personally, I'd recommend the following items. Note: According to the website to which I'm sending you, the prices listed are "wholesale to doctors; schools; hospitals; government. Prices to the public are required to be 50% additional."

  • Aperture Rule Trainer Kit (http://www.bernell.com/category/22).

    I love this item. It trains me to fuse/fixate/focus my eyes in both CONVERGENT and DIVERGENT positions–in other words, it helps them WORK TOGETHER. . . . One of the key items I like about it: It gives me enough feedback to know whether I'm suppressing on one eye or using both eyes to see the objects I'm looking at.

    Take a look at http://www.bernell.com/fullsize/307/22 for a somewhat closer view of one set of images that this device uses. At the bottom of the pictures you will see sets of circles–the set on the left features a dot BELOW it; the set on the right has a plus-sign ABOVE it. –It is those symbols that give the user feedback on whether s/he is using both eyes or not. If s/he is suppressing, s/he will see only the dot below or the plus-sign above. . . . Very eerie!

  • A set of four adjustable "Prism Training Goggles" of various powers.

    Doctor Manniko has a set of maybe 10 different powers, but I don't see the need.

    Doctor Manniko would have me use a 7-diopter pair for 10 minutes, then a 3 for 10 minutes, then a 5 or a 12 . . . and so forth, for an hour.

    As I indicated above: he would have me shoot baskets. Then he'd have me change powers of glasses and do the same set of rotations (up, right, down, left, out, in, up-down, down-up) with the new power glasses while throwing a ball against a bounce-back backstop–ten throws and catches per setting of the prisms. Then he'd have me do the same kind of thing–different set of prismatic glasses, ten sets per direction of the prisms–while trying to locate places on a world map. Then the same thing while walking the length of a balance beam. . . .

    And so forth.

    If we had room in his office, he would have had me playing foursquare.

    A couple of us played tetherball with those glasses on. (Each time we finished a game, we'd turn the lenses.)

    Foosball. . . .

    We would do any game that required quick eye movements and where it "cost" something if we were unable to focus.

    The point is: we were putting our eyes (and bodies) under stress.

    One point Dr. Manniko made to me: about 20% of the capacity of our optic nerves has to do with BALANCE . . . so he always stressed us by placing us on balance boards or personal mini-tramps (even bouncing up and down on the mini-tramp!) while playing the bounce back games or throwing baskets. . . .

    You can find rotating prismatic glasses beginning at http://www.bernell.com/category/30. If I were buying a set, I'd probably get a "3," a "5″ an "8″ and a "12."

    ******

    One last thing you can get–or create–easily enough: the "Fusion String."

    Mine is about six feet long and has a red bead attached every six inches down its length (with about 6″ free on each end). You're supposed to attach the string on one end to a wall (I've attached it to a door knob) and then hold the other up to the end of your nose. You're then supposed to sight down the string, focusing on each bead in succession. "If you're nearsighted, start with the closest bead and work outward. If you're farsighted, start with the farthest bead and work up toward you."

    I have found this Fusion String to be pretty good. (It's the cheapest tool you can get and it gives you quite a bit of the kind of feedback the Aperture Rule Trainer gives you.)

    –Again, this is great for me, as an adult. But I'm not sure how much a young child may be willing or able to attend to the DETAILS necessary in order to train his or her eyes.

    Doctor Manniko seemed most inclined to have people "play games" while wearing the prismatic glasses . . . and he wanted to ensure you turn them on a regular basis . . . and don't OVERDO it. . . . An hour of that kind of therapy twice a week is all he normally recommends, though an hour every day is not too much. But more than that, he warned: you're going to fry someone.

    I found, when I first started, the therapy tended to make me feel dizzy. And it made my eyes hurt. Not necessarily that day or even the next. But two days later, I would find my eyes were BURNING and I'd just want to go to sleep.

    I was in therapy for six months, twice a week. But it paid off.

    ********

    One more item. I don't know how important this is. Doctor Manniko has us use this for two minutes BEFORE therapy and between each exercise (defined as–each set of glasses). It's called a Translid Binocular Interactor (or "TBI" for short). It's a tool that generates high speed light pulses or flashes: one eye gets a burst, then the other, back and forth, from side to side. You hold it up to your eyes while they are closed. The light shoots through your eyelids. . . . Apparently, it is meant to "wake up the brain" to keep it from suppressing or ignoring one eye or the other.

    I looked this up on Google and noted that someone sold a TBI on eBay for all of $21.40 plus shipping! (Normally $154, he said, from Bernell.) I'll let you do whatever research you want on this tool. Doctor Manniko has TBIs that look like flashlights with two lightbulbs hanging out the front end. Others that are simply DC adapters with double lights at the end of a six-foot length of thin wire. . . . The benefit comes NOT from brightness of light, but, apparently, from the flashing itself.

    (I found an article about this at http://www.i-see.org/archive/amblyopia.)

    And one last resource: you can watch a brief video about vision therapy at http://www.thedenverchannel.com/health/7135072/detail.html.

    Oh. And I should add one last note.

    Sometime in the past two years, someone wrote about this issue on the Sonlighter Forums. I have looked into it myself, and Dr. Manniko seemed aware of it. But for Jill Snapp, her developmental ophthalmologist, apparently, was unaware. May you not be unaware!

    Jill wrote,

    [We learned] about some vision issues [our son] had that were not recognized or accepted by the developmental ophthalmologist. That doctor did a great job bringing Evan’s vision up to 20/30 in both eyes with glasses, but Evan still hated to look at paper and just wouldn't even try to read words. At the recommendation of another doctor, we had him screened for scotopic sensitivity. I learned so much just from watching the screening. Evan said the words "flashed" at him and wiggled. It gave him a headache to even look at the page. When the screener tried using colored overlays on the paper, Evan’s ability to see what was in front of him improved tremendously!!! It was truly amazing. Evan is very attached to his overlay now. He can make out words without it but only reads with ease if the overlay is on the paper or the text is printed on colored paper. As a part-time GED teacher, I have done informal surveys with my students and found that at least one-third of the! students benefit from using the overlays. Almost all of the GED students had trouble in the traditional school environment. I wonder if they would have been more successful if they had the opportunity to use overlays from the beginning. I've learned that it is a required screening in Australia. You can find more information about it at www.irlen.com.

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  1. Amy

    This is a great article. We discovered that our 8 year old daughter has both tracking and focus problems. That is why reading is so hard and draining for her. We are in our second month of vision therapy. It is a lot of hard work, but we know it will pay off in the end. I think all educators and optometrists need to be aware of these type of vision problems. Our optometrist was not. I learned where to seek help from the Sonlight Forums.