Dec 2016

Paediatric binocular vision
What about that phoria? Jack’s story
Jack presents to a paediatric optometric
practice, on referral following a recent
educational psychology assessment. Jack, age
12, thinks his eyes are fine, and this was recently
confirmed at his ‘free’ optometric eye test two
weeks ago.
At school Jack has always struggled with
handwriting, copying off the board and maths. He
is OK at reading but has a low processing speed,
and is not completing tests or assignments on
time. He is off to grammar school next year and
Mum is concerned about how well he will keep up
with the curriculum, “I know he is smarter than his
test results show”. Jack is fit, happy and well with
no general health concerns.
Their family history is positive for maternal
moderate myopia of late teen onset. Jack’s
developmental history is uncomplicated and he
has no history of concussion or significant injury.
Structurally Jack’s eyes are fine, he is an
emmetrope with healthy eyes and normal colour
vision. He has passed his B4 school check, school
vision screenings, GP eyesight check and the recent
optometric eye test.
During an ocular motility examination Jack can
Fig 1. Howell Near Phoria
BY EVAN BROWN*
make smooth eye movements in all positions of
gaze but he would prefer to track and saccade by
moving his head, rather than his eyes. He has a
normal near point of convergence. Cover testing
reveals a mild exophoria of 4pd using a Howell
Card (fig 1.) and 6pd behind the refractor head.
Jack shows a normal accommodative range and
his relative accommodation findings are normal.
His MEM for complex word reading is +0.50 DS OU,
and moves out to +0.82 on easily-known words. He
finds the green side prominent and dots clearer on
the Shapiro-Evans Golf Ball (fig 2.).
A brock string probe shows remote vergence
posture, and positive fusional vergence ranges
at near are low. AC/A assessment reveals a low
minus gradient and moderate plus gradient. The
Richman-Garzia Developmental Eye Movement
Test shows vertical processing speed at 30th
percentile (primarily recognition), horizontal at
the 2nd percentile (recognition and tracking). The
Berry-Buktenica Visual-Motor Integration test
demonstrates normal graphic-motor (drawing)
ability, but Jack’s knuckles are white with tension
and effort.
Discussion
Fig 2. Shapiro-Evans paddle
So does Jack have a
visual problem that
might impact upon his
learning aptitude? The
literature demonstrating
association between
vision problems,
behaviourally at-risk
pupils and adjudicated
adolescents would
suggest this is an
important question to
answer 1-6 .
We can think about
a phoria as a muscle
Surviving a brain injury
When Professor Clark Elliot suffered
a traumatic brain injury in a car
accident, he was told to get used to the
debilitating symptoms that prevented him from
living the life he loved. But as a single father and
professor of cognitive science, he wasn’t about
to let that be the end. Together with a neurooptometrist,
he fought to restore his visual and
mental function. NZ Optics caught up with him to
ask him a bit about his life, his work and his book,
The Ghost In My Brain, about overcoming brain
injury.
What did you do before your injury?
At the time of the accident in 1999, I was a
tenured professor of artificial intelligence and
cognitive science at DePaul University in Chicago.
My research area was computational models of
human emotion. I was working on a computable
model of story generation based on complex
emotional interactions of the characters. Prior
to my life as a professor, I was a professional
classical musician studying at the Eastman School
of Music.
How did the injury happen and when did
you know something was wrong?
I was rear-ended by an SUV while waiting at a
red light. I didn’t think much of the crash at the
time. I seemed to be OK, but from the moment of
impact very strange things began happening to
me. For example, I was holding my insurance card
in my hand, but I couldn’t figure out how to give
it to the police officer. On my way home, I realised
I had completely lost my previously infallible
sense of direction. I couldn’t figure out how to
walk from the car to my front door and I couldn’t
work out how to unlock the door.
Concussion is insidious this way: often the brain
machinery necessary to realise that something
has gone missing is exactly the same machinery
that is gone. I couldn’t initiate action; it might
take me 10 minutes to rise from a chair. I couldn’t
make decisions. I was often nauseated from
balance problems. I didn’t understand time or
dates any more. I couldn’t understand what
people were saying to me. I was overwhelmed by
any kind of loud sound. But I still didn’t realise
BY JAI BREITNAUER
anything important was wrong until days later.
I finally sought help after deciding it wasn’t
normal for me to take six hours to figure out I had
put my shoes on the wrong feet.
Even so, it was probably six months before I
even began to understand this wasn’t like a case
of the flu that would soon get better - that I had
a serious injury. Doctors told me many times that
I would never recover, but it wasn’t until my third
year that I finally came to terms with that.
Why weren’t the professionals you first
spoke to more helpful?
The doctors were almost universally wellmeaning
and had something been immediately
dangerous they would have saved my life.
Unfortunately, especially then, the medical
treatment for brain injury was essentially, “Can
you go away now? …because I can’t help you
and if you don’t get better on your own there
is nothing we can do.” This was frustrating for
everyone. What I heard over and over was that
after two years of possibly terraced improvement,
no one ever gets better so I should learn to live
with my symptoms.
What was the turning point for you?
After eight years I was at the breaking
point where I would lose my job, my house,
custodianship of my children and become a ward
of the state. In a last-ditch effort, after reading
Norman Doidge’s The Brain That Changes Itself
we began searches on ‘brain plasticity’ and found
Dr Donalee Markus (originator of Designs for
Strong Minds, a programme to improve ‘mental
flexibility’), who in turn immediately referred
me to her colleague Dr Deborah Zelinsky, (a
neuro-optometrist in Illinois). Within a month of
starting (brain retraining) treatment I was about
70% recovered.
That’s incredible, what did they do and
how important was the vision element?
Dr Donalee and Dr Zelinsky both work at
reconfiguring the brain through retinal
stimulation, taking advantage of the brain’s
plastic nature. Dr Donalee works at cognitive
restructuring with visual puzzles and Dr Zelinsky
or motor imbalance, however another way
of interpreting the information is that it is an
indication of the ease and accuracy with which
that individual is centring the visual process to
gather and process information.
Is there a vergence lag or lead in the process?
How does this person organise associated
processes such as accommodation, central
suppression, attention and effort to achieve single
clear perception?
Will this phoria cause more problems when the
visual process for acquiring information becomes
dynamic, as when making the continuous,
effortless saccades required to read fluently?
The optometric results for Jack suggest this is
probable. Jack can recognise and name a vertical
array of numbers within the normal variance for
his age, but place the numbers in a horizontal
spatial array and his accuracy and speed slow to
below the fifth percentile! Acquiring information is
now slow and an effort.
Jack can draw patterns and shapes to the
80th percentile for his age on a standardised
assessment of drawing, but produces the content
equivalent to a nine-year-old in a simple sentence
copy test under time constraint.
So the message here is simple. All children
attending an optometric evaluation should
receive in-depth binocular and accommodative
assessment when presenting with performance
problems at school.
How should you measure that phoria?
The question phoria assessment asks is: “does
this person organise their visual system closer
to or further away from the stimulus presented.
To answer this question it is important to not
penalise proximal awareness - this is why I like
using the Howell Card as a primary tool for
assessing the ‘phoria’ 7 .
The Howell Card probes the disassociated phoria.
Disassociation uncouples the disparity component
used in centring but proximal, tonic, consensual
and blur driven components remain active.
When asking the patient to look through two
small apertures (the refractor head) we penalise
proximal awareness and will likely obtain a finding
that does not reflect the person’s true proximal
works with prescription
eyeglasses. In my case,
Dr Zelinsky, using neurooptometric
testing, found
healthy tissue in my brain
which she could work with.
She redirected the output
from my retinas to emphasise
those healthy pathways
through my brain, balancing
centre, peripheral and nonimage-forming
retinal input
as well. We think of these as
dirt roads through new brain
areas. Dr Donalee then had
me rehearse structured visual
Professor Clark Elliot
puzzles over and over to turn
those dirt roads back into the
super-highways that let me return to my work as
a professor.
The key that makes these treatments effective
is that the human brain is primarily a visualspatial
processing device, down to the very core
of how we represent the symbols that are at the
root of what makes us human. And our retinas
are essentially a crucially important part of our
brains hanging out the front of our heads—the
perfect window for assessing and treating this
magnificent device.
How has your recovery affected your own
professional life?
response.
If the target does not offer a strong
accommodative stimulus we will likely receive a
different result. Clinically, the tests we use need
to be consistent and we need to understand the
limitations of the information generated.
The magnocellular dorsal ambient stream
has been credited as providing us with the
construct platform from which we perceive space.
Proprioception, audition and vestibular input
have a role in the overall interpretation of spatial
relationships such as ‘which way is up’, ‘me to it’
and ‘it to it’. But ophthalmic professionals know
that changing a person’s visual input with lenses
or prism will alter their perception of distance,
velocity, midline projection and balance.
We can help Jack to manage his remote visual
centring responses by prescribing appropriate
lenses, prisms and or optometric vision therapy, so
that he can enjoy and achieve academically with
an efficient and sustainable visual process. ▀
References:
1. Zaba J. Social, emotional, and educational consequences
of undetected children’s vision problems. J Behav Optom
2001;12:66-70.
2. Johnson R, Nottingham D, Stratton R, et al. The vision
screening of academically and behaviorally at-risk pupils.
J Behav Optom 1996;7:39-42.
3. Johnson R, Zaba J. Vision screening of at risk college
students. J Behav Optom 1995;6:63-65.
4. Johnson R, Zaba J. The visual screening of adjudicated
adolescents. J Behav Optom 1996;10;13-17.
5. Maples W, A comparison of visual abilities, race and
socio-economic factors as predictors of academic
achievement. J Behav Optom 2001;12:60-65.
6. Johnson R, Zaba J. The link: vision and illiteracy. J Behav
Optom 1994;5:41-43.
7. Howell E. The differential diagnosis of accommodation/
convergence disorders. J Behav Optom 1991;1:20-26
* Evan Brown is a certified
behavioural optometrist with
specific interest in visual
dysfunctions related to learning
and paediatric optometry. He is
co-lecturer for the ACBO practical
vision therapy programme and
clinical co-director for the NZ Special
Olympics Healthy Athletes Opening
Eyes Programme.
Because of my own experiences, I am filled with
compassion for the six million people living
with the long-term effects of brain injury in the
US alone. I wrote The Ghost In My Brain with
the idea that we might make some dent in
this epidemic. Coinciding with publication I’ve
seen an international groundswell of interest in
understanding brain injury, and because of this
I’ve spoken to more than ten million people via
radio and TV interviews. Along the way I’ve run
into scores of highly dedicated people working
at the leading edge of these new plasticitybased
approaches to treatment. Through them
I’ve learned a great deal about neuroscience
approaches to understanding the brain.
I’m still an A1 scientist at heart. But I’ve
come to realise how crucial it is to develop
much more sophisticated models of the visualspatial
nature of human
symbol processing - the
symbols that give us our
internal human voice and
awareness.
What role do you think
optometry has in the
rehabilitation of brain
injury patients?
Neuro-developmental
optometry is the wave of
the future. It will be at
the core of understanding
how the brain works and
of diagnosing problems
and fixing them when
something goes wrong
with cognition. Consider, for example, that even
in listening to the world around us, including
speech, once our brain has detected the audio
input signal all the rest of the massive processing
that goes on to interpret the meaning of those
sounds is visual-spatial in nature: I tap a wine
glass behind your ear, you see the glass in your
mind’s eye, you understand what it is, where
it is, and that it is not you. You see the color of
red wine. You know you can drink it. You recall
two friends you shared wine with last week at a
restaurant. So hearing is primarily visual-spatial
in nature, so is proprioception, so is planning and
decision making, and significant elements of
both our complex human emotion system and
our spiritual lives. Retinal processing is also part
of our balance systems and helps control our
emotional body states.
You are having hearing problems? You might
need glasses that treat all three of the retinal
pathways. You have balance problems? You
might need glasses. You can’t think? You might
need glasses. You are anxious or have attention
problems? You might need glasses.
A major pathway into understanding cognition
is through the retinas and neuro-developmental
optometry will be one of the foundations of
neuroscience in the years to come. ▀
For more information about Professor Elliot
or his book, The Ghost In My Brain, visit www.
ClarkElliott.com
December 2016
NEW ZEALAND OPTICS
21