This article first appeared in the St. Louis Beacon, Nov. 25, 2011 - Nick Matteucci was in third grade when his teacher reported that he was slow learning to read and not writing well. The teacher suggested he might have an attention deficit disorder, but because his IQ was high and he was not yet behind grade level, the school was not ready to test him.
His mother Sandra, a faculty member in the School of Engineering at Washington University, didn't think that the attention deficit diagnosis fit Nick. He could play the same game for hours, and he could answer any question about a story read aloud to him. In fact, after a particularly bad social studies quiz, she persuaded the teacher to read the questions to him -- and he showed dramatic improvement.
So Sandra went to the Web and found the home page of the Center for Vision and Learning in Creve Coeur. On a hunch, she made an appointment for testing. Nick's vision was 20/20 and his eyes were healthy. He was able to focus correctly for a time, but when Gail Doell, a developmental optometrist, and her therapists observed his eye movements, they found that his eye moved well for a short time and then stopped scanning correctly. His eyes were experiencing extreme fatigue.
The good news was that Nick's problem was amenable to vision therapy, according to Doell. Exercises could strength his eyes to let them move quickly and accurately without fatigue.
After eight weekly sessions of vision therapy exercises, and daily practice of those exercises at home, Nicky's eye strength had increased from the 5th percentile to the 50th. After another eight weeks, he was in the 90th percentile, and he stopped office visits. He continued to do the exercises at home, and began to read enthusiastically -- once he discovered Harry Potter.
Today, four years later, Nicky is a straight A student taking advanced coursework. His mother says vision therapy was "the turning point" for him.
How Does Therapy Strengthen the Eyes?
A visit to the Center for Vision and Learning showed a seemingly chaotic space where children were doing a variety of quiet and not-so-quiet activities with individual therapists. Seated, a junior high school student was reading through "flip lenses." As the therapist reversed the lens orientation, she had to change her focus from distant to close and back again repeatedly. A young boy was hitting a ball hanging on a rope back and forth with a target device. Another 8-year-old was reading a chart of random letters while standing on a balance board.
Some exercises, like the flip lenses, seemed more aimed at the eye itself -- working the lens accommodation apparatus. To bat the tethered ball in the right spot, the eye had to follow the moving ball -- again working the accommodation. It was sort of physical therapy for the eyes.
The kid on the balance board? He had to maintain his concentration on reading the letters while his body maintained his balance. This seemed more like occupational therapy, strengthening certain mental pathways by working through distractions.
Doell explained that the therapy is designed not only to train the eye muscles, but also to develop awareness of when the visual system is working correctly, and when it is not.
As an example, she used convergence insufficiency, a common visual problem in which eyes that can see perfectly at a distance are unable to synchronously rotate inward the slight amount needed for close work. Because the eyes do not converge, print will be out of focus or may appear to jump around on the page.
One exercise used to treat convergence insufficiency is the "pencil pushup." Two pencils are held together at a distance. One pencil is brought closer and closer to the face, and the patient must maintain focus on that pencil. If both eyes are working together, the pencil closest to the face will look single, but the far pencil will appear to be double.
Other checks for using both eyes may involve red and green "3-D" glasses and transparent strips. If a vinyl sheet is laid over a sheet of reading materials, a reader using both eyes will be able to read through all the stripes. But if the reader is using only one eye, one of the colored stripes will appear black.
Where Do the Patients Come From?
Referrals for screening by a developmental optometrist come from reading specialists, occupational therapists, psychologists and other doctors of optometry not trained in this specialty.
The screening includes a thorough eye exam (is vision 20/20 or correctable to that with glasses, and are the eyes healthy?) and then tests for binocular vision, depth perception, smoothness of eye movements and other functional tests not usually performed in a routine eye exam.
Joanne Curran is a reading specialist in the Ladue school system. About 18 years ago, she was working with a third-grade student reading at the first grade level. "It was clear to me that her eyes were jumping around as she was reading." She suggested to the parents that they look into developmental optometry, and after about four months of office treatment and home exercises, the child was reading two years above grade level.
Since then she has looked for vision problems as one component of reading difficulties and has found that many students have problems with the eyes. Some just need glasses or a new prescription. Others, though, may have difficulty in moving the eyes smoothly across the page from left to right or eyes that jiggle vertically while reading a line of type. In her testing, she looks for certain types of errors like omissions of parts of words, a mistake that may indicate difficulty of maintaining focus. She is also careful to ask students whether reading gives them headaches, whether it is harder to read the longer they read, whether print words seem wiggly to them, and other questions that might indicate difficulty with convergence or other eye muscle problems.
Alyson Aviv, a neuropsychologist, also mentioned visual spatial deficits such as difficulty judging directionality (identifying which two arrows are pointing at the same target from an array of arrows) and being able to match pictures and rotations of complex shapes on standardized tests as a reason she might refer to a vision therapy office.
Kay McCarthy, an occupational therapist who treats children with sensory problems, also looks for discrepancies in eye-hand coordination. Suppose a child has age-appropriate hand skills but can't use those skills in an exercise that requires hand-eye coordination. A 3-year-old, for example, may have normal pincer grasp, and the ability to pick up and use a pencil, but may not be able to push the shoelace through the holes in a lacing card. She will start looking for other evidence that eye function gives trouble, such as a cocked head when watching television.
Vision Therapy is Not Just for Kids
Not only children go to vision therapists. Greg Heille, a 63-year-old priest, had amblyopia (often called lazy eye) since birth, and considered himself blind in his right eye. Although as a child his parents had taken him for treatment, patching the strong eye to strengthen the weak one did not help him.
When his ophthalmologist suggested plastic surgery on his "blind" right eye to correct a droopy eyelid and excessive tearing, he hesitated. Upon a friend's recommendation he went to see Lisa Dibler, the other developmental optometrist in private practice in St. Louis. Dibler showed him that he did have some sight in the right eye, and he began working with her. "Almost immediately, the eyelid stopped drooping, and the eye stopped tearing." After two years he has full stereoscopic peripheral vision in both eyes and reports that he was able to see the movie "Avatar" in 3-D. Central vision in his right eye is still impaired.
Jo Seltzer is a freelance writer with more than 30 years on the research faculty at the Washington University School of Medicine and seven years teaching tech writing at WU's engineering school.