It is commonly understood and believed that vision therapy is great for treating children and adults that suffer from amblyopia, strabismus, and deficits in basic visual skills such as accommodation and oculomotor function.
However, I want to share a little secret with new graduates and all eyecare professionals, who may not have had much exposure to vision therapy.
Vision therapy is not "muscle training," but rather the training/re-training of the visual pathways to create more efficient ways to gather, process, and integrate visual information.
Geared with this understanding, vision therapy can be used to treat many patients, including those with various special needs.
I HIGHLY recommend you purchase “Visual Diagnosis and Care of the Patient with Special Needs” by Drs. Taub, Bartuccio and Maino. This book is my go-to for understanding all aspects of different special needs populations and how to manage them from a visual standpoint.
These are some of the more common special needs patients that I encounter, and how I approach treatment and management:
1. Acquired Brain Injury (Including TBI, CVA, and Vestibular Dysfunction)
TBI in particular has become a massive area of research with the recent focus on the effects of concussions. We are now realizing the huge impact these injuries have on our visual systems, mostly impart due to coup/contra-coup mechanism that shears axons, impacting the biochemical cascade and slowing the transmission of signals within the brain. The end result is usually patients suffering from the following visual issues:
- Oculomotor dysfunction
- Accommodative deficits
- Visual memory and visual attention deficits
- Visual motion sensitivity
- Visual information processing issues
- Visual-Vestibular interaction deficitis
- Spatial localization problems
- Visual field defects
- Tear Film Insufficiency
For this population, my advice is to:
- Go Slow. If it takes 2-3 exams to gather all of the information you need to properly diagnose and understand all of the patient’s visual issues, that is okay.
- Be Patient. Vision therapy may take longer with a TBI patient versus a ‘non-TBI’ patient with similar diagnoses.
- Trial Therapy. I typically do a ‘trial’ of 12 sessions with my TBI patients to be able to gauge how the patient responds to therapy and track rate of progress. After those 12 sessions, I can have a better estimation for the patient/patient’s parents on how long the remediation process might take.
- Set Goals. What is important to the patient? If you get the patient’s findings to improve, but they still can’t function in everyday life, therapy was NOT a success.
- Integrate. The key to success with TBI patients is using the final stage of therapy to focus on integrating the visual, auditory, and vestibular systems. Challenge the patient to complete visual tasks with all of these systems working together.
Tip: Check distance fusional ranges in this population or use the new Bernell Tannen Flipper developed by Dr. Barry Tannen to assess distance fusional facility! Oftentimes, TBI patients show a deficit in distance fusion that translates into a sense of visual instability to the patient. Work on this with projected vectograms/RDS or prism flips (BI/BO) with a distance target encouraging fusion.
2. Autism Spectrum Disorder
Before optometry school, I worked as a vision therapist under Dr. Melvin Kaplan (Tarrytown, NY) who primarily deals with the Autistic population. He has a very different approach to therapy, mainly utilizing yoked prisms. You can read more about this in his book "Seeing Through New Eyes."
There are many different views on vision therapy within this population, and my intent is not to recommend one specific treatment method. What I want to focus on is one of the most important things Dr. Kaplan taught me when working with these patients:
" Labels are for cans, not for kids."
What this means is to not look at a child's (or adult's) diagnosis/label, but rather look at their level of visual function, and determine your approach to their therapy and set goals from there. You will be surprised at what can be accomplished in therapy when there are no pre-conceived notions.
My advice for this population is as follows:
- Be a team player. ASD is a pervasive disorder affecting every aspect of your patient’s life. This means you will be part of a large team of medical professionals helping your patient reach their highest level of functioning. Be open with your approach .
- Observe. If you take the time to really look at your patient and how they approach tasks visually, they will give you all of the answers you need to understand their visual system. Even when they are non-verbal.
- Think Outside the Box. There is no ‘cookbook’ approach to vision therapy here. Each patient will be different and your therapy must reflect that.
3. Learning Disabilities
5% of the population has been classified as learning disabled! The chapter on learning disabilities in the Visual Diagnosis and Care of the Patient with Special Needs written by Drs. Garth Christenson and Eric Borsting, describe learning disabled as, "a heterogeneous group of learning problems." They indicate that, "Affected individuals often show anomalies in neurologic functioning, educational achievement, social/emotional status, and/or attentional issues. These lead to difficulties in one or more of the following areas: listening, reading, writing, reasoning or mathematical skills."
From an optometrist's perspective, it is a good idea to be aware of the common disabilities. Included in this list are:
- Non-specific reading disabilities
- Dyslexia (all types: dyseidesia, dysphonia and dysphoneidesia)
- Non-verbal learning disabilities such as poor motor coordination, poor organizational skills and social awkwardness
Just because a patient suffers from a learning disability in one area, does not mean all other areas are affected. You may have a child who is dyslexic, but has exceptional skills in another area.
For this population I recommend:
- Taking a Complete History. Have the patient fill out paperwork, asking specifically if there are any learning disabilities. If it is not filled out, you must follow-up by asking the patient/parent directly. Don't be shy, it is a very important piece of the puzzle. If necessary, a child can be taken into a separate room to 'play' if the parent feels more comfortable talking about the disabilities without the child being present.
- Perform Visual Information Processing (VIP) Testing. Almost all of my vision therapy work-ups include a full battery of VIP and visual perceptual testing skills. Adding in tests that screen for reading disabilities help me flag any potential patients that may have a learning disability versus a visual issue. If something is amiss, I will refer out for proper educational testing. Here are some of the tests included in my work-up:
- Development Eye Movement Test (DEM)/Visagraph
- Test of Visual Perceptual Skills (TVPS)
- A phonetic skills test: WIAT-II
- Test of Silent Word Reading Fluency (TOSWRF)
- If suspected, the Dyslexia Determination Test (DDT)
- Others: Tach/Span, Wold Sentence Copy
- Golden Rule. Vision therapy can help a patient with a learning disability! Don't automatically rule out a person with a learning disorder for vision therapy. Yes, they may have dyslexia, but their accommodative and convergence insufficiency isn't helping their cause. Set your goals accordingly for your patients!
My hope is that all of you new graduates see the potential of vision therapy, the vast amount of people it can help and how many lives you can change!