The following is a review of chapters 1 and 2 of Handbook of Vision Therapy by Dr. Joaquín Vidal. The author of this review is the optometrist Stanley Tien, Master in Clinical Optometry and Vision Therapy at SAERA. He currently works at Suntime Vision Specialist (Kuala Lumpur, Malaysia) .
Visual problems are actually the visual capacity/skills of the person that could not match with his/her visual demand. For example: A sales person, Mr. John, usually spends most of his time outdoors but recently he has been promoted to the rank of manager, which requires him to stay in office and spends at least 8 hours per day in front of the computer. John may get tired and develop symptoms of vision problems due to the vast difference between his current visual demand compared to the previous one. It is beyond his visual skills capacity. Another way of seeing it is that our external presentation does not match with the internal presentation.
When people hear about vision therapy, the first thought that came to mind is a self-help eye exercise such as “seeing without glasses” but this should not be confused with vision therapy. In certain countries, that merely do eye patching, occlusion activities are also called vision therapy. Vision therapy includes orthoptics (eye muscle training) but vision therapy is more than orthoptics exercises. Vision therapy includes visual guide motor, eye movement, visual spatial awareness (laterality), integration with other senses, including auditory and kinesthetic and also knowing how to apply it while doing the activities.
The beginning of this book has a greatdiscussion about the history of vision therapy and the different principles of vision therapy in different countries.
As a beginner practitioner of vision therapy, this would help to understand and have a foundation of vision therapy. Learning is the way to let you experience the present and compare the past so that you will be aware and able to make a change. Therapy is a learning process under the supervision of a therapist. It is not an activity exclusively performed for its results, but about how you do it and its process. The ultimate goal is the automaticity to perform a task effortlessly without thinking how your eyes are moving.
It discusses and analyses how age and the characteristics of the patients affect the quality of the result of vision therapy and how can we help and resolve these problems throughout a vison therapy programme. For example, if a patient has a physical limitation, we will learn to adapt materials to his needs and not just because the procedure suggests so we must follow it. We can alter according to the requirements of different patients.
The core value of vision therapy is to understand the patient’s goal and needs. In our optometric record, the vision specialist or therapist’s goals may not be the same as the patient’s goal. For example, a patient could have shown a high recovery and break in fusional reserve but may still present some symptoms of vision problems. This patient’s goal is to be free of any symptoms, so it is yet to be considered a successful treatment because we have not achieved his goal. This is also why we must spend time to understand and discuss each patient’s goal, whereas in younger children, most of the time you are achieving their parents’ goals, because they are the ones who paid for vision therapy. On hindsight, do not forget the most important thing is the compliancy and motivation of the patient. We have to make sure to achieve the patient’s and the parent’s goal. It can be compared to a coach who instructs the player to shoot the ball, but the player does not want to shoot. We cannot control the player but we can provide and setup a good environment to get them experience and learn to utilize their vision effortlessly.
The book also deals with how language and one’s cognitive level would affect the therapy. In terms of communication, we need to understand the level of patient’s understanding, and give clear-cut instructions for them. The core of any therapy is the relationship between the patient and the vision specialist/therapist, how you handle or manage the patient and how you present or deliver the message to the patient. First of all, we have to get to know their characteristics because not all processes are always fluid in reality and this is the reason why we have to understand which type of patient we are dealing with and the level of challenge to push or cease once hitting on the patient’s stress point. Chapter one will give some idea on how to maintain a qualitative vision therapy when faced with patients with inattentive or attention deficit disorder. The more you try to understand the patient, the higher the success rate of the treatment. Sometimes we should change or alter our therapy technique according to the patient’s level. Personal characteristics (e.g. depression) can affect the development of the vision therapy programme. Some professionals did not realise vision therapy can help patients with low self-esteem and it can be very efficient.
Vision therapy is not as simple as getting a series of activities completed at home. It has to be run under the guidance of a vision specialist and therapist. An efficient vision therapy programme cannot either be too easy that it bores the patient out, nor too difficult up to the extent that the patient would want to escape from the activities. There should always be an in-between to sustain the attention of the patient.
Most of the times practitioners, especially in the case of new ones, think that they should apply specific activities or procedures for every patient. For example, the Marsden ball only works for eye movement. But actually, the core is the theory, reasoning and foundation of vision therapy, so it can be applied on any patient. Not every patient receives the same method of treatment. In order to have a successful and efficient therapy, the first step is to understand your patient. The whole principle of vision therapy is not about completing the tasks per se. It is about how the patient completes the task and to provide an opportunity for learning from the tasks and what changes could be done to make the task easier and faster. In the management of vision therapy sessions, it suggests different methods to deal with patients who are difficult to work with.
After the theory and principle of vision therapy, Chapter 2 shows how theory applies to practice. Lenses are usually the first and commonly used tool in the management of a visual problem, before vision therapy comes in. The principle of the treatment plays an important role, as stated above, the most important thing is the theory behind the activities not the activities itself. As a vision specialist or therapist, you need to understand what to expect and what should not be done. You would not want to break the suppression of one eye if the motor fusion is not ready yet, otherwise it may cause a diplopia (double vision).This is regarded as a cook book for vision therapy in coaching practitioners about to start vision therapy. Discussion includes length of home activities, hierarchy of vision therapy, and this is my favourite part of the chapter, from monocular, biocular to binocular phase. You would have to train the skill of both eyes to work equally, then bridge the 2 eyes (biocular), then binocular working together. Vision therapy procedures would have to change based on different types of patients, or sometimes may have to adapt to the patient’s preference. When doing pursuit activities, you may have to use a cartoon target on a 4-year-old patient.
Diagnostic tools always play an important part in vision treatment; from that you could obtain some ideas about the prognosis of the treatment. This chapter explains each tool used for assessment including DEM for eye movement and the worth 4 dot for sensory fusion. The organisation of visual acuity chart, crowding or non-crowding, makes a difference when you perform it. The most importantly you have to understand what the test does, and what does it measure/test so it will help you a lot when the treatment part comes. Besides the diagnostic tool, it explains that some of the vision therapy equipment used in office and home therapy (e.g. Marsden ball), can be used in training pursuit saccades, accommodation, peripheral etc. It categorised nicely on specific activities on a specific phase, for example near far hart chart on accommodation, monocular and binocular, mirror septum for biocular and red/green fusion filter/card, as well as brock string for binocular vision. The tools that we can use for vergence include biopter, aperture rules, loose prism, prism bar, mirror scope, life saver card, and they can range from central fixation to free space activities. The last part of the chapter discusses the aspect while doing vision therapy. It showed on pearl point and guides the practitioner step by step about how to perform vision therapy.
Author: Joaquín Vidal-López