"The eyes respond to light. Vision, or the sense of space, emerges from the way the eyes work together. One cannot predict this locating skill from the condition of one eye or the other."
My own relationship to my vision was haphazard but began in fourth grade when, having difficulty sitting still in class, I was diagnosed by our local ophthalmologist as being near-sighted.
Lenses with minus diopters — the refraction unit indicating the strength of correction — were prescribed. By college, I was wearing minus 6 lenses, which is probably about legally blind.
Having suffered through college from vague perceptual distortions, occasional dizziness and a lot of anxiety and yet being in the safe environment of a small campus, I discarded the lenses except for driving, which I seldom did then. This was in 1978. By 1980, I was able to drive my uncle's speedboat and locate water skiers while driving the boat at a distance of about two football fields away. My nearsightedness, or myopia, was not cured, but I was seeing better, and subsequently have passed driving visual exams without my lenses — now at a minus 3 diopters — ever since.
By then, I had read works by William Bates, an ophthalmologist, who about 70 years ago had found even more profound improvements to be the norm for myopic patients who he treated with reduction of stress and training in eye movement.
It was 1980 when I met Cincinnati optometrist Bruce Wolff, who had a complete vision training program for children and adults. Little did I or the medical community at large know that vision training not only was addressing many common eye problems but also was improving the treatment of attention span problems and learning disabilities in children and adults.
As I knew from reading Bates' work, Bates measured improvements in nearsighted patients by watching the "error of refraction" on his patients' retinas — the backs of their eyeballs — and theoretically observed correction of these errors through his eye training. Instead, as it turned out, he really had no accurate anatomical explanation for his results. On the other hand, Bates had been able to greatly reduce the development of myopia among schoolchildren by having them use their distance vision periodically throughout the school day. This result has been repeated today by optometrists under more rigorous research conditions.
By becoming familiar with Wolff's program in Cincinnati, I discovered that Bate's exploratory results had been somewhat transformed. Wolff was training in the 1940s and 1950s, which saw an explosion of research and discovery surrounding the care of vision as opposed to the care of the eyeball.
Optometry was now the field focusing on vision. As Wolff, who died in 1989, wrote, "Visual space ... involves what we see now and what we have seen (visual memory); and what we can visualize in anticipating the future as well as in imagination."
Lenses, starting with an optometrist named Skeffington and others, now were not only used for correction of a problem, but for changing visual space to train the eye or, perhaps put in even a better way, to allow the eye to work to its potential. The range of results became measurable with mathematical precision — how the eye tracts for example, or how the eyes work as a team, enhancing binocularity.
The results of improving these measurements are more far-reaching: from correcting crossed eyes or eyes that point away from each other, to improvement in the nearsighted, to enhance posture and coordination and the reduction of stress during near-point work. This last effect was extensively studied by one of Skeffington's associates, Boyd Harmon, an M.D. at the age of 17, who demonstrated that a weak plus diopter lens — a slightly concave lens — could enhance the reading without stress phenomenon in schoolchildren.
Practitioners then began finding they could reduce attention span problems and provide help in learning disabilities.
More dramatically, Wolff and others, particularly a psychologist named Samuel Renshaw, applied eye training to improve the eyesight of aviators during World War II. By resolving myopia to the point where these aviators could spot enemy fighter planes, more aviators were incorporated into the flying forces.
Wolff went on to provide vision training for the Cincinnati Reds from 1960 to 1962. I remember seeing a vision training picture of a very young Pete Rose in Wolff's office.
Later, in addition to running a practice, he consulted to organizations dealing with cerebral palsy, learning disabilities and childhood education.
Seeing is believing in Cincinnati
The Wolff Vision Center, now directed by Dr. David Muth, carries on Wolff's legacy in Cincinnati. But this is really a limited statement. Almost every behavioral optometrist I talked with, regardless of where in the country, deferred to Wolff.
"He profoundly influenced my thinking," says Dr. Paul Harris, of the Baltimore Association of Behavioral Optometry.
The 1960s, 1970s and 1980s saw a fragmentation of the field into multiple approaches.
Some optometrists — who traditionally do standard correction with eyeglasses — now are lobbying to be more like ophthalmologists, providing pharmaceutical and surgical therapies for eye disease. Others are practicing any number of styles of behavioral optometry, providing lens training, vision training or both.
For behavioral optometrists, lens training and vision training are not truly separate. Training glasses can be worn in everyday life to train the eyes during work and play activities.
The patient can then supplement this training with specific tasks in the optometrist's office.
Although the optometric research is voluminous, it is not coordinated under any single organization with any focused funding. The medical profession remains largely unaware of all of this, although many ophthalmologists have begun to realize that lens correction has somehow developed beyond tradition, and they are referring patients to optometrists.
Some elementary schools in Cincinnati also have been referring children to behavioral optometrists for years, and the fact that children can see with 20/20 vision but have functional vision problems such as the eyes not working as a team has led to the notion of "hidden disability."
"To think of many visual problems as something wrong, or as a disease, is not very useful," says Muth, sitting in his office at the Wolff Vision Center in Springdale. "We live in a very myopic environment, for example, so myopia, as an adaptation, can make sense optemetrically. The point is, instead of changing the environment, which we often can't do, to use lenses to change visual space optimally and attempt to optimize vision as a result."
Walk to the back of the Wolff Center, and you might see a child crossing a low balance beam, called a walking rail, wearing different prisms that change surrounding space, making it larger, smaller or slanted. The child might be wearing stress relieving "plus" lenses and tracing a figure from visual memory after it is flashed on a board for a hundredth of a second. After walking the rail, the patient might be asked to focus on a Vis Flex — a red light that moves along a steel bar on a tripod, working on the smooth transition of the eyes, from very close to farther out and at the same time centering the vision to maintain binocularity or teamwork of the eyes.
Accu vision, another therapy, has the child moving all over a vertical board, touching different quarter-shaped spaces that light up in different patterns, using both hands and different lenses that change visual space for the type of skills an athlete needs.
"All of these tasks are essentially similar to biofeedback," Muth says.
Despite the specific visual measurements each task attempts to train, all exercises are trying to establish visual centering, allowing the individual to develop the three-dimensional sense of himself in his environment.
How the eyes work (and don't)
In terms of the lens of the eyeball, the lens muscle is the only one in the body that has a muscle to flex or look close and does not have a separate muscle to extend or look back at the distance. Looking back at the distance then, involves relaxation. As in biofeedback, this requires adjustments in the autonomic, usually "involuntary," nervous system.
Although vision training ultimately is about just how we move through space, the parameters that create the training are: centering, the ability to look "where it is"; identification, or seeing "what it is"; binocularity, or the process of developing centering and identification; and the individual's visual space, which is part of human development.
Arnold Gessell, a medical doctor who extensively defined visual development in newborn children through early childhood, says, "Early, eye-guided movements of the hand are the 'dress rehearsal' for the day when it becomes necessary to follow the lines of the printed page."
An initial optometric exam also will include screening for pathology and possible referral to an ophthalmologist, an extensive general interview and an assessment of posture, movement, speech and hearing as they relate to vision as a "lead system."
Harris describes his practice in Baltimore in terms of the types of visual "problems" treated, including learning visual problems due to eye-tracking difficulties, eye-teaming difficulties and visual focusing difficulties. Group 2 treatments are for eye turns (strabismus) and lazy eyes (amblyopia). Group 3 treatments are for performance and or stress-related visual disabilities such as attention difficulties, reading comprehension problems or slow reading speeds. The patient also might be experiencing headaches, double vision or general eye strain and fatigue.
My own biggest reason for referral to behavioral optometrists in adult friends and patients has been eye strain associated with computer use. A cardiologist friend was able to immediately reduce his minus correction — lens correction for nearsightedness — from 7 or 8 diopters to 4 or 5, with relief of headaches he had had chronically for years.
Recently, a young adult entering the business world received a mild plus lens to put over her minus diopter contacts when using the computer terminal. She now notices the relief of eye strain to the point where she "won't use the computer without the glasses."
The parents I talked to in Muth's office were most satisfied with the effects of vision training on school performance for their children.
As to when to start treatment, because many problems can be prevented in the first place, the earlier the better. Early in life, the environment of the developing infant can be changed. For example, not feeding an infant from only one side all of the time or making sure exposure to bright light is not always from the same direction.
Later, treatment might involve only lens adjustments or lenses and training and might take six months to two years.
This time is variable depending on the problem and the individual's motivation and flexibility.
Despite the nature of the field, its results and its basic science, and perhaps because of its youth, behavioral optometry is unknown to most medical doctors. Part of this is that it is not even an alternative medicine but an alternative field altogether.
"One of the problems for M.D.s in understanding our field," says Dr. John Streff of Lancaster, Ohio, "is that they look for an understanding in terms of a specific mechanism, such as biochemical reactions, surgical corrections or a single neuromotor pathway. Vision, however, is sensorimotor, with an emphasis on motor."
Thus visual improvement, ultimately, rather than any one process or reaction, is measured by improvements in performance, which may be visual and motor, intellectual or emotional.
"But there is a dilemma in the field," Muth says. "The '70s and '80s saw a loss of attention to original discoveries and practices to the point that even national optometric associations have not only lost some of the original concepts but can't agree among themselves on correct terminology and practice. Many if not most professionals miss the idea that a majority of common vision problems are actually adaptations to a type of visual space. Although these adaptations can help us control our environment, they often exact a cost. Also, even most optometrists are only vaguely familiar if even aware of what it is we do. Finally, our culture itself is quite concerned with the quick fix rather than long-term solutions that give the individual more control over long-term destiny."
This essentially warns the consumer to find a behavioral optometrist with advanced training and advanced experience, not to mention results.
Russell Firor, m.d., is a doctor of internal medicine practicing in Cincinnati.