Feature Article: Optometric Vision Therapy for Visual Deficits and Dysfunctions: A Suggested Model for Evidence-Based Practice Graham T. Peachey, B. Optom, FCOVD, FACBO Paula M. Peachey, Opt. Disp. COVT Editor’s note: To preserve the international flavor, we have elected to utilize the authors’ Australian English spelling, which differs in some respects from their American English counterparts. Owing to the length of the article, we have incorporated a brief content outline as a preview.

Content Outline Abstract Keywords Introduction • Factors that comprise functional vision efficiency • An evolving approach to optometric vision therapy (OVT) • Evidence-based practice (EBP) Part 1: EBP Principles Related to Best Research Evidence and Theory Correspondence regarding this article should be emailed - Science of mind and neural plasticity to Graham T. Peachey, B.Optom, FCOVD, FACBO, at [email protected]. All statements­ are the author’s - Neuro-developmental aspects of functional personal opinion and may not reflect the opinions of the vision College of Optometrists in Vision Development, Vision - Dynamic functional vision Development & Rehabilitation or any institution­ or organi­ - Visual science and functional vision zation to which the author may be affiliated. Permission development to use reprints of this article must be obtained from the editor. Copyright 2015 College of Optometrists in Vision - Functional vision and cognition Development. VDR is indexed in the Directory of Open - Principles of learning Access Journals. Online access is available at covd.org. https://doi.org/10.31707/VDR2015.1.4.p290 Part 2: EBP Principles Derived from Clinical Peachey GT, Peachey P. Optometric vision therapy for Expertise and Expert Opinion visual deficits and dysfunctions: A suggested model - Functional visual deficits and dysfunctions for evidence-based practice. Vision Dev & Rehab - Visual inspection schemata 2015;1(4):290-339. - Optomotor functions - Technology and optomotor biometrics - Optometric vision therapy interventions Keywords: defects, deficits and dysfunctions; discharge-graduation Part 3: EBP Principles from Patient / criterion; disruptive technology; dynamic Caregiver Perspectives vision; optomotor cycle; evidence-based - Patient-centered services and OVT practice (EBP); instructional set; motor - OVT as a goal-oriented and diagnosis- learning neural plasticity; optometric focused intervention vision therapy (OVT); perceptual learning; - Therapeutic alliances and collaborations - Criterion-referenced therapy and discharge schemata; therapeutic alliance Summary and Conclusion

290 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Abstract Evidence from neural science supports a neuroplasticity thesis where the development and rehabilitation of functional neural pathways can be facilitated by management of biological factors, central processing and environmental interactions. Healthy eyes and clear sight are not themselves sufficient for efficient functional vision. How a person uses vision determines their operational skill. Efficient functional vision requires dynamic interactions between and within visual receptive and reflexive biology, acquired neural networks that serve basic visual inspection processes and visuo-cognitive operational patterns driving top down visual – spatial analysis and problem solving.

This presentation is a review and discussion of evidence-based practice (EBP) principles that we utilise in clinical neuro-developmental and rehabilitative optometric vision therapy (OVT) for selected visual deficits and dysfunctions.

OVT services, like other collaborative therapies such as cognitive behavioural therapy, speech therapy and occupational therapy, must progressively adapt to new knowledge and advancing technology through EBP. Clinical services directed at treatable neuro-developmental and acquired dynamic functional vision problems require the application of an emerging set of principles resulting from systematic logic and EBP related to the art and science of case analysis, practice management and OVT delivery.

INTRODUCTION occlusion, and stimulation procedures to initiate Contemporary neural science, visual science ocular calisthenics, fixation reflex, fusion reflex and clinical research have advanced the and diplopia awareness responses. The early understanding of functional vision efficiency concepts of visual function were linear input and the treatability of specific aspects of —> black box —> output in nature. They can visuo-motor and perceptual organisation. The be characterised as a bottom-up perspective, as emerging science of the mind has recently vision was considered something that happened combined with visual science, innovative “to” a person. The eyes were viewed as optical laboratory technologies adapted for clinical systems that responded relatively instinctively measurement and consequential systems for and were not greatly influenced by the mind- management that are applicable to optometry. set or cognitive functioning of the viewer.1,2,3 Neural science and innovative technologies are With the realisation that binocular vision was for vision care providers ‘disruptive’ because an intrinsic psychic faculty and that voluntary their use and application extends clinical services mental effort could play an important role in beyond the usual defect/dysfunction construct. the treatment of selected strabismic patients, Our goal is to detail the evidence-based practice top-down models of visual function began to (EBP) and applicable principles related to neuro- emerge. Early behavioural views of vision have developmental and rehabilitative optometric needed to adapt and shift perspective to clinically vision therapy (OVT).1 apply the new paradigm. Neural science now Historically, early vision therapy philosophies supports a functional neural developmental and were based on visual biology and reflexive rehabilitative plasticity construct where biological physiological optics. This produced “orthoptic” factors, central processing and environmental procedures that were applied to the patient. These interactions contribute.4 Additionally, the neural early procedures included lens prescriptions, basis for self-directed visual inspection, working

291 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 memory, procedural memory, motor learning subitizing can be identified and now objectively and perceptual learning has become better assessed. understood. Traditionally only aetiological distinctions Both top down and bottom-up processes between adverse environmental factors, bio­ are now known to influence human neural logical defects and behavioural dysfunctions development, neuro-cognitive operations and could be made. Essentially, the optometrist functional vision efficiency. Research5,6,7,8,9 sought to understand positive and negative has added understanding to how executive environmental influences on child health and control comes to gain voluntary management welfare, child development, functional vision and over important aspects of visual inspection. school readiness. Clinical assessment then moved Under natural viewing conditions our eyes are to defect analysis by objective measurements of continuously moving and jump from place to structure, aspects of eye health, neurology and place making about 3 fixations per second. Eye physiology, and then the use of observational movements provide spatial exploration while fine assessments to psychometric performance tasks detail and feature analysis requires accurate and to identify dysfunctions. stable fixation. The quality of static vision clarity As neuroscience added to the neuro- is measured by visual acuity but the quality of developmental understanding of functional dynamic vision is not. Dynamic vision requires vision, research measurement technology was coordinated organisation of eye movement, adapted for clinical use. Since 2002, clinical fixation hold, and attention to detail. The quality identification of basic neuro-developmental of a person’s dynamic vision can be measured optomotor and perceptual deficits has been by procedures that use dynamic stimuli. The possible.12 The ability to make an aetiological subject must process the time order and the clinical distinction between reported adverse content of the incoming spatial and feature environmental factors, and diagnosable defects, related neural messages to gain ‘meaning’ from deficits and dysfunctions has resulted. functional vision. Measurement technology can now objectively Dynamic functional vision abilities develop assess basic neuro-developmental functions of as each person learns to integrate their visual optomotor and perception. Delayed acquisition inspection and processing systems. Their of the functional neural circuitry for age optomotor cycle10,11 then assists in the self- appropriate fixation stability, binocular stability, directed management of when to look, what to dynamic vision, saccadic organisation and look at, how to analyse and understand what selected perceptual thresholds can be clinically is viewed, when to leave a target, and where diagnosed and such deficits can be effectively to go next. Basic neuro-developmental aspects treated.13,14,15,16,17 Additionally, the application of top-down visual inspection (optomotor and of criterion referenced progress assessments perception) are acquired as functional neural of these deficit biometric markers can track assemblies connect attention processes, the the OVT progress during delivery. While much ‘where am I’ and ‘where is it’ magnocellular of the speculation of early VT theorists has streams, and the ‘what is it’ parvocellular been validated, a more focused and structured stream to respond to frontal lobe based approach to OVT delivery can now emerge. executive control.12 The development of this frontal lobe component is essential for efficient An Evolving Approach to Optometric fixation stability and saccade generation during Vision Therapy (OVT) general visual inspection. Functional neuro- Optometric Vision Therapy (OVT) can be developmental deficits involving fixation stability, defined as the art and science of therapeutic binocular stability, saccadic organisation and experiential interventions appropriate for

292 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Table 1: Factors that Compromise Functional Vision Efficiency

diagnosed functional vision deficits and / or it’ deficits are then addressed by therapeutic dysfunctions. The goal of OVT is to achieve procedures that require the visual direction and optimal visual performance, comfort and control of general mobility. When appropriate, efficiency. During the OVT process, each visually directed fine discriminative activity is patient gains a greater understanding of, and added – such as having the small muscles in the operational control over, their functional vision fingers reaching for grasping and manipulation applications. tasks. Typically, these skills are coordinated with In general terms, OVT goals are achieved or in response to accurate visual inspection. by the application of a sequential therapeutic In other words, visual inspection and body intervention designed to address the specific movement controls develop and learn to work treatable functional vision neuro-developmental in combination to produce coordinated actions. issues, remediate visual inspection and perceptual The term visuomotor skills is often used to deficits and dysfunctions or to facilitate visual describe this visually directed behaviour. Specific rehabilitative neural plasticity. attention to the basic aspects of voluntary eye Initially OVT may need to address under- movements (optomotor control) and perceptual developed functional neural organisation of sub- accuracy then occurs. cortical collicular, multi-sensory, pathways that After basic optomotor ’where is it’ and provide spatial orientation. Calibration deficits perceptual ‘what is it’ deficits are remediated, within or between the vestibular, somatosensory OVT procedures then develop visual abilities and and visual maps that support ‘where am I’ non- capacities. The focus now is to efficiently apply conscious processing can be addressed.18,19 general visual inspection to relevant performance Basic visual inspection optomotor ‘where is tasks and problem solving activities. The

293 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 optometrist’s primary goal when implementing Evidence-Based Practice OVT is to treat diagnosed visual deficits and Evidence-based practice (EBP), defined dysfunctions limiting the patient’s functional as the integration of best research evidence, vision efficiency that are not totally addressed clinical expertise and patient values by Sackett45 by other methods. It is for the patient, a guided has gained considerable interest and influence learning and self-discovery opportunity directed during the last decade and can be expected to at developing the functional neural pathways remain an evolving approach to clinical decision- required for an improved functional vision making and treatment delivery. accuracy, capacity, endurance and automaticity. The OVT treatment plan, prognosis and probable duration can be predicted by careful analysis of the presenting symptoms and signs, and confirmed by the comprehensive functional vision assessment. This prediction is based on the assumption that the patient will engage and comply with the OVT plan. Patients do not often present to an optometrist Figure 1: Evidence-Based Practice (EBP) Sackett D. asking for OVT. They frequently present however, with visually related symptoms that are not EBP and basic principles applicable to the successfully resolved by traditional defect related neuro-developmental and rehabilitative OVT care alone. Specifically, the application of neural perspective are provided by fields including science, the laws of visuomotor perceptual mind science, neuroplasticity, visual science, learning and cognitive developmental principles cognitive development, perceptual learning and are used to achieve these goals. Simplistically, as educational psychology. While OVT must be Hebb20 theorised – ‘Cells that fire together, wire tailored to the needs of each individual, specific together.’ Thus repetitive applications of neural operational best-practice principles apply and pathway activation within a planned sequence underpin all case management. of related experiences are used to direct, The three essential components of EBP establish, consolidate or restore functional (Figure 1), provide context for discussion of basic neural networks. Remediation of the specifically principles applicable to neuro-developmental diagnosed visual deficits and dysfunctions is and rehabilitative optometric case analysis, conducted with experiential and instruction practice management and OVT delivery. We will procedures that ensure patient engagement. therefore divide the balance of our presentation Twenty-plus years ago basic visual science had into three major parts: confirmed the importance of the dual interactions Part 1: EBP Principles Related to Best Research of bottom-up processes and top-down controls Evidence and Theory with research that demonstrated the importance of proximal cues to the operation of accommodation Part 2: EBP Principles Derived from Clinical and convergence functions.21,22 Since then, what Expertise and Expert Opinion has been termed ‘new science of mind’ has been Part 3: EBP Principles from Patient/Caregiver introduced within many fields including; neural Perspectives science, visual science, psychiatry, developmental psychology and clinical optometry.23-44 Mindful awareness can be therapeutically applied during top-down OVT to visuo-spatial ‘where am I, where is it and what is it’ procedures.

294 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Part 1: EBP Principles Related to Best rehabilitation has resulted in what Kandel called Research Evidence and Theory A New Science of Mind. A neuro-developmental Optometry graduates in Australia, USA and and rehabilitative multidisciplinary perspective Canada are prepared as primary eye-care health to clinical interventions has been found to practitioners. To quote Anderton …‘evidence- be applicable in many clinical fields including based practice is appropriate for all aspects of mental health care, clinical psychology, speech optometry but it may be most useful in the pathology, special education and optometry. selection of treatments with topical therapeutic Top-down executive control processes of the agents and in optometry’s growing public health mind have been shown to be the basis for the role in the detection and management of sight- aspects of skillful optomotor and perception threatening disease’.47 Randomised controlled behaviour and that these aspects of efficient clinical trials have become commonly equated functional vision have milestones. Innovative in treatment- centered care to ‘evidence-based measurement technology12 enabled objective medicine’. This is appropriate when researching assessment of the developmental milestone treatments for things are ‘done to the patient’ markers that show how well a patient can such as drug or surgical trials. control their eye/head/body movements for Patient-centered care involves ‘doing things stable visual inspection, selective attention with a patient’. How things are done now and span of perception. Non-culturally biased become important. It is not just ‘what is done’ performance markers have been compared that is the determinant of patient-centered to age/grade expected responses to identify outcomes. Nursing,48 speech/language therapy,49 functional deficits. The diagnostic bio-marker occupational therapy,50,51 special education,52 measurement and treatment technology has educational psychology,53 education,54 and facilitated the application of mind science cognitive behavioural therapy55 all share the related management to OVT. The basic holistic challenge OVT has in conducting patient- neuro–developmental and general rehabilitative centered research. perspective provided by the new science of The EBP Principles derived from Best Research the mind can be succinctly summarised to four Evidence and theory will be discussed under the points: following headings: 1. Mind emerges from the structures and a. Science Of Mind and Neural Plasticity. functions of a living brain. As the master b. Neuro-Developmental aspects of regulator for neuro-endocrine, autonomic, Functional Vision. immune, and neural-integrated circuitry systems, the brain is the key organ of c. Dynamic Functional Vision. stress reactivity, coping, and recovery d. Visual Science and Functional Vision processes. Development. 2. Neural networks are formed into e. Functional Vision and Cognition. functional circuitry by experience f. Principles of Learning. dependent processes. Mal-adaptation can result from lack of appropriate and timely Science of Mind and Neural Plasticity experience, toxic stress, and poor social Neuroscience has established that neuro- support. On the other hand, beneficial developmental processes contribute to the adaptations can result from appropriate, functional organisation of brain circuitry and timely experiences, and support that neural assemblies. Basic neural science and related directly shapes the genetic expression research on the complex molecular neurobiology process. Repetitive experience is needed of neural network development, plasticity, and to maintain, strengthen, refine, and

295 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 elaborate neural circuitry on which the 2. Basic neuro-developmental optomotor mind functions depend. and perceptual deficits can be co- 3. The mind is enriched by a number of morbid with poor school performance, developed processes such as memories, dyscalculia, dyslexia and ADHD. procedural learning, perception and, 3. Neural plasticity principles apply to basic cognition. These emerge from complex optomotor and perceptual processes, interactions between genetic and as deficits in these typically respond to environmental factors.56,57,58 specific treatment procedures even when 4. The mind has a lifelong capacity to re- the student has co-morbid conditions organise and learn new tasks. Neuro- such as dyslexia or ADHD.7 plasticity refers to the capacity to change 4. Basic optomotor and perceptual learning the wiring of neural networks in response transfers to aspects of education. to maturation and experience. Positive Performance deficits diagnosed with changes in functional neural complexities FonoFix clinical procedures can be co- are more likely to result when the social morbid with dyslexia.6,8 and task experiences engage attention, 5. Clinical equipment and assessment operate at an achievable but challenging procedures from optomotor and level of demand, provide positive perceptual research tools and data have reinforcement to quickly recognise success, been developed.12 utilize task delivery that motivates repetitive interaction, and is sequentially moved in The specific focus of these assessment small steps from simple responses to more procedures is to study in detail the functional complex integrative behavior. organisation of the optomotor cycle. This is achieved by technology that objectively measures Neuro-Developmental Aspects specific optomotor and perceptual bio-markers of Functional Vision that are unavailable to direct observation. By Since the foundational longitudinal research electronically recording both right and left eye report on vision development by Gesell, Ilg, timing, movement symmetry, and saccadic and Bullis,59 the understanding of the dynamics organisation as the eyes move from light to light of both the sensory and motor contributions the clinician can study more basic optomotor has been elaborated. In the context of our operations than that addressed by, for example, discussion, key elements of neuro-developmental the Visagraph (http://goo.gl/TxZ8h2)62 analysis research occurred following the discovery of of fundamental reading eye movements. express saccades in 198360,61 as laboratory It is now evident that it may never be too research went on to further study optomotor late to influence the functional wiring of the and perceptual development. Full details of this brain. There is neural plasticity that can take research, conducted at Albert Ludwig University place at all ages as new tasks are learned. The of Freiburg can be viewed at www.optomlab. older person, however, can expect that longer com. Within that site, a brief summary of practice time and greater commitment will be evolving research along these lines is provided. required for rewiring. Case studies on subjects 1. Developmental milestones have been with diagnosed post trauma vision syndrome established for dynamic vision, fixation and the expected symptoms have shown stability, binocular stability, pro–saccade functional vision rehabilitation can assist many reaction times, anti-saccade reaction to relearn functional vision behaviours that were times, anti–saccade error percentage, lost following TBI events. Unlike the child with subitizing, and auditory–spatial decoding. neuro-developmental visual deficits, adults with

296 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 acquired neural damage can recruit undamaged stability deficits can exacerbate the procedural memory that is still stored. During condition. The text Visual Aspects of rehabilitation the therapeutic strategy is to Dyslexia6 provides a recent review of this recruit available procedural memory circuitry complex debate. and facilitate the available neurons in the 3. Post Trauma Vision Syndrome (PTVS): region of damage to re-establish functional The visual sequelae that can follow even connectivity via axonal and dendritic sprouting mild head trauma and neurological injury and synaptogenesis where new synapses are may have a severe impact on the person’s created. During OVT neural plasticity can be quality of life. Clinical rehabilitation encouraged by having the patient engage has applied Hebbian theory and neural in top-down processing that requires the plasticity concepts to facilitate the neural prefrontal cortex (executive control) to utilise potentials in the region of damage and to and access the visual processes that have been re-establish functional conductivity.9,39,40 impaired.9,39,40 4. Amblyopia: Amblyopia is a disorder Research has reported on visual neural plas- that results in an otherwise healthy ticity induced by optomotor learning, perceptual visual system from deprivation of the learning, and biofeedback experiences. Clinical necessary neuro–developmental visual and laboratory research has typically centered experiences early in life. Amblyopia on four identifiable groups of subjects: typically results from refractive and/ 1. Convergence Insufficiency Syndromes or strabismic conditions. The neuro- (CIS): These near point visual inspection developmental visual deficiencies that dysfunctions seem to have a neuro- result from deprivation were traditionally developmental deficit, a fatigue related thought to be irreversible after the first AC/A dysfunctional breakdown or a decade of life73-76 as it was assumed that combination aetiology. CIS can present the developmental maturation windows with associated basic optomotor deficits for all aspects of vision were then and symptomatic Learning to Read closed. Amblyopia is characterized by issues. Others present with Reading to several functional abnormalities in spatial Learn, quality of life issues related to vision77-80 including reductions in visual small print, reduced ability to sustain acuity (VA), contrast-sensitivity function and comprehension. Clinicians have for (CSF), and vernier acuity as well as spatial many decades considered CIS to have distortion, abnormal spatial interactions, an excellent prognosis from OVT.63,64,65 fixation instability, and impaired contour Recently the efficacy of active OVT detection. In addition, amblyopic individuals for CIS AC/A rehabilitation has been may suffer from binocular abnormalities confirmed by multi-centred randomised such as impaired binocular stability, stereo control studies.66-71 Active OVT is now the acuity, binocular rivalry, visual projection standard of care for this condition.72 and abnormal binocular summation. The 2. Specific Learning Disability (SLD/ loss of these functional vision processes Dyslexia): While this condition is gen­ is thought to result from the abnormal er­ally considered to be a life-long con­ operation of the neuronal networks within sti­tutional defect (possibly genetic) the primary visual cortex, particularly of that results in compromised language orientation-selective neurons and their related processing, other co-morbidities interactions that result from deprivation of such as treatable neuro-developmental the necessary neuro-developmental visual optomotor, perceptual and binocular experiences early in life.

297 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Perceptual learning procedures have been found to improve visual grating discriminations, stimulus orientation judgements, motion detec­ tion, texture discrimination, time to perceive randot stereograms, vernier acuity and object recognition with many amblyopic patients.81-88 These studies were designed to train specific perceptual processes by efficiently stimulating their neuronal populations and promoting self-directed spatial interactions and self-correction. Active OVT for selected patients with amblyopia is well documented and supported by case studies.89,90,91 To summarise, OVT can provide those patients who have been specifically diagnosed Figure 2: Brain structures for optomotor control and dynamic with treatable neuro-optometric deficits and vision (source Prof. B. Fischer). performance dysfunctions, the opportunity to improve these aspects of their functional The complex and dynamic interactions vision efficiency. The efficacy of optomotor between eye, brain and ocular motor processes interventions, motor learning and perceptual involve both reflex responses and purposeful learning has been addressed with the visual visual inspection. The retina in each eye codes aspects that can be co-morbid with dyslexia, the relative spatial distribution of incoming light dyscalculia, ADHD10 and amblyopia.86 Clinical components and also detects movement of any reports have provided details on the use of OVT part of the image. The processing within the for post trauma visual rehabilitation.9 Scheiman brain requires the comparison and integration of and Wick92 provide an excellent review of this information from the other sensory systems assessment, management and prognosis for to form a composite representation of the the clinical management of binocular vision environment. The images of the two eyes are disorders of heterophoria, accommodation, fused to form a single percept, and comparison fusional vergence, or ocular movement control. of the minute differences in the images from Scheiman and others66-72 have shown that OVT each eye also provides direct information about is the treatment of choice for convergence three-dimensional depth. Analysis of the relative insufficiency. size, overlapping contours, and relative motion parallax provides further clues to the structure Dynamic Functional Vision of the environment. The visual perception and Contemporary visual neuroscience has built interpretation of the environment is tempered upon Harmon’s notes on a dynamic theory of by the information from other sensory systems vision based on what is now known regarding and a person’s experience. These perceptual and the role of brain-mediated visual pathways and cognitive processes lead to a motor response networks.93 in reaction to environmental input. When Vision in this context is a constructive process attention is directed toward a component of the that emerges from eye, brain and ocular motor environment, top-down cortical control directs dynamic cyclic feedback/feed-forward loops. the eyes to fixate on the object of interest, to Figure 2 provides a simplified model of dynamic filter bottom-up distractions, to hold stable functional vision and the neural bottom-up and fixation for detail analysis and then release. top-down relationships between eye, brain and The eye is where the sensory coding of light ocular motor processes. distribution and change on the retina can initiate

298 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 basic reflex responses. Additionally, the person motor systems can use for movement and the can direct purposeful looking and tell the eyes spatial localisation of “what is it” features.94 to seek a specific light distribution. Anatomy The top-down and bottom-up neural provides a constricted macular zone for clear pathways connect mind-eye and eye-brain. Basic sight and precise binocular alignment. sub-conscious organisation is provided by the The brain is where objects in our bottom-up, often sub-cortical, reflex responses. environment are localised by two different These psychoptical reflex responses serve to alert, visual processes. Sub-cortical “where am I” orientate and protect. Top-down higher cortical magnocellular pro­cesses provide orientation and centres of the brain orchestrate the purposeful a spatial map where objects are egocentrically visual inspections critical to complex tasks such localised and the cortical “where is it” as reading. During visually directed performance, magnocellular processes perceptually analyse bottom-up neural flow can be filtered by top-down spatial relationships­ between objects via a selective attention. The motor outflow systems can retinotopic perspective. The processing of then be integrated to manage purposeful fixation information from the two eyes into a unified stability, pursuits, saccade eye movements, and the single visual percept is dependent on retino- accommodation-convergence synkinetic coupling corti­cal neurology. The higher cortical centres adjustments, with the alerting, orientating and provide top-down selective visual attention­ and protective reflexes running in the background.95 are engaged during the conscious decisions Precise aiming of this spot provides the sharpest for “what is it” processes. The parvocellular­ point of visual acuity or clarity of sight. The areas stream carries neural coding related to fine form of the retina away from the central macular or and texture to conscious perception, further fovea are less sensitive to detail; consequently inspection, analysis and recognition. peripheral visual acuity is less sharp. The koniocellular stream carries the neural coding related to colour; this pathway serves the red, green and the blue/yellow systems that colour our visual experiences (Fig. 3).

Figure 4: Eye movement and perception (Ref. Noton & Stark) Stable fixational engagement facilitates motor, optomotor and perceptual feedback loops for 95 Figure 3: Major neural streams to Brain from Retina. accurate accommodation and accom­ modative/­ vergence synkinesis.96 To obtain a complete picture The primary visual cortex is interconnected of the visual field, it is normal to perform between by the dorsal and ventral streams with the 3-5 saccades, or snapshots per second. Saccade posterior parietal cortex and the infero-temporal control is the ability of aiming the eyes to fixate cortex. A critical function of the parietal cortex and see a particular point. These movements is to spatially localise neural responses that are not random. This is illustrated by the eye enters from constantly moving eyes, to mediate movement recording taken while the subject was attention shifts and to select the next objects viewing the photograph in figure 4.97 The person or features for further attention. The “where studies fine detail by precise sensory inspection am I” and the “where is it” streams provide and feels the spatial relationships of these features information that the ocular-motor and skeletal by optomotor activity.

299 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Form perception is highly dependent on threat. Fixation stability, binocular stability efficient sequential visual inspection. Number, and the frequent of express saccades letter and sight word recognition are all (reaction time of about 100 ms) provide influenced by the optomotor control that neuro-developmental bio-markers. Per­ enables the eyes to reach out, take hold, attend sist­ent reflexive optomotor responses are to detail, and then release so they can move to disruptive to purposeful activity and the the next point of interest. Seeing (sensory) and building of motor memory dependent eye movement (motor) feedbacks from contour features rings. Normal development of analysis are connected by each person into voluntary optomotor top-down responses our unique features ring95,97,98 or sequence of is expected to modulate and selectively images each having a specific spatial location. suppress most bottom-up reflexive express An example of how the feature ring for the saccades. letter ‘A’ could be learned is shown in figure 5. 2. Slow Regular Saccades. Conscious, vol­ un­­tary saccades emerge as the mind comes to use visual inspection processes to extract meaning and understanding from the visible environment. Voluntary optomotor actions are initially dependent on active involvement of the conscious mind. Thinking time makes the response much slower than the reflex. A saccade Figure 5: Features ring (Ref. 97). reaction time that exceeds 200 ms is the bio-marker for this unskilled but task The stability of gaze control is a complex directed level of neuro developmental challenge to the visual system. The ability to organisation. select one item amongst several is a further 3. Regular Saccades. Task specific automatic development. In order to change the direction optomotor responses provide the basis for of sight quickly and accurately the stability of efficient visual inspection. With practice gaze control has to be finely integrated with optomotor and perceptual responses learn the visual optomotor functions. The top-down to become more efficient and micro- optomotor cycle (see Figure 6) links eyes, brain management delegates some control to and ocular motor processes. acquired neural assemblies. Saccade reaction times of 150-200 ms are the bio-markers indicating that neural networks have organized to support and shorten reaction time for skilled movement patterns. That is an optomotor and perceptual memory scheme, which has reduced demand on conscious attention. Schemata are built for simple tasks before they can become Figure 6: The Optomotor cycle (7). available for more complex use. Saccadic Eye movement control, like other aspects of organisation changes are first recorded for motor control, can result from three different basic tasks such as Express Eye and Fix Test functional neural loops: procedures before they can be applied to 1. Express Saccades. These are fast reflex tasks with higher cortical demand such as eye movement responses to startle or Visagraph readings.

300 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Saccade control enables the eyes to move behavioural therapy,100 occupational therapy,101 selective visual attention quickly from one education,102 speech pathology,103 low vision, point of interest to the next, and to briefly special needs,104 and orientation/mobility.105 Struc­ hold each fixation steady for attentional tured guidance principles can also be used during engagement with a perceptual snapshot. To OVT to improve selected visual inspection and obtain a complete picture of the visual field, visuo-cognitive problems. The developmental a normal adult has to perform between 3-5 processes relating to visual inspection and visuo‐ saccades and fixations (snapshots) per second. cognition begin early and take place for most Sensory and motor details are captured into people mainly as social interactions. feature ring experiences. The brain organises Foundational child development theories the constantly moving visual information from such as Piaget and Vygotsky have intertwined visual inspection so that it appears to us as an into contemporary developmental psychology unbroken stable image. It also uses saccades and educational theory.106-108 Piaget explored and saccadic suppression to selectively filter the developmental aspects of child thinking, detail that would be counter-productive to the cognition and problem solving as they interacted construction of a stable visual world. with their environment. His schemata theory assists us to understand child thinking109 and Visual Science and Functional to identify110-112 the thinking patterns that can Vision Development present. Vygotsky explored the role of an adult Severe environmental neglect and sensory or more capable peer on task performance. deprivation of young children such as unmanaged­ The Vygotsky ‘Four Stage Recursive Loop’ amblyogenic factors can result in major neural construct,113-114 has been adapted to OVT (Fig. developmental delay. Healthy neural development 7) as it provides a bridge between cognitive of aspects of functional vision results in part from developmental narrative, neuroscience and self-directed behavioural interactions. functional vision care child development Optomotor and perceptual deficits can result theories. from a delayed interconnection of the functional neural circuitry required to move visual inspection Stage One: Performance is often Reflexive performance developmentally from impulsive but modulated by social interactions. reflex responses, to slow self-directed novice Before children can function as independent behaviour, and then eventually to reasonable agents they must rely on adults or more capable fast semi-automatic and skillfully sustained peers for outside regulation of task performance. operations. In early primary grades, optomotor The amount and kind of outside regulation a and perceptual deficits are impediments that child required depends on the child’s age and the can challenge access to the learning to read nature of the task. During the earliest periods curriculum. Indeed a visual inspection pattern of development, the child may have a very that displays a high frequency of reflex express limited understanding of the situation, the task, saccades suggests that the student will not be in or the goal to be achieved. Only gradually does a state of engaged attention during many of the the child come to understand the way in which fixation periods.6,7,8,17 For students in later grades parts of an activity relate to one another or to and young adults, functional vision aspects understand the meaning of the performance. related to reading to learn can go undetected The performance a child demonstrates to unless specifically clinically assessed. an assessment procedure reflects the child’s Structured guidance strategies are applicable independent self-organisation relative to the and useful during the delivery of many human processes challenged. This performance can be services such as child psychiatry,99 cognitive expected to improve if the assessment procedure

301 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 was to be repeated after some coaching. mean that the performance is fully developed Their assisted performance would set the level or automated. of potential that is available. The difference Once children begin to direct or guide between the self-dependent performance and behaviour with their own speech an important the assisted performance defines what Vygotsky stage has been reached. A major function of called the Zone of Proximal Development (ZPD). self-directed speech is self-guidance and its This is essentially the achievable but challenging developmental origins have to do with early task demand level and where new functional social experience and which increases under neural assemblies for learning will occur. Seeking task circumstances involving obstacles and this ZPD guides OVT planning and delivery difficulties. Self-control may be seen as bridges during stages 1 and 2. between help by others and fully automated, Assistance of performance has been fully developed capacities. described as scaffolding and is achieved with Impulsive children with deficient self-control the adult selectively assisting the child by a are taught to instruct themselves before and coach directed instructional set. The clinical during a variety of performance tasks. Children application of this will be discussed later. also employ self-directed vocalization, reminding themselves to go slowly and be careful as an Stage Two: Performance can be self-directed example, to assist performance under conditions but is supported by coaching, timely of stress and task difficulty. A major function guidance and positive reinforcement. of self-directed speech is self-guidance, which During the transition to Stage 2, the child remains true throughout lifelong learning. will have now taken over some tasks without Self-talk is encouraged by initially having the assistance from others. However, this does not child speaking out load and telling themselves

Figure 7: Vygotsky’s Four Stage Loop and Developmental and Rehabilitative OVT.

302 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 what to do next. As the content and task visual dysfunctions occur regularly and most can relevance improves usually so does task be resolved by rest and self-directed recursion performance. Later on the child will be asked through Stage 2. Making self–talk external is a to use sub-vocal self-talk. The ability to use form of Stage 2 recursion that can be effective sequential planning and related self-talk is more in restoring competence. Further retreat or than instrumental in skill acquisition, it is itself remembering of visual bio-feedback procedures an aspect of cognitive development. may be required. Clinical issues arise in functional vision when self-direction responses Stage Three: Performance has become are insufficient to restore required operational automated into functional neural assemblies integrity. A symptoms checklist such as the or schemata. Appendix 1 ‘Functional Vision Efficiency related Once all evidence of self-regulation has vanished Survey’ can help to identify clinically significant the visual tasks they then are executed smoothly, acquired visual dysfunctions. The rehabilitation efficiently and are integrated with other activities. of acquired visual deficits and dysfunctions has It has been internalized and automated into excellent prognosis. Clinical intervention will functional neural assemblies. Assistance from the consider refractive care, visual ergonomics and/ adult or self is no longer needed. Indeed assistance or guided therapeutic OVT intervention with would now be disruptive. Vygotsky, Piaget and Stage 1 and 2 recursions. Greenfield all emphasise that performance at this third stage can now operate at a distance from Functional Vision and Cognition the social and mental forces. The conscious mind Dynamic interplay between internal pro­ is free from most task management duties and can cesses occurs before and during complex attend to other aspects of higher order thinking visually directed behaviour. Theory of Mind and comprehension. principles,32 as applied by cognitive science, inform us that people are cognitive beings with Stage Four: Performance can regress to internal processes such as mental states, beliefs, require conscious self-directed management. motives, memories, feelings and intentions that Schemata breakdown, the fourth stage of are not always accessible to others but often Vygotsky’s loop, also called de-automatisation, guide internal processes triggering behaviour. constitutes a part of the normal developmental From an understanding of the neural basis of process. Schemata breakdown can result as a perceptual33 and optomotor learning,7,93 the neural organisation mal-adaption. They may be functional vision cycle (see Figure 8) operates to triggered in fragile systems from factors such as provide visually directed action, detail analysis excessive demand, fatigue, cognitive overload, and cognition.115 Top-down processes tell the eyes adverse health conditions or stress. They may what to look for, manage selective attention and also be due to environmental changes, aging link perceptions to cognitions; while bottom-up or individual stress, major upheavals or physical processes provide an egocentric spatial anchor. trauma. This general developmental principle Science has presented us with nine major internal applies to functional vision. processes in this repetitive functional vision Loss of visual inspection automaticity can and cognition cycle that operate to produce a compromise single, clear, comfortable and product such as a written report. Each of these efficient binocular vision and distract attention can be described as follows: from the task. Acquired visual inspection dysfunctions, that is, functional vision schemata 1. Sensation: The basic, immediate stimulus breakdown, can interfere with cognitive opera­ on sense organs. tions and processing of visible data. Transitory

303 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 2. Perception: Both top-down (voluntary experience that a stimulus such as light, sound or touch elicits on a sense organ.- motor learning) and bottom-up (reflex) processes can contribute to looking. The development of optomotor and perceptual abilities involves learning from experience as attentional weighting is selectively applied; stimulus imprinting feeds memory and differentiates salient features; and unitization groups the Figure 8: The functional vision cycle. basic neural operations into function neural assemblies. This allows accurate inspecting, interpreting, organizing and some basic elaborating on the raw materials of sensation to occur. 3. Selective Attention: The active cognitive selection of a limited amount of stimuli from the vast amount available from all the senses, in memory and through the cognitive processes. 4. Visual Attention: Selective visual attention enables us to attenuate irrelevant stimuli, while focusing on the relevant stimulus. Selective visual attention links perception Figure 9: Working memory model (Baddeley and Hitch) with cognition. 5. Working Memory (WM): This, sometimes and skilled performance. Long-term called short-term memory, is the cognitive main­tenance also is facilitated by self- process that connects central executive directed repetition and error correction. control with the linguistic and the visual- Schemata can be explicit (motor and spatial domains115-117 (see Figure 9). WM is procedural) or implicit (facts, details and responsible for holding and manipulating declarative). Inadequate functional vision transitory information while the dynamic schemata development and/or schemata mechanisms associated with the retrieval breakdown may contribute to functional of details about past experiences are vision problems. activated. 7. Cognitive development: Age-related neural organisational changes that occur as 6. Schemata: A schemata, also called a mental activities come to manage processes cogni­tive structure, develops as functional such as attention, perceiving, learning, neural networks come to connect basic thinking, action and remembering. optomotor, perceptual and/or cognitive 8. Cognition: The activities of knowing and experience into simple stored memory. the thinking processes through which the With repetitive use, error correction and central executive’s knowledge is acquired. gradual elaboration, these functional 9. Behaviour: Convenient term for all neural pathway connections become the reactions of the person which are the basis for transferred applications mediated by the neuro-muscular system.

304 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 A behaviour movement pattern is simply perceptual learning processes are reversed to a definable formed response to a specific involve less complicated input levels. Functional situation (motor learning). Developmental vision deficits and dysfunctions may thus be milestones are revealed by outward triggered by repetitive performance failure, fear movement patterns of behaviour during of failure and stressful performance anxiety. controlled testing. Behaviour now alters Multi-sensory learning strategies and structured the stimuli and the functional vision cycle guidance on “challenging but achievable” tasks repeats. can provide a better signal-to-noise ratio for 10. Product: In this context product refers to perceptual learning. The principle that feedback the external consequence of behaviours is a critical variable of motor and perceptual that remain. These external products learning is supported by research.19,25,120,121 from task are typically measureable in Key principles of general learning, that have some way such as through reading com­ been identified by educational psychology122-125 prehension­ tests, spelling tests, math are also applicable to the instructional tests or handwriting assessments, written components of OVT. Typically active learning assignments, driving tests and academic requires selective attention, detailed analysis exams. and interpretive responses.126 While there are significant differences in content and purpose Principles of Learning between the learning activities that occur in The principles of perceptual learning a classroom and OVT procedures, OVT finds have been emerged from extensive research. common ground in the science and practice of Goldstone118 has conceptualized how the four eight principal areas with which we’ll conclude sub-mechanisms below contribute to perceptual Part 1: readiness, exercise, effect, primacy, learning. retention, intensity, freedom and goal setting.127 1. Attentional weighting: Perception be­ comes adapted to tasks by increasing the 1.  Readiness: This implies that a physically attention paid to important dimensions (biological), mentally and emotionally and features. (mind) and behavioural organisational 2. Imprinting: Special receptors are devel­ status provides a prerequisite for learning. oped that are set for specific stimuli. The degree of self-understanding, 3. Differentiation: Stimuli that were once self-organisation and self-confidence indistinguishable become cognitively can modulate a child’s willingness to separated. engage with OVT instruction. Readiness 4. Unitization: Tasks that originally required learning is incremental and experience detection of several components are dependent.128-130 Individuals learn best accomplished by detecting a single when therapy procedures are achievable construct. but challenging; and do not learn well if they see no reason for learning, find Ahissar’s119 reverse hierarchy theory of visual the task unrewarding, too difficult or perceptual learning links behavioural findings of frustrating. Getting patients ready to visual learning with physiological and anatomical learn, creating interest by showing the data. Essentially, the reverse hierarchical theory value of the subject matter, providing asserts that perceptual learning is a top-down continuous mental or physical challenge, guided process, which usually begins at high- and providing positive feedback are all level areas of the visual system. When these usually the therapist’s responsibility. If processes are inadequate or do not suffice, the patients have a strong purpose, a clear

305 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 objective, and a definite reason for repeats important procedures at assigned learning something, they make more intervals, and provides opportunities progress than if they lack such motivation. for practice while making sure that In other words, when OVT tasks engage this process is directed towards the patients at their zone of readiness to automaticity of efficient functional vision. learn, the therapist/patient collaborations become most productive. 3. Effect: Each learner brings their own power to produce results to the instruction Since OVT includes active motor learning setting. The competency of the evolving and perceptual learning process, patients self (Domain 2 of visual thinking) and must have adequate rest, health, and the emotional state can have a direct physical ability. Basic needs of individuals relationship to motivation.122-129 The must be satisfied before they are ready importance of effect is that OVT learning or capable of learning. OVT patients who usually occurs in a social context and is are exhausted or in ill health cannot learn strengthened when accompanied by a much. If they are distracted by outside pleasant or rewarding feeling and that responsibilities, interests, or worries, learning is weakened when associated have overcrowded schedules, or other with an unpleasant feeling, anxiety or unresolved issues, patients may have little anger. Positive reinforcement is more interest in learning generally and OVT in apt to lead to success and motivate the particular. learner so the therapist should recognize and commend improvement. Whatever 2. Exercise: Humans learn to do by doing. the learning situation, it should contain Things most often repeated are best elements that affect the patients positively remembered.12-126 Educational studies and give them a feeling of satisfaction. have shown that students learn best and retain information longer when they have One of the important obligations of the meaningful multisensory practice and therapist is to set up the learning situation repetition.129 The key here is that the OVT during OVT in such a manner that each practice must be meaningful and address patient will be able to see evidence of the processes of visual inspection and progress and achieve some degree of basic visuo-cognitive operations. success. Experiences that produce feelings of defeat, frustration, anger, confusion, Human procedural and declarative or futility are unpleasant for the patient. memories are fallible. The mind can rarely If, for example, a therapist attempts to retain, evaluate, and apply new concepts use advanced procedures on the initial or practices after a single exposure. engagement, the patient is likely to OVT patients do not learn complex feel inferior and be frustrated. This can procedural tasks in a single session. They impressing upon patient the difficulty learn by applying what they have been of the OVT tasks and can make future told and shown. Every time practice task involvement difficult. Usually it is occurs, learning continues. These include better to avoid starting a procedure that visualisation, recall, manual drill and has a possibility for failure, but to start physical applications. All of these serve with procedures that are achievable. The to create the functional vision schemata achievable task can then modified to related to learning habits. The therapist gradually increase its level of difficulty

306 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 and then modulated up and down and following a sequential treatment between easy and difficult. This removes plan facilitates correct delivery of the the risk of failure but also gives a sense therapeutic experiences and instructions. of achievement to the patient who demonstrates an improved performance 5. Retention: The things most recently at the difficult level. They experience that learned are best remembered. Conversely, although the task was difficult, it was the further a patient is time-wise from within their capability to understand or instruction on new strategies, actions or perform. Every learning experience does understanding, the more difficult it is not have to be entirely successful, nor does for them to remember. For example, it is the patient have to master each procedure fairly easy to recall a telephone number completely. However, every learning dialed a few minutes ago, but it is usually experience should contain elements that impossible to recall a new number dialed leave the patient with some good feelings. last week. The closer the instruction and The patient’s progress and chance of application therapy is to the time of success is definitely increased if the OVT actual need to apply such organisation, experiences are pleasant and rewarding. the more apt the patient will be to utilize this new approach successfully. 4. Primacy: It has been observed that things learned first create a strong impression in Retention of learning is enhanced by the mind and that these impressions are practice and the meaningfulness of the often difficult to erase. The consequence changed behaviour and knowledge that is that our first meaningful engagements results. Imagery, spacing of learning, often create a strong, almost unshakable, metacognition and generative processes impression. For the optometrist and the can aid recovery past experiences from patient this means that what is taught long-term memory storage.130,131 must be developmentally appropriate the first time. For example a student Frequent review of instructions and appli­ who came to pencil and paper tasks cation therapy is required to establish the before they have developed the finger/ functional neural assemblies in the mind thumb dexterity required may adopt the the material covered. OVT planning should developmental thumb grip and write with recognize the principle of retention when primarily wrist manipulation. In such planning the home practice procedures. cases the therapist will have a difficult The therapist repeats, restates, or re­ task replacing such practiced bad habits. empha­sizes important points at the end of a session to help the patient and The first experience should be positive, home assistant remember the required functional and lay the foundation for all instructional set. that is to follow. The therapist must present subject matter in a logical order, step 6. Intensity: This implies that the patient will by step, making sure the students have learn more from their multisensory real life already learned the preceding step. If the self–directed experiences than from passive task is learned in isolation, is not initially observation of others, a video or from applied to the overall performance, or if verbal instruction only. The more intense it must be relearned the process can be the experience on the instruction material, confusing and time consuming. Preparing the more likely it will be internalised and

307 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 retained. A sharp, clear, vivid, dramatic to be for them to learn, assimilate and or exciting learning experience has more implement the strategies and processes therapeutic impact than a routine or boring addressed during therapy. Compulsion experience. In most cases, a child can get and coercion are counter-productive more understanding and appreciation to personal growth. Since learning is of a movie by acting out the story then an active process, patients must have by passive viewing alone. Likewise, the freedom; freedom of choice, freedom patient is likely to gain greater self- of action, freedom to bear the results of organisation and understanding of tasks action. These are the three great freedoms by performing them rather than merely that constitute personal responsibility. observing others perform or to be told If no freedom is granted, a patient may what to do. For example, a child with have little interest in the OVT process. convergence insufficiency syndrome and unable to voluntary converge is not 8. Goal Setting: The principles of Goal likely to be successfully treated by the Setting Theory132-135 and fostering a therapist demonstration their voluntary “Be the best that you can be” student convergence or by just telling the child to mind set136 are applicable to this discussion.­ cross their eyes. As the student’s life journey progresses new challenges arise. These can be The more immediate and dramatic the OVT related to ability, skill, the use and control is to a real situation, the more impressive of instrument, a procedure, a problem- the procedure is upon the patient. solving strategy or anything that may help Real world applications that integrate us to learn or gain something. A starting procedures and tasks that the patient finds point goal is needed to motivate and to achievable but challenging will require maintain active engagement with learning. them to move from business as usual and For the OVT patient their goal may relate to apply greater self- management and to something they wish to obtain such as attention to specific detail. comfortable and efficient visual inspection. Older children and young adults are often The goal is to have the task make a vivid motivated to eliminate or significantly impression on them. OVT instruction reduce eyestrain, blur or other visual distress; can benefit from a wide variety of others to improve their slow, sloppy or instructional aids that aim to improve disorganised visually directed performance. realism, motivate learning, or challenge Younger children are often more motivated the patient. Therapists should emphasize to just please their parents and to show important points of instruction with them how they can improve the product of gestures, showmanship, and voice. functional vision processes. Young children Demonstrations, skits, and role-playing do may only be able to understand OVT as much to increase the learning experience a way of helping them with their writing; of patients. Examples, analogies and keep their eyes on task and learn letters but personal experiences can also make their parents must appreciate that OVT is learning come to life. not academic education but a treatment for deficits and dysfunctions of the developing 7. Freedom: Things freely learned are best functional vision processes that are related learned. Conversely, the more a patient to school readiness; learning to read or is coerced, the more difficult it seems reading to learn.

308 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Part 2: EBP Principles Derived from Clinical Expertise and Expert Opinion Beyond research, components of evidence- based practice are derived from clinical expertise and expert opinion, identifiable as four essential principles.

Principle 1: OVT can address many diagnosed functional vision deficits and dysfunctions that are not responsive to other approaches. While there is a wide range of approaches to OVT care, three broad perspectives can Figure 10: Clinical optometry, the three broad perspectives. be identified. The conceptual scope of each approach is represented as changes in area in Figure 10. of functional vision.142 This is a body/mind or 1. The Traditional Perspective. A mechanical hardware/software construct. The contemporary optics and bio–physics, bottom-up perspective considers aspects of binocular approach emphasizing defects. vision as dynamic, modifiable behaviour and 2. The Contemporary Perspective. A bio­ functional vision abilities to be the product of lo­gical–psycho-physiological optics primary our inherited potentials, our past experiences, care approach emphasizing defects and and current visual information. This perspective dysfunctions. opens opportunities for management of 3. The Behavioural Perspective. A neuro- visual experiences by selective occlusion, developmental/rehabilitative approach em­ prism compensation, AC/A manipulations, phasizing deficits in addition to defects therapeutic contact lens use, or simple fusion and dysfunctions, with OVT as a specialty exercises. It provides an excellent orientation service. for most primary care optometrists, but can be limiting for the assessment and management The traditional approach equates vision to of patients needing vision therapy. clarity of sight and uses the scientific principles The behavioural approach has emerged of biology and physics to underpin the clinical to serve the needs of helping patients care of refractive errors, systemic and ocular with functional vision issues through OVT. health issues, and defect detection within the Behavioural optometrists have a long history of neuro-visual pathways and physiology. The using performance tests for developmental and visual process is conceptualised essentially as perceptual assessments and to identify visual a ‘bottom-up’ response with little influence dysfunctions and developmental delay.143,144 from the conscious mind. Weak muscles, With these procedures the optometrist observes anatomical defects, genetic conditions, behaviour in relation to psychometric tasks as trauma and pathology are the commonly they are performed and graded. At its cutting assigned aetiologies for visual problems. It edge, the behavioural perspective includes is a medical defect perspective that provides both the traditional and the contemporary but limited opportunity for OVT intervention, and then expands to include neuro-developmental this view is well represented in professional deficit analysis and management to defect and literature.137-141 dysfunction considerations. Contemporary is an extended professional A person’s general functional efficiency is largely scope indicative of a broader understanding determined by their self-directed sensori­ ­motor

309 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 interactive experiences5,9,27,35,36,43,62,76,96,99,109,112-114,118,145-147 conducted, most operational dysfunctions will and depends on a complex interaction of be identified.92 At least three parallel processing innate factors and learned skills. During streams serve visual inspection and project novice performance, conscious decisions are to multiple areas in the brain. In brief, two significantly involved in planning and managing cortical systems, the “where is it” and “what appropriate visual responses. Later, with skilled is it” streams develop in a two-way interaction performance, pre-programmed automatic mech­ with the sub-cortical orientation “where am anisms for action and thinking free the conscious I” system.5,18,19,25,33,38,39 These cortical systems mind from the mechanics of the task. OVT show a staged development with the “where therefore recapitulates development through is it” stream being most vulnerable during the acquisition of an increasingly more complex development. Behavioural milestones depend on repertoire of task-specific automatic processes. the emergence of visuomotor functional neural networks that are called modules by Atkinson Principle 2: A neurodevelopmental and rehab­ and Braddick5 who state that these modules il­itative model of dynamic functional vision first develop as specific networks and then later guides assessment of the need for OVT. become coupled for integrated behaviour. The OVT is most commonly offered to development of spatial attention is considered symptomatic patients with treatable functional to be intimately linked with target selection vision deficits and /or dysfunctions. (Sample and planning in this visual-motor functional Adult Symptom Survey: see Appendix 1). The system.5,38 neuro-developmental and rehabilitation OVT Area 3: Visuo-cognitive Schemata. Our for visual deficits and dysfunctions may require ability to extracting understanding from visual multi-disciplinary contributions. A narrative experiences emerges as perceptual learning, of efficient functional vision that results from mindful awareness and problem solving cascading interactions between three areas: operations develop. the Visual Biology/Physics; Visual Inspection OVT is an opportunity for each patient Schemata; and Visuo-cognitive Schemata148-149 with treatable visual deficits and dysfunctions has been clinically useful (Table 2). to explore their self-organisation and visual Area 1: Visual biology and physiological capacities as they develop functional neural optics. The comprehensive functional vision circuitry. The interconnection of simple reflex assessment starts with ruling out defects of pathways, motor learning, perceptual learning, optical structure, physiology, neurological cognitive development, and memories into a fast integrity and general health. The clinician response functional neural network is termed considers family history, patient history as schemata. Schemata development moves from well as current symptoms and signs and seeks simple to more advanced and then finally to relevant data from other professionals. This is the stage where efficient functional vision is then followed by detailed assessment of areas integrated into skilled performance on required including clarity of sight, integrity of eye optical tasks. The neural network circuitry that support structures, ocular motor integrity, and visual each schemata are formed by processes that fields. The initial goal is to identify and manage include the formation of cell bodies, selective or co-manage all clinically significant defects cell death, the growth of axons and dendritic that could limit functional vision. processes, as well as the formation of functional Area 2: Visual inspection schemata. This is the synaptic connections and the elimination of specific clinical domain of optometry. After an unused synapses. Repetitive experience can age appropriate assessment of accommodative, have the effect of incorporating the task specific fusional vergence and ocular motilities has been neurons and synapses into a strong functional

310 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 neural circuitry. Building such schemata provides clinical technology1,6,7,8,10,12-17 A brief overview the neural base for task related functional vision of the assessment equipment is provided below. automaticity.

Principle 3. Assessment of visual inspection schemata is informed through biometric technology. Our assessment of visual inspection schemata is built around a clinical model of optomotor and perceptual learning. This model provides the basis for diagnosis of optomotor and perceptual deficits, and provides a scientific foundation for this objective approach to OVT intervention. Table 2 provides an overview of general visual Photo 1: FixTest: Equipment & Analysis Software inspection schemata as a cascading interaction of the three areas described in Principle 2 above. The FixTest (Photo 1) is used to assess the Our premise is that accommodative and/ quality of dynamic vision at near. Under natural or vergence dysfunctions tend to occur viewing conditions about 3 fixations are made with basic optomotor performance deficits. each second. Visual processing has to operate Overuse of voluntary controlled corrections fast enough to keep the time order of the for convergence or accommodation deficits, content of incoming neural messages and their fatigue and pain avoidance, and adverse visual spatial locations apart. The perception of fast ergonomics are examples of factors that may changing retinal images requires a dynamic co- contribute to dysfunction. Breakdown in the operation between the “where is it” and the form of de-compensation or avoidance of visual “what is it” processes. The FixTest procedure inspection skills can follow efforts to cope with uses a small visual stimulus (T) that changes high demand in the presence of co-morbid in orientation every 200ms. This challenges defects and/or deficits, reflected in optomotor the patient’s control of fixation stability, biometrics. Optomotor biometrics are layered accommodative stability, pro-saccade and anti- onto vision dysfunction theory, research and saccade operations and visual spatial perception. clinical management, topics well covered by They have to keep watching the targets so that optometry and vision science texts authored at the end of the series the orientation of the by Press,3 Suter & Harvey,9 and Scheiman and last stimulus can be indicated by pressing an Wick.96 arrow key. This procedure can be performed monocularly or binocularly to provide clinical Technology and Clinical Protocols of Basic information about quality of basic near dynamic Optomotor Biometrics vision accuracy. Three assessment procedures Basic optomotor and perceptual neuro- are used to collect five data groups; developmental assessments are currently 1. Fixation: Fixation stability is measured facilitated by four equipment units. Concept­ when the ‘T’ stimuli are all presented at ually these assessments and related treatment the same place on the display. technology require a paradigm shift for 2. Jump-C; Jump: The pro-saccadic control is many and the understanding of the neuro- measured by two tasks. Both require the developmental perspective. There are texts subject to jump the fixation of their eye that provide a detailed understanding of the ‘toward’ the peripheral queue to fixate research base and clinical applications of this on the last stimuli.

311 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Table 2: Functional Vision – a cascading interaction of three areas.

3. Anti-C; Anti: The anti-saccadic control is The percentage of correct dynamic vision also measured by two tasks, both requiring responses to all the FixTest procedures has been the subject to jump their fixation ‘away shown to vary with age, as previously discussed. from’ the peripheral queue and then to fixate on the last stimuli. Data from normal subjects aged 8 to 16 years has been compared to an age-matched group

312 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 diagnosed with dyslexia. Approximately 40% of the dyslexic group were found to have co- morbid dynamic vision deficits7,17,150 Figure 11, shows age related normative data and the data spread within the dyslexic group for each of the sub-components of the FixTest assessment.

ExpressEye Equipment and Analysis Software The ExpressEye system (Photo 2) is used with older children and adults to assess and diagnose for optomotor deficits. Calibration, fixation stability, binocular stability, saccadic organization, and self-correction factors are measured. The instrument is a head mounted eye-movement recording device that uses three mini-lasers positioned in the box above the head to provide the fixation stimulus. Infra-red sensors are positioned just below the eyes to collect the data required to study basic mind/eye organisation. 1000 readings per Figure 11: Comparison of Dynamic Vision results. second for each eye over 16 minutes is recorded and available for microanalysis.

ExpressEye Data Collection Four procedures are used during the ExpressEye assessment: • Calibration: The organisation and control of the body, head, and eyes is typically developed sufficiently by the age of seven to enable instrument engagement and computer software calibration. Calibration is essential for fixation stability, binocular stability, pro-saccade and anti-saccade assessments. Failure to calibrate with a normal healthy eight-year-old or older is considered to be a performance marker for a probable orientational ‘where am I’ deficit. • Fixation: The ability to hold steady fixation on a laser light spot projected on a blank screen at one meter from the head mount has normative age expected data. Unstable fixation attention hold correlates with frequent intrusive saccades. This is Photo 2: ExpressEye. a basic aspect of the optomotor cycle (figure 2), where magnocellular and

313 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 parvocellular pathways integrate with selective visual attention to hold fixation. • Pro-Saccades: These saccadic movements are towards the stimulus and make limited demand on voluntary fixation release control. Imagine standing before a person, holding the index fingers of each hand raised to eye level, about 30cms apart. Instruct the person to look at your nose. Ask them to observe when one of the fingers moves, then look from your nose to the moving finger. This Figure 13: Mean response time as a function of age for anti- saccade movement towards the target is saccade task. the pro-saccade. Data on pro-saccades as a function of age are given in Figure 12. available for computer analysis and for graphic inspection of all or selected movement pattern responses. Set protocols are used to measure and analyse response times, control accuracy, binocular stability, and error profile for fixation, pro-saccade and anti-saccade tasks. The clinician then compares each patient’s performance profile with established norms. Fixation Stability: A marker for fixation instability is a statistically significant frequency of fixation drift from the target light with quick return intrusive saccade recoveries. The age- expected fixation stability for this procedure is Figure 12: Reaction times by age. determined by counting the number of error saccades (intrusive saccades) per trial. • Anti-Saccades: Now the saccade move­ Binocular Stability: Recording the relative ments are away from the stimulus velocities and synchrony of actions for each eye and this imposes a higher demand on as they make saccadic movements from one voluntary optomotor control. Repeat the laser light to another enables the assessment of task above, but now instead of looking the optomotor aspects of binocularity during the at the moved finger gaze is directed to eye movement and saccadic suppression. The the finger that did not move. A saccade symmetry of eye movement actions and timing must be made to move fixation away between fixations to each spot of light is an from the moved finger. This consciously index of dynamic binocular optomotor stability. controlled eye movement away from a Saccadic Organisation: Response times stimulus is an anti-saccade. Data on anti- provide markers for saccade responses. There saccades as a function of age are given are three saccade groups of interest when in Figure 13. assessing neuro-developmental status. Express saccades utilise a reflex pathway without frontal ExpressEye Data Analysis lobe involvement. They are classified by rapid Digital recordings of all fixation, pro-saccade responses, which occur around 100ms after and anti-saccade procedural responses are the stimulus. High frequency express saccade

314 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 patterns are typically accompanied with many required for the scanning of short-term errors and poor self-correction. The next are the memory imagery as with the CountFix slow voluntary saccade responses, which occur procedure. 200ms or more after the stimulus. Finally, fast 5. Finally task specific schemata for reading skilled saccades are marked by their response eye movements emerge as is detailed in time of 150–190ms. These saccade response the developmental table for the averages time markers are used to determine the deficit for measurable components of the diagnosis and also to monitor optomotor learning fundamental reading skill.63,64 during the acquisition of saccade control. Response Times are used as markers to From data analysis of recorded responses identify 3 Levels of motor control: to ExpressEye assessment procedures, patterns 1. Express saccade – 100ms (reflex control– of neural organisation, response accuracy, self- Stage 1, Vygotsky Recursive Loop). correction and reaction times are identified. 2. Slow voluntary saccade – 200ms+ Saccadic response times, for example, could (unskilled–voluntary–Stage 2, Vygotsky cluster around the express saccade 100ms and Recursive Loop). indicate a reflexive behaviour; or be at 200 ms 3. Fast voluntary saccade – 150ms (skilled– or more and indicate a slow conscious unskilled voluntary–Stage 3, Vygotsky Recursive operation. Skillful saccades enable the response Loop). times to cluster around 150ms. A developmental aetiology, where the required neural connections Self-Correction: The number of errors and have not been acquired, is proposed for the cases response patterns to errors during the simple with optomotor deficits without vision defects ExpressEye procedure provides markers that relate and a history of slow school readiness/learning to self-correction responses. This data provides to read. Some cases with later onset visuomotor a window into an aspect of visuo-cognitive dysfunctions have also been found to have development, the evolving self. The optomotor optomotor deficits indicating the possibility of developmental changes that are typical as a a breakdown of previously developed functional person progresses from pre-school to advanced neural assemblies. reading to learn abilities show that the trend is ExpressEye performance responses of for the developmentally immature to: age matched normal students (control) have 1. Start with poor fixation hold, lots of been compared to students diagnosed as intrusive saccades and/or reflex express dyslexic. Systematic deficits with anti-saccade saccades with poor accuracy, and limited performance, but not pro-saccade responses were self-correction. co-morbid with many students also diagnosed as 2. Move to good fixation, hold and release, dyslexic, ADHD and/or dyscalculia. The percent and use slow voluntary saccades that of uncorrected errors for anti-saccade procedures show improved accuracy and some self- for controls and dyslexic students aged 8 to 20 correction. years is illustrated in Figure 14. 3. Eventually demonstrate limited express Treatment for basic optomotor deficits has saccades and a mix of fast and slow been shown by laboratory studies to be generally voluntary saccades with good accuracy effective (about 85%).8,150,151 Figure 15 illustrates and fast, accurate self-correction. the changes in the percentage of uncorrected 4. Following good saccadic organisation, the anti-saccade gap responses for a group of next step is to develop attention shifts dyslexic students aged 8 to 15 years; the before for form analysis of detail covered by a treatment data is above the after treatment data single fixation. These attention shifts are collected by ExpressEye procedures.

315 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 response profile with normative data. CountFix assessment can discriminate between normal control students and students classified as having dyscalculia. Additionally, the basic visual perceptual deficit processes related to the ‘where is it’ subitizing analysis of dot patterns does respond to treatment.1

FonoFix: Equipment and Analysis Software The FonoFix procedures have been designed to assess aspects of auditory discrimination and “where is it” analysis that does not rely on language processing. Figure 14: Anti-saccade data for controls and dyslexics. The FonoFix assessment has five procedures and each of these procedures involve many trials. Each task trial starts with listening to sound patterns and to analyse specific features that can be spatially understood as going up; going down; going to my right or going to my left. Each trial is concluded when the subject presses the arrow that represents their answer.

The FonoFix procedures assess: 1. Intensity: While the subject is wearing earphones, two white noise sounds are presented sequentially. The first sound will differ in intensity from the second sound. When the first sound is lower in Figure 15: Training effects of CountTrain. volume and the second sound higher in volume, the arrow up is to be pressed A high frequency of reflex ‘express’ to indicate difference between the two. saccades suggests impulsive optomotor cycle When the first sound is higher in volume organisation and that the student may not be in and the second sound lower in volume, a state of engaged attention during the fixation the arrow down is to be pressed. The period. Infrequent express saccade suggests a task starts with an easy to discriminate reflective ‘over hold’ optomotor cycle pattern. difference in auditory volume (what is The communication of a patient’s ExpressEye it) and establishes that the subject can performance on the initial assessment and on perceive the “where is it” relationship the graduation assessment can be graphed in time between the two stimuli. The on age expected ‘marker’ data as shown in procedure then moves on to determine Appendix 2. the subject’s perceptual threshold. The The diagnosis of a visual perceptual deficit task concludes when a 50% error rate related to how a number of presented circles occurs. are immediately seen. ’Subitizing’ requires 2. Frequency: Two sounds with different the psychometric comparison of a student’s frequencies are presented. When the CountFix visual tachistoscopic ‘where is it’ first sound is a high frequency and the

316 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 second a lower frequency, the change When the sound that seems to start in in frequency relationship is going down. the left ear and finish in the right ear the When this frequency relationship is arrow pointing right is pressed. Side order reversed, it is going up. The appropriate tasks start with an easy to discriminate arrow key is pressed by the subject to difference in time between the first and indicate choice. The task again starts the second sound. The procedure then with an easy to discriminate ‘what is it’ moves on to determine the subject’s difference and then alters to determine perceptual analysis threshold for the the subjects threshold for the perception analysis of “where am I” and “where of ‘what & where’ analysis. The task is it”. The task concludes when a 50% concludes when a 50% error rate occurs. error rate occurs. 3. Gap Detection: Two white noise sounds are presented. In the middle of one of Auditory–spatial perception deficits have these sounds a short gap of no sound been shown to improve with treatment. One occurs. This sound pattern observation reported success rate1,11,14 for the volume, requires auditory discriminations and frequency, gap detection and time order is directionality understanding. A sound shown in Figure 16; and evidence for transfer pattern can be represented as “------of improved auditory–spatial perception to an ---“ where the gap is located in the last educationally related spelling accuracy task is heard sound; the arrow pointing right is shown above. then pressed. When the gap is located in the first sound, the arrow on the left is pressed. The task again starts with an easy to discriminate difference and then alters to determine the subject’s threshold. The task concludes when a 50% error rate occurs. 4. Time Order: Two very short sounds of different frequency are presented and the difference between the two gradually reduced. When the first tone is a lower frequency and the second a higher frequency the up arrow is pressed to indicate that the sound frequency was going up and vice versa. The time order task again starts with an easy to discriminate difference and then alters to determine the subject’s threshold. The task concludes when a 50% error rate Figure 16: Development of Auditory Discrimination. occurs. 5. Side Order: A short white noise is presented Principle 4. OVT baseline data and to one ear and after a short time break procedures are scaffolded onto optomotor another equal sound is presented to the and perceptual functions. other ear. Sound that seems to start in Functional vision projection (FVP) is the the right ear and finish in the left ear is ability to organise for binocular visual inspection represented by the arrow pointing left. and analysis of virtual space stereogram targets

317 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Table 3. Brewster Stereoscope: FVP developmental milestones Age Expection 21 mths Too complicated for this age. Typically only peers in. 24 mths Now shows some engagement. 2.5 Typically makes some response, names years one or both animals, pig/dog. 3.5 Identifies both animals easily. Asked years to touch – points to lens. 4 years Quickly identifies both animals. Touch, may get to card surface. 5 years Now more exploratory. May use right eye to look through left lens, etc. Pointer typically needed for Vertical and Horizontal posture. 2 ball response often given. Sign posts - may get to 5 or 7 with pointer, by pointing. Rejects repetitions110 6 years Most cards give information, but "pointer" may be needed. 3 balls usually. Sign posts - expect 6-7 OU, R & L. Figure 17: Optical design of the Brewster Stereoscope. 3D - 5 to 2 balloons, colour naming, but no SILO. Fine stereo 2-5 of 12, some may get and then to respond to the understanding of to 8/12. Randot often seen. Binocular rivalry - may now be measurable, this projected construct. Systematic study of the typically more rapid and child’s visual projection responses to virtual space Piecemeal than the adult.111-115 and selected targets in a Brewster stereoscope 7 years Vertical and Horizontal posture easy and stable. was initially reported as an aspect of vision 3 balls and stable. development by Gesell et al.59 Over the years Sign posts 8-9 correct OU, R&L. 3D - 5 to 2, colours named, some get SILO. the series of cards have been modified into a Fine stereo 6-7/12 (some get all), Randot general use series and an extended test series. – correct response expected. The stereogram cards present sensory and Other cards have variable success. Reflect individual organisation and engagement with visual detail. motor challenges to the observer’s binocular organisation. Some of these stereogram cards 8 years 3 balls stable. Sign posts - 10/10 OU, R&L. Verbal responses solid. are shown in Appendix 3. FVP cards have various Further cards, good data from most, may optomotor and perceptual complexity and have fatigue and children often report. Responses been used to progressively and selectively probe reflect personal spatial organisation. Internalisation of fusional vergence control how the person uses their functional vision. typically poor and repeats avoided. The FVP screening assessment is rarely 9 years Expect stable binocularity and ability clinically useful for children under the age to organise virtual space. of 5 years, but for older patients it offers an Precision and crisp awareness of detail exceptionally fruitful portal for quantitative and spatial relationships. Neural development for binocular rivalry and qualitative clinical appraisal of top-down reflects endogenous attention processes. Table 3 builds on the work of Gesell and aspects of optomotor efficiency.116-118 et al59 to provide a contemporary understanding Usually stereoscope responses now reflect similar of the developmental response related to the spatial organisation as real space tests. FVP stereograms152-163 and provides typical 12+ Internalisation of fusional vergence control variable. years Adult expectations. Binocular rivalry emerges from the performance achievements that are found cortical mechanisms of 3D vision119 is modified by in young adults with single, clear, binocular, experience 120 and rate decreases as a function of age.121

318 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Table 4. FVP Adult Expected Results Task Specific Visual Inspection Involving Reading We generally conduct Visagraph assessment164 to identify task specific visually related reading dysfunctions­ after OVT has remediated­ basic optomotor and perceptual performance deficits and dysfunctions. Good readers can integrate sequential­ visual inspection with language processing and do this with minimal demand on their conscious attention. Maximum attention can then be directed to comprehension enhancing strategies. Ciuffreda and Tannen cite clinical guidelines for for the assessment of the measurable visual inspection components that relate to reading.62 Expected Visagraph performance for each grade level is shown in Table 5. efficient, comfortable, flexible and sustainable The final stage of the “reading to learn” functional vision. Table 4 provides adult expected OVT program may then include activities such responses, and the processes involved. as Moving Window reading, tachistoscopic FVP screening provides useful information as procedures, controlled­ reader and trombone­ part of an OVT work-up as it probes top-down reading. OVT is directed at ensuring that general operational efficiency of functional vision. This dynamic visual efficiency can also be ap­plied to provides a broader context to the assessment of reading tasks.165-168 presenting symptoms and the other defect, deficit, and dysfunction assessment data. Serving as Visuo–Cognitive Schemata Assessment baseline data for the initial consultation, changes (Area 3 referenced in Table 2) in FVP data are noted in follow-up assessments Neuro-developmentally, it can be argued that and key aspects are included during OVT delivery basic attention driven optomotor and perceptual to monitor performance change. Responses to factors are fundamental to the acquisition of more lens therapy alone can also be monitored. complex visual inspection and visuo‐cognitive

Table 5. Visagraph: Measurable Visual Inspection Components Relating to Reading Performance. Grade Level 1st 2nd 3rd 4th 5th 6th JrH HS Col Fixations per 100 words 240 200 170 136 118 105 95 83 75 Regressions per 100 words 55 45 37 30 26 23 18 15 11 Average span of recognition (words/fixation) .42 .50 .59 .73 .85 .95 1.05 1.21 1.33 Average duration of fixation (sec) .33 .30 .26 .24 .24 .24 .24 .23 .23 Average rate of comprehension (wpm) 75 100 138 180 216 235 255 296 340

319 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 schemata.8,112,165,166 This construct addresses Matrices.111 Raven’s matrices require the student the functional vision aspects of the interactive to visually identify pattern sequences, to analyse relationships between three domains. spatial location (the “where”) and feature Domain 1: Sensorimotor thinking emerges characteristics (the “what”) within a pattern to from experiences that generate me/it thinking identify the missing element that completes a as the person comes to understand and relate pattern. self to the environment. This domain includes the psycho-physiological constructs that relate Data Applications for Progressive to visual-spatial analysis, visual-detail analysis, Monitoring and Case Management visual-motor and visual-auditory integration During OVT delivery basic optomotor and aspects during motor and perceptual learning. perceptual performance are monitored and Essentially this is visual information processing, trained by the FixTrain, CountTrain and FonoTrain and it is well detailed in various texts.167-171 procedures. These three training­ units are similar Domain 2: The Evolving Self emerges as me to the FixTest, CountFix and FonoFix assessment thinking generates a self-understanding and units. The major difference is that unlike the organisational base for receptiveness, natural assessment units, the training units can be set curiosity and responsiveness to others. Aspects to run a level of demand that the patient would of this psychosocial domain that relate to find achievable but challenging. Other aspects OVT include self-awareness, self-organisation, of top-down functional vision development self-correction, self-confidence.112,113,114 The are monitored as required with stereoscopic ExpressEye procedure provides objective assess­ procedures and perceptual task scores. ment of some basic optomotor and perceptual functions essential to the visual aspects of the FixTrain: evolving self. Calibration for the normal child The FixTrain procedures use a small visual over 8 years of age is primarily dependent on their stimulus (T) that changes in orientation every self-awareness and then the self-organisation of 200ms. This challenges the patient’s control body, head and eyes to specific spatial postures. of fixation stability, accommodative stability, Additionally, the neuro-optometric assessment pro-saccade and anti-saccade operations and of fixation stability, bino­cular stability, saccadic visual spatial perception. The patient watches or­gan­isation and perceptual processes provides the target continuously so that at the end of objective data on basic self-awareness, self- the series the direction of the ‘last’ stimulus by organisation, self-correction responses to error, pressing an arrow key. These procedures can be and attention application. Other observations performed monocularly or binocularly. related to the evolving self can be made during each of the procedures of the functional vision CountTrain: assessment battery. The CountTrain procedure is similar to the Domain 3: Problem Solving involves it/it CountFix testing protocol. However, the task is think­ing as specific detail is related to other now set at a level appropriate for the patient’s factors. This domain is philosophical in that ability. development occurs as an understanding of truths and principles emerge. The competency FonoTrain: of this domain can be assessed clinically by Each of the five subsets of the FonoFix observation of problem – solving during an assessment are able to be trained with the inventory of Piaget’s developmental tasks110 FonoTrain. Training levels start where the patient and/or a psychometric assessment by a pattern- has a reasonable level of success, typically at or matching test such as the Raven’s Progressive about the 75% level.

320 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Aspects of selective attention and inter­ responses. Sub-conscious calibration of the actions between the bottom-up and top- multi-sensory “where am I” reflexes and then down mechanisms can be functionally the acquisition of re-calibration adaptability to manipulated, modulated and directed during challenge lenses that manipulate inter-sensory OVT.19,39,40,149,166,167 Bottom–up processes enable relationships between visual, somatosensory fast reflexes and impulsive responses such as and vestibular can be used during OVT. When eye/body movements to a startle, vestibular required such activities can assist in the refining ocular reflex (VOR) and optokinetic reflex (OKN) of reflexive spatial orientation calibrations and responses to hold fixation on a target and doll’s the gaining of a flexible adaptability. Bottom-up eye pursuits during head rotations and righting reflexes include reflex fixation, express saccades, reflex. The righting reflex, also known as the OKN, fusion reflex, blink, VOR, startle reflex and labyrinthine righting reflex, is initiated by the righting reflex. vestibular system and corrects the orientation of Top-down OVT utilizes tasks that require the body when it moves from its normal upright conscious visual inspection and self-moni­ position. The perception of head movement toring.155 Biofeedback is used to assist the patient involves the body sensing linear acceleration or to gain an awareness of how they control their the force of gravity through the otoliths and own eye aiming and eye focus. Top-down visual angular acceleration through the semicircular processes are dependent on the functional canals. Ocular motor related reflexive responses neural assemblies that serve to provide executive use a combination of visual, vestibular and control over selective attention, search, analysis somatosensory inputs to make postural adjust­ and visually guided behaviour. The higher ments. Attention and motivational modulation cortical brain centres become actively engaged of the input responses are used for basic when the person decides to searches for efferent motor memory calibration. Such specific detail, analyse spatial context (“where survival alerting processes and reflex responses is it”) and identify salient features (“what is it”), are sub-cortically organised. They have aspects rapidly match naming to features such as color that are calibrated/recalibrated by experience and form., and contemplates the experience for and provide a ‘where am I’ spatial locus with an understanding. egocentric multisensory spatial map.23 Basic optomotor and perceptual markers The responses to yoked prism,18 isometric include measurements that relate to fixation vergence prism172, AC/A manipulations95,96 and stability, binocular stability, saccadic response motivational manipulation indicate that neural times, saccadic accuracy, saccadic error scores, comparisons and adaptive calibrations occur self-correction responses to saccadic errors and as the person experiences visual challenge subitizing. General visual inspection progress will and altered feedbacks from expected posture be demonstrated by improved accuracy, faster (memory) and their actual perceived posture. responses, self-correction of errors, capacity Sensory integration adapts to best resolve for to sustain and the ability to generally apply the difference. This is the bottom-up aspect of these inspection skills to new circumstances. functional vision that may need to be addressed Accommodative and optomotor demand is at the early stage of an OVT program. sequentially advanced for example and could Bottom-up OVT can use traditional orthoptic start with monocular viewing from a chart techniques173-177 and adaptive responses such at far to a chart at near then move to on/off as those explored by the Held effect, Veagan and a moving lens challenge, a +/- flipper lens effect,172 and/or accommodation/convergence challenge, a mental minus and beyond. synkinesis95,96,173 to activate and exercise OVT typically addresses the required reflexive neuromuscular and sensory fusion aspects of visual inspection and visuo-cognitive

321 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 operations in a developmental sequence. In During OVT therapeutic interventions, the final stages of the OVT plan, both general patients need to assimilate both bottom-up and and task specific visual inspection involve top-down experiences.173,178,179,180 Aspects of cognitive loading loading as the patient both bottom-up & top-down visual processes engages in problem solving, text reading or can be addressed during a single OVT procedure. other visuomotor-perceptual challenge. The Consider the following example: focal vision operational mode with heightened Optomotor Therapy Level 3 (Procedure top-down processes is required for learning, 2 – Station Chalkboard. Level 3 - Alphabet reading, writing and accessing much of the Soup). This procedure requires visually directed academic curriculum. integrative performance and aims to develop basic schemata for skilful application of A sample therapeutic stream is as follows: semi-conscious visual inspection and spatial 1. FVP: Binocular rivalry, VO Star, Cheiroscopic organisation. It has been preceded by Level trace, Vectograms (range, float, pointer). 1 (visually directed general movements for 2. Optomotor cycle: FixTrain for fixation “where am I”/“where is it” thinking) and Level stability, dymanic vision, saccadic organ­ 2 procedures (self-directed visual inspection for i­zation, anti-saccade response time and “where is it”/“what is it” analysis.). accuracy. Materials: Charts (simple to complex); 3. Rapid automatic naming: charts, stroop magnetic letters or Post-It notes; head torch; procedures, CounTrain, visual processing laser light. speed, tachistoscope. Procedure: A letter chart is placed on the 4. Auditory/spatial integration: FonoFix, magnetic white board at eye height for the auditory-visual integration. patient. Around this the magnetic letters on 5. Voluntary accommodation: Mental plus, the board are randomly placed. The therapist mental minus, SILO. asks the patient to put the head torch light on 6. Voluntary vergence: Brock string, converg­ a letter on the chart and asks them to say the ence fusion, divergence fusion, thumb letter (or alternative, shape/numbers/symbols) fusion, binocular projection awareness, while keeping the head torch light on this area apeture rule. of the chart. While holding head and thus 7. Visuo-motor adaptions: AK arrow head torch still, the eyes scan outside the chart procedures, Kraskin squinchel. to find the corresponding letter. Once this 8. Visual-spatial manipulations: Laterality, has been located within the scattered letters chalkboard procedures, key pegs, tootie the patient is then to indicate the location by launch, directionality, Harry’s blocks, putting the laser light on the required letter. geoboards. Subsequently the letter is now in the alphabet 9. Visual imagery: Button bag, blind box, soup. Finally the head torchlight is moved touch induced imagery, form emergence, slowly and accurately to this magnetic letter chalkboard visualization, typewriter bunt. and the patient says a word that starts with 10. Problem solving: Sorting, matching, classi- this letter. An appropriate instructional set fication, conservation, cogs, logic. and Socratic dialogue can be combined with 11. Reading related visual performance: loading modulation and VT Rx. Con­trolled reader, Vision Builder, Reading An essential component of EBP is data Plus. documentation. A sample OVT record sheet that we use is provided in Table 6.

322 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Table 6: Sample OVT sheet. Session 4: Date: Station 1. FixTrain VT Rx: Plus 1 . 00 Station 2. CB Lev. 3 VT Rx: 5 prism BD Procedure Anti-sacc Posture Sitting Procedure Alph. Soup Posture Standing Goal Goal Best effort Load Say letters, spot with Load Plus 1.50 torch, spot with laser Comments Aspects to Emphasise Comments Aspects to Emphasise 1. SC 1. SC Good attention to task A little slow to shift from letter to letter. 2. Vis. Inspection Overall score 89% 2. Vis. Inspection Accurate laser pointing

3. VCO 3. VCO it/me me it/it it/me me it/it Station 3. Computer VT Rx: Plus 1.50 Station 4. T. Launch VT Rx: Plus 1.25 Procedure M. Window Posture Sitting Procedure Posture Standing Goal Goal Moving window Load Spatial adaption, bilater Load 10 prism number count. integration, awareness yoked Comments Aspects to Emphasise Comments Aspects to Emphasise 1. SC 1. SC Double digit numbers Much more accurate at 65wpm. Accurate 2. Vis. Inspection with catch when prism 2. Vis. Inspection RAN, counting 80% yoked up and down. 3. VCO Hard to do when left 3. VCO it/me me it/it and right. it/me me it/it HP. Prev. Week: Performance HP. This Week: Conditions 1. Shape chart 80% 1. Monocular loose lens (-4.00) Mon. 2. Flashlight activities 90% 2. Look, ready, touch - to beat Bin. 3. Near/far clear plastic 80% 3. Tootie launch (vary objects) Bin.

Good compliance reported by Mum. Therapist: Paula Optom: Dr. G.P HP given to: Mum Notes Father to collect next week.

Part 3. EBP Principles from Patient/ that are limiting, distressing or otherwise Caregiver Perspectives problematic. The clinical goals of the patient/ The third and final part of Sackett’s approach parent and the practice must be realistic and to evidence-based practice illustrated in Figure related to the treatable condition. It must be 1 incorporates principles related to patient/ recognised that the evidence base for OVT will caregiver perspectives. We conclude our model not make the decisions, it can only guide people with seven organizing principles essential to this to make their decisions. aspect of care. Initial presenting complaints as related by parents, teachers or the patient are rarely Principle 1. OVT management aims to provide described or understood in terms of an high-quality patient-centered services. operational visual deficit or dysfunctional The purpose of therapeutic OVT for the processes. More often at the initial presentation patient is to address the treatable problems of a patient treatable reading to learn related

323 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 functional vision processes will report concerns later refined and written down as their goals about visual inspection clarity, stability, or at the start of OVT. The optometrist uses these comfort. The younger students with functional tools to illustrate the functional vision problems vision deficit or dysfunctional processes related and help the patient/parent to understand how to learning to read may report little or no these deficits or dysfunctions are limiting their visual symptoms. More typically slow progress ability to perform to potential. with learning to read or spell is reported alone Both parents and patients are asked to detail with some observed visual performance issues the three major goals that they wish to achieve at school such as reversals, poor attention to from OVT. These goals should revolve around detail, sloppy handwriting or poor tracking. functional vision related symptoms/signs. The early primary students that present for an eye examination to confirm that all is okay Summary of the steps: are a special challenge for the optometrist. For 1. Establish the presence of performance a large group of these students they will have limiting visual problems. healthy eyes, clear sight and no visual defect. 2. Demonstrate the patient’s visual problem Within the group a sizeable proportion (about as a disruption of a process. 20 - 30%) will be found to have clinically 3. Discuss the relationship between processes significant issues beyond any ocular defect, (internal functional vision network cycle) as they present with neuro-developmental and product (educational or performance optomotor and perceptual deficits and/or visual outcomes). dysfunctions related to learning to read. Parent and teacher questionnaires can disclose the cases Principle 3: OVT requires sound therapeutic experiencing slow progress with measurable alliances and collaborations. educational performance product outcomes such The therapeutic relationships that commonly as reading age, writing, math, and/or spelling operate during the delivery of OVT are between delay. Observable signs of neuro-developmental the optometrist and therapist, and between the issues with functional vision processes may not patient and the home assistant. The therapist/ be reported. It may be necessary for parents to patient relationship is an ongoing process that observe their child during the functional vision is readily accomplished with most patients as assessments before the frustrations associated the therapist demonstrates good coaching, with visual tasks are apparent. They need to accurate understanding, positive reinforcement understand how functional vision process issues and empathy and the patient becomes aware of can induce problems including poor visual measurable progress. attention to detail, reversals, spatial confusion, Home assistant/patient. This is primarily slow to copy far/near, asthenopia, eye strain, motivated by love and nurturing. For the short intermittent double vision and reduced access time of OVT home practice they are asked to to the educational curriculum. be a developmental coach where they supervise and report on the child’s performance. Principle 2: OVT is a goal-oriented and While the optometrist is professionally diagnosis-focused intervention. responsible for the OVT, in many practices aspects The patient’s (and parent’s) goals are of delivery are delegated to a qualified vision oriented around their awareness of, attitude to therapist. The duties that are assigned include: and motivation to address the visual issues they 1. The vision therapist implements the experience. optometrist’s plan, makes observations The patient’s problem is typically expressed and records performance details. as symptoms in a QOL questionnaire and then

324 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 2. The vision therapist empathetically patient is visibly tiring set a time limit, works to build the therapeutic alliance “We are going to do this … more times and collaboration with the patient. or for … more minutes”). Demonstrations, coaching and guidance 4. Lead, don’t push against resistance, which techniques are used to empower the is likely to lose the child’s engagement. patient. Positive reinforcement is provided Modify, redirect, or change the by showing the patient that they can instructional set. Use some of the other control focus and eye aiming and that motivating techniques. Suggest if they practice makes the control more accurate work with you on this, they can choose and easier. or get to do something they’ll want to 3. The vision therapist demonstrates the do. If the child is unwilling to co-operate, authoritative developmental guidance as a last resort, tell them that they can approach to coaching and discusses choose to leave that task for now. how to apply this during home practice. 5. Be in charge and confident. The child may Other suggestions are also provided to test the therapist but they needs to know help the home assistant build therapeutic who is the boss. If the child tries to take alliance and collaboration with their charge explain that they need to help the child. Socratic dialogue is provided, such therapist in their role, which is being the as asking the patient about their feeling teacher. Arrange for the controlling child and observations involving during the to have some choices. procedures. 6. Stay “cool!” If the therapist loses of their 4. As the vision therapist demonstrates and cool, the child is in control. Kids can read reviews the assigned home practice, a feelings and they love to push “buttons”. therapeutic alliance and collaborative With some aggravating kids, it helps if relationship is fostered between the vision the therapist reminds themselves that are therapist and the patient. the adult. 7. Encourage positive self-talk and self- Working with young children requires special coaching. Discuss the positive words. I considerations, which we summarize here can … I want to … I am getting better through thirteen guidelines. … I like … I’m smart … I’m capable … 1. Work on the floor with small children I’m learning … I did a good job … (clarify when necessary. Contact with the floor negative words which “we won’t use in helps some children to improve control of here”) I can’t … I’m not good at … I’m their eyes, attention, and body. stupid … I don’t like … 2. Touch, but respect the child’s response. 8. Give choices. The therapist should en­ Some children are uncomfortable with courage decision making within the being touched. Watch for the child’s child’s boundaries. “Do you want to do response and ask if it’s ok. Children may (this) or (that) first”? “Which stool/book/ learn better when touched as touching pencil would you like to use?” expresses empathy and caring. It helps 9. Allow child some control. “Your turn on the wiggly child control his body and the switch… push the button…plug in attention. the cord”. 3. Use time to motivate. Set a small task and 10. Set boundaries. Establish the rules/ ask …’How long will it take you to…? expectations which should be reasonable, (use timer or count). Can you decide/ definable, enforceable and consistent. complete/do … before I count to…? If What’s the rule? Rules and boundaries

325 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 make children feel secure. Rules enable emotional warmth but a reluctance to set freedom. Help the child understand this. boundaries and enforce rules. 11. Encourage listening. Whenever the child 3. Uninvolved parenting (low demand; low says “what?” ask “what did I say?” responsiveness) is similar to permissive good, you’re a good listener, you heard parents in the failure to enforce standards. everything I said … you heard everything But unlike permissive parents, uninvolved I said except … Look at me and listen parents are not nurturing and warm. They carefully and I’ll repeat it.” provided the child food and shelter, but 12. Acknowledge feelings. “I see you are upset; not much else. do you want to talk about it?” “You’re 4. Authoritative parenting (high demand; tired … but we’ll do it just … times”. “I high responsiveness) is a more balanced know this is boring, but we have to do empathetic developmental parenting it.” “I’ll set the timer for … minutes.” approach. Parents now expect children 13. Watch for learning plateau. Take a break to meet certain behavioral standards but when performance levels plateau or also encourage their children to think for diminish. Help the child observe how themselves and to develop a sense of learning continues during these breaks. autonomy.

Therapeutic engagement at the Zone of Parent/child attachment relationships based Proximal Development (ZPD) on the child’s response to their caregivers Earlier in Part 1, on the section addressing can be classified as: Visual Science and Functional Vision Development, 1. Secure attachment style is demonstrated we introduced the concept of the ZPD within by the child when they can use caregiver stage 1 of Vygotsky’s Four Stage Loop (see Figure attachment as a safe base to explore 7). This is a crucial component to therapeutic their environment and are comforted by engagement. The patient with an excellent secure physical contact with their caregiver when attachment relationship and playful engagement upset. with assigned procedures will reach their potential 2. Avoidant attachment characterised by the faster. This basic principle has become a core child’s lack of distress when separated feature of EBP among the performance-guiding from their attachment figure and seems professions. The importance of therapeutic visual to avoid interacting with caregivers. engagement is supported and informed by the 3. Ambivalent/resistant attachment is where literature on saccadic organisation115,181 and goal the child tends to cry when separated setting, task motivation and self-management from the caregiver but then continues to theory.182 cry and be unresponsive upon the return Distinct parenting styles and parent-child of the caregiver even when comforted. attachment relationships have been described183 4. Disorganised/disoriented attachment is and are categorized as follows: demonstrated by not responding in any 1. Authoritarian parenting (high demand; systematic way with their caregiver. low responsiveness) emphasizes blind obedience, stern discipline, and the OVT procedures that aim to engage the child controlling children through punishments, at an achievable but challenged level (Vygotsky’s which may include the withdrawal of ZPD).113,114 The authoritative parenting style and parental affection. a child with a secure parent/child attachment 2. Permissive parenting (low demand; provide the best dynamics for home practice. high responsiveness) is characterized by When the activity level is set too high, home

326 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 practice can become frustrating, anxiety inducing, 2. Positivity. Positive comments from the unachievable and then quickly rejected by the home assistant during practice build child. OVT progress is more rapid when the home motivation, sustain involvement and assistant can authoritatively direct activities, foster the progression to the next level modulate the level of demand to achieve the of task difficulty. Alternatively negative ZPD to positively reinforce and rejoice in each of comments from others can destroy the the patient’s personal best performances. moment and may make the child unwilling to participate. The home assistant is Principle 4: Engagement and compliance instructed to focus more on the positives, that is complementary between office and not to overemphasize the negatives. therapy and home practice procedures 3. Planning. This involves deciding who facilitates transfer of learned skills. will be the home therapist, where the The OVT treatment plan requires the training will be conducted, when it will repetitive home practice of selected procedures be conducted and, how record taking will between visits to the office or clinic. The clinic be done. The home assistant determines visits set up conditions so that activities are a suitable location and time of day. It is achievable but challenging. At the various office best conducted in a quiet environment, visits three procedures are usually assigned for away from distractions, interruptions and home each week. Thirty minutes of supervised siblings. The selection of a suitable time instruction (10 minutes for each procedure) is requires consideration of both the home required for ideally five days each week. The assistant’s other roles and responsibilities optometrist/therapist demonstrates how each and the child’s needs. assigned procedure is to be conducted and 4. Partnership. It is emphasized that the home provides written instructions. assistant is in partnership with the OVT These instructions designate specific require­­ clinic and the home practice is a vital part ments such as instructional set, viewing condi­ of the therapy program. The optometrist/ tions, methods to modify the task demand and therapist provides the treatment plan, the the process to be emphasized. Computer software basic therapeutic experiences and guides may be assigned when appropriate to reduce the home assistant in the implementation demands on the home therapist and facilitate of the home practice OVT procedures. engagement and compliance through feedback. Communication between the home assistant A daily diary is provided for the home and the optometrist or vision therapist is assistant to record a running account of the essential for on-going management. home practice for the optometrist/therapist to 5. Process. The home assistant is made review at the next clinic visit. At the initial OVT aware of various processes or skills visit, the home assistant is given orientation that are to be coordinated to perform and basic instruction on the key aspects of OVT any of the assigned VT procedures. delivery. A summary of this “Instruction for An analogy is given in terms of golf: Home Practice” is provided below. improving performance is facilitated by “6 P s” for the Home Practice Delivery coordinating a number of interactive (Guidance for the home assistant).65 processes, including the grip, posture, a 1. Patience. The home assistant must appre­ balanced interaction of the two sides of ciate that performance changes can be the body, motor planning, and eye/hand rapid, but are more usually slowly achieved coordination. Facilitating the control and with persistence and regular practice. sequential organisation of each of the related processes contribute to skilled

327 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 performance of the targeted behaviour. confusion, form perception, tracking and The same paradigm is then applied to the visual memory as they strive to learn to patient’s visual dysfunction. read, write, calculate and spell. 6. Practice. The need for task or procedure 2. After the student has learnt to read they repetition in order to develop automaticity move on to reading to learn. A portion in executing the task is a key aspect of the “learning to read” OVT patients in successful VT. Some find demands require additional “reading to learn’” of repetition boring and seemingly OVT sessions as they move up in grade unrewarding. However, this is the time that and print size decreases, content becomes the child should develop the awareness more demanding and the volume of of his ability to increasingly gain control, reading increases. expend less effort and energy, and master 3. Complicated OVT cases occur when the particular procedure. defects, deficits and dysfunctions co- exist. The OVT management and delivery Principle 5: OVT includes time projections is more complex for these patients to completion, incorporating goals, and and additional sessions are anticipated monitored through progress evaluations. as progress is demonstrated through This time related principle requires that measurable performance changes. OVT standard OVT interventions be wisely planed, time can now be a journey taken in steps of limited, therapeutically focused, developmentally 10 OVT session units, pending progress, appropriate and that regular criteria referenced and with planned breaks between units. procedures probe performance progress and monitor for expected change. With young children, a diagnostic trial period of 2 to 4 therapy sessions may be appropriate for Treatment Duration evaluating a child’s maturational readiness and Projected treatment duration for patients social ability to engage with clinic sessions. If the with accommodative and vergence dysfunctions child is unable to engage, home practice activities can vary widely with complexity of individual may be introduced as a helping measure while cases. The published set of guidelines from the waiting for the child’s readiness for OVT. American Optometric Association provides data from pooled clinical experience evidence-base.184 Early Discharge Relating our personal clinical experience When it becomes apparent that the patient below, we refer to sessions - with each session cannot, or will not, engage with OVT, a being 60 minutes in duration. reappraisal of the case details is required. Early 1. Given good compliance and engagement, OVT discharge may be triggered by: uncomplicated optomotor and perceptual 1. Patient related factors such as refusal to deficits and mild dysfunctions can be wear prescribed eyewear, to do home expected to plateau at or near age practice, or to follow the rules of the OVT expected after 14 to 16 treatment clinic and therapy directions. sessions. Typically these are happy, healthy 2. Improper or inadequate home support children who are smart at everything or home practice related factors. When except school. They are in early to mid- the patient is a child, and home practice primary grades and are unable to perform cannot be supervised and developmentally to their potential. Symptomatically, they directed, OVT progress will be affected. experience visual performance difficulties 3. Lack of expected progress could be due related to attention to detail, spatial to another co-existing but undiagnosed

328 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 condition. An update on general health direction and the application perceptual-motor and wellbeing may be confirmed by an learning principles, further skills development appropriate referral, for example to a and application can be expected. paediatric or educational psychologist for assessment. OVT may be put on hold Principle 7: OVT graduation moves the while other opinions are sought. patient to planned follow-up and self- managed maintenance. Principle 6: Criteria for completion or After active OVT has concluded, 3 or 4 three- graduation should be established. minute procedures are assigned for weekly self- The OVT plan must include graduation assessment and to refresh motor and perceptual criteria. Patterns of response to OVT can vary. memory. Performance regression is possible but The majority of cases, about 80 percent, with usually easy to rectify when identified early. The uncomplicated neuro-developmental optomotor patient is advised that regression toward pre- and perceptual deficits, along with visual therapy visuomotor behaviour may result from inspection and visuo-cognitive dysfunctions, illness, excessive fatigue, or non-use of pre­ respond reasonably fast at the start and then scribed therapeutic eye wear. The purpose and slow down towards the later sessions when importance of follow-up, visual ergonomics, the visuo-cognitive dysfunctions are being Rx support, and ongoing self-assessment is addressed. A small number of cases may either explained. respond very quickly or require additional time. A scheduled follow-up review is made The quick responders reach their plateau before for about 4 – 6 months after the post OVT the predicted time and can graduate early assessment. In addition to primary eye care in contrast to slow but steady responders for the functional vision status is reviewed and whom additional sessions may be indicated. maintenance activities are now reconsidered Regression to past dysfunctional behaviour, or and perhaps modified. Lens and/or prism schemata breakdown is a future risk to recently requirements as well as visual ergonomics acquired visual skills. We explain and demonstrate are revisited. The longer the new visuomotor to graduating OVT patients how to self-assess behaviour has been effectively used, the less basic visual abilities and explain the need to likely regression becomes. An annual review may clinically assess the maintenance of their new now follow, but each case must be individually visual efficiency. Graduating OVT patients (or their assessed relative to further follow-up. parents) have experienced how functional vision performance can be modified by their active Summary and Conclusion experiences. It is not hard for them to appreciate Evidence-based practice (EBP) leads to that newly acquired abilities can regress if they are structured and personalised optometric vision not compliant with the doctor’s recommendations, therapy (OVT) interventions informed by mind as noted below in Principle 7. science, innovative measurement procedures Graduation from active OVT clinic sessions and management strategies. We have presented occurs when the developmental deficit/dys­ the basis for a model used successfully in clinical function markers related to the initial diagnosis practice, predicated on the following points: have plateaued and their application to functional vision efficiency demonstrated. In the context of 1. Evidence-based practice and principles the developmental and rehabilitative loop (see related to neuro-developmental and rehab­ Figure 7) a patient has reached a plateau or Stage ilitative optometric perspective guides 3 with respect to age/grade functional vision OVT diagnostic work-up procedures, the developmental milestones. With applied self- personalised treatment plan and therapy

329 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 delivery for functional vision deficits and The optometrist reviews weekly clinical dysfunctions. performance data, therapist notes and 2. Treatment delivery, timing, mode of home diary, providing an indicator of deliv­ery, procedure selection, zone of home practice engagement. proximal development (ZPD) modulation, 6. OVT graduation is followed by self- therapeutic support and activity loadings management of visual ergonomics, and can be managed through EBP principles appropriate self-assessment. If required and practices. OVT is structured around early recognition of modest regressions an individualized plan to address the can be self-managed by an active home diagnostic entities and the patient’s goals maintenance plan monitored through and, to be most effective, typically involves scheduled clinical follow-up assessments. weekly clinic sessions. An individualized­ plan is based on the initial assessments, Regarding office-based OVT sessions, we reports from other professionals, diag­ noted that neural network building through noses, Rx, optometric goals and the rehabilitation treatments occurs via instruction patient’s functional vision problems. An and positive feedback used to foster self-directed estimation of the probable number of engagement. An appropriate, personalised treatment sessions. The plan is continuously sequence of instruction and Socratic-like ques­ monitored and adjusted as required during tioning supports treatment delivery. OVT delivery the course of active OVT delivery. is individually planned for each subject to 3. Principles common to many therapeutic include both bottom-up and top-down factors. disciplines guide the vision therapist/ The therapist provides structure to the patient optometrist team. These principles as they explore and reflect upon self-guided, also provide the vision therapist with a visually directed experiences. Response analysis structure and a therapeutic purpose to of these experiences, purposeful self-correction patient coaching. The instruction of the and problem solving develops the synaptic home assistant regarding supervision of organisation required to improve functional home practice is by direct instruction, vision efficiency. demonstrations and written handout. The clinical management of basic neuro- 4. OVT is dependent on the patient’s developmental deficits in functional vision is therapeutic engagement. Clinical man­ complicated when deficits and dysfunctions age­ment should address the patient’s are co-morbid with other performance limiting compliance, progress, interests and conditions. However, basic optomotor and readiness. Advancement toward thera­ perceptual deficits can be objectively diagnosed peutic goals is monitored and docu­ and successfully treated even when co-morbid mented through progress evaluations at with conditions such as dyslexia, or attention designated intervals. deficit disorder/attention deficit hyperactivity 5. Time-related factors are critical to disorder (ADHD). Successful treatment transfers effective OVT management. Appointment to educationally-related quality of life outcomes. times, duration of time engaged on any specific procedure, frequency and Acknowledgement duration of task avoidance, and home We thank Keith Masnick Ph D. for editorial practice compliance are some of the advice and assistance with the organisation of factors that are individually considered. references. Progress monitoring and compliance data is collected by specific routine procedures.

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334 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 150. Fischer B, Hartnegg K, Mokler A. Dynamic Visual 169. Scheiman M, Gallaway M. Optometric Assessment: Perception of Dyslexic Children. Perception. 2000; Visual Information Processing Problems. In: Scheiman M, 29:523-30. Rouse M, editors. Optometric Management of Learning 151. Dyckman KA, McDowell JE. Behavioral Plasticity of Related Vision Problems. 2nd ed. St Louis: Mosby; 2006. Antisaccade Performance Following Daily Practice. P. 369-406. Experimental Brain Research. 2005; 162:63-9. 170. Rouse M, Borsting E. Vision Therapy Procedures for 152. Griffin JR, Grisham JD. Binocular Anomalies: Diagnosis Developmental Visual Information Processing Problems. and Vision Therapy. 4th ed. Boston: Butterworth In: Scheiman M, Rouse M, editors. Optometric Heinemann. 2002. Management of Learning Related Vision Problems. 2nd ed. St. Louis: Mosby; 2006. P.585-652. 153. Hudak M, Gervan P, Friedrich B, et.al. 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335 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Appendix 1. Functional Vision Efficiency Related Survey.

336 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 Appendix 2. Documenting ExpressEye assessment results.

Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) Black vertical line indicates patient age.

Appendix 2. Documenting ExpressEye assessment results. Appendix 2. Documenting ExpressEye assessment results. Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) Black vertical line indicates patient age. 3.Black Pro-Saccade vertical line indicates patient Mean age. Response Appendix 2. Documenting ExpressEye assessment results. Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) 3. ProTime-Saccade ms. Mean& Age Response expected. Time ms. & Age expected. 1. Percentage of Express Saccades. Black vertical line indicates patient age. 1. Percentage of Express Saccades. 2. Binocular Instability (BIndex) Initial examination 5% ( over ‘hold ) Initial examination 286ms Initial examination 286ms Post OVT examination 212ms InitialPost examination OVT examina t5%ion 1 0( %over ‘hold ) 2.Initial Binocular examination Instability (BIndex) 61% Post OVT examination 212ms

Post OVT examination 10% Post OVT examination 10% ms Initial examination 61% Post OVT examination 10%

Above scale – 61%

Years. ( Age)

Age in Years Age in Years Age in Years

Appendix 2. Documenting ExpressEye assessment results. Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) Black vertical line indicates patient age. 4. Task Appendix 2 Anti-Saccades: 2. Documenting ExpressEye Mean assessment Percentage results. of Errors. 5. Mean Reaction Time Anti-Saccade: Gap Red – Initial Examination (14/1/09) Blue – Post OVT Examination (31/12/09) 5. Mean Reaction Time Anti-Saccade : Gap Black vertical line indicates patient age. Initial examination 38% error InitialInitial examination examination 348ms Post348ms OVT examination 240ms Post4. TaskOVT 2 Anti examination-Saccades; mean percentage 14% of errorerrors. Post OVT examination 240ms Initial examination 38% error Post OVT examination 14% error

Age in Years Age in Years

337 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015 AppendixAppendix 3 – ‘Functional 3. ‘Functional Vision Projection’ Vision :Projection’: Sample Stereogram Sample Cards Stereogram. Cards

Distance.

1. 3.

4. 5.

9. 10.

11. 14.

15. 17. (continued)

338 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015

Appendix 3. ‘Functional Vision Projection’: Sample Stereogram Cards, continued

Near.

1. 5.

8. 9.

339 Vision Development & Rehabilitation Volume 1, Issue 4 • December 2015