Question: What is vision therapy?
Dr. Fuerst: In a nutshell, vision therapy is focusing on the visual skills that are absolutely crucial for learning. This is not measured by how well you see at 20 feet (20/20).
Studies indicate that between 15-18% of kids have a visual processing difficulty which adversely affects their ability to read and learn in school. We look at different processing disorders. First we look at focusing, which should be automatic and easy, but for many kids is not. They will complain of blurred vision, and difficulty maintaining concentration and keeping things in focus after even just 5 and 10 minutes of reading.
In addition to that, you have binocular vision disorders, where you have to converge the two eyes together during reading. The eyes need to work together as a team, and there are a number of kids who have a lot of difficulty with this. For example, a child may look at something that is 12 inches away, but their eyes begin to wander out to 14 or 15 inches, and then back into 12 inches. This creates a tremendous amount of stress on the visual system.
These same six muscles in the eye that are involved in binocular vision are the same muscles used for tracking. As a result, one of the most common things that we see is children that have issues with skipping words, skipping lines, losing their place, missing the prefix, and missing the endings of words. Next we look at visual perception to find out how are you processing the information.
Question: Is there a connection with learning and reading disorders and ADHD?
Dr. Fuerst: Yes and no. True ADHD is something totally separate. However, if you go back and see how they measure the brain waves and concentration that is indicative of cognition, you will find a ton of research from the 60’s and 70’s about the alpha rhythms, the proverbial dial-tone of the brain, also called bio-feedback. In a normal alpha rhythm, when you are taking a walk in the woods, not really focusing on anything, kind of just taking it all in, the amplitude of the alpha rhythm wave is quite high. It will oscillate up and down with a good high point and a good low point. Then we ask the same person to really concentrate on something, for instance to calculate a mathematical equation, the amplitude of the alpha rhythm becomes very small, going up a little bit, and down a little bit, up a little bit and down a little bit. Back in the day, there was a whole thing about bio-feedback, and what happened is that we had these type A personalities that were having heart attacks and they’d measure these folks with the alpha rhythms and saw that their alpha rhythms are the same when they are relaxed as when they are concentrating on something. So they worked with these people to try and get the standard alpha rhythm pattern, and that helped them to more fully relax.
Then they researched children with learning disabilities, such as dyslexia and ADHD or ADD, and those kids had the opposite alpha rhythm. When they were concentrating really hard, their alpha rhythms were high, oscillating up and down with a huge wave of high point and a good low point, as if they are not focusing and just relaxing.
If you want to measure the alpha rhythm of the brain, the best place to place the skin surface electrode is right above the occipital lobe of the brain on the back of the skull. This occipital lobe strictly deals with vision. So, to say that attention and concentration is highly tied to vision is not a difficult link to be able to prove physiologically.
I will get kids who have a lot of the hallmark symptoms of ADHD or ADD, such as not being able to concentrate for more than 5 minutes, can’t stay focused, and so on, and you find out they have a massive tracking problem, a massive convergence insufficiency. I say, “Yeah. No wonder you are manifesting ADHD-like symptoms. Unfortunately these kids get misdiagnosed with ADD or ADHD. It’s not true, it’s not accurate. They just need vision therapy.
Question: In terms of the medical side of optometry, where does vision therapy fit in?
Dr. Fuerst: Dr. Jeff Cooper in New York City helped develop a computerized vision therapy program for binocular vision, and the whole area of convergence insufficiency and so on. He was one of the founders that helped develop the CISS questionnaire. In terms of percentages, the fastest growth would be the ophthalmology version of vision therapy for convergence insufficiency.
The problem that we face is when you don’t measure convergence, do a cover test, measure the child’s phoria, or measure what the accommodated response is, then you are not going to find it. That is part of the eye exam, and always should be part of the eye exam.
If a doctor dilates the child’s eyes, they are wiping out their focusing ability so the doctor can’t measure it to begin with. If a doctor does a cover test to see if the child has a crossed eye, but doesn’t measure the child’s phoria (the muscle balance of the eye), which, by the way, is all taught in first year optometry school to every optometrist, then he’s doing a disservice to the child.
If the optometrist’s goal is just to process as many pairs of glasses and refractions per day, then these are the first things that get dumped from the eye exam and are not done. There are more and more ophthalmologists getting involved in this all the time.
Question: Would you agree that vision therapy is not enough in the main stream?
Dr. Fuerst: I absolutely, wholeheartedly agree. Part of the issue is that doctors have a set protocol for a routine eye exam. The patient comes in, they check him in at the front desk, fill out paperwork, take down insurance information, the technicians do the basic tests and then put the patient in the doctor’s room and buzzes the doctor, then the doctor goes in and takes over. They can turn out patients every 20 min and make a great living that way. Now, how does that type of doctor fit vision therapy into their “protocol” or scheduled template which they use for each patient that comes in? Therein lies the problem. How can they make it work in their practice?
Question: So is the reason more eye doctors don’t offer vision therapy laziness?
Dr. Fuerst: It’s deeper than just that. Let’s turn the tables a bit. Ortho-K and CRT is FDA approved, so do you feel that it’s viable?
EyeCarePro: Absolutely. I’ve been researching OrthoK a bit, and do believe it’s a very good solution for Myopia.
Dr. Fuerst: So how come more doctors don’t offer Ortho-K and CRT?
EyeCarePro: That’s a good question. It is very profitable.
Dr. Fuerst: What it is, is that there are a lot of doctors that have a pucker factor – they want to be an expert in something before they do it, but how do they become an expert unless they practice and do it?
Vision therapy is in this category. If you were to take an informal poll of a dozen optometrists, you will get some that say “I have no interest in that.” A bunch that say “I always wanted to do that but I just couldn’t figure out how to integrate it into my practice.” Then a few that say “I tried it a little bit, but I couldn’t make it make sense money-wise.” So, it’s not laziness, it’s not knowing how to integrate it and/or wanting to be an expert before offering the service.