Visionary Optometry

By Mark Moran
WebMD Feature

Nov. 26, 2001 -- See that picture on the wall? Now hold your index finger up in the line of vision and focus on the finger.

If you are lucky, you can hold a single image of your index finger in focus, while the picture on the wall in the background is liable to be double.

Now, try another simple exercise: Name the number that comes three before 97. If you said 94, that's because you were able to hold a visual image of a sequence of numbers in your mind and produce the correct answer.

These two exercises illustrate principles of "behavioral optometry," a field that offers not only an innovative form of vision care but also a unique approach to understanding the role of the eyes in thinking and learning.

'Retraining' the Eyes

Stephen Miller, OD, explains that behavioral optometrists are interested in how the eyes work together with the brain and the rest of the body to perceive images and help us navigate the world. It is an extension of the work of more traditional ophthalmologists and optometrists who specialize in how the eyes receive images, and who typically prescribe glasses, contact lenses, medicine, or surgery, he says.

Behavioral optometrists believe that some eye problems can be improved through techniques that "retrain" the eyes and the brain to work together better. Miller calls it a form of "occupational therapy for the eyes."

For instance, some people who have healthy eyes and relatively good vision may nevertheless find it hard to focus on nearby objects -- such as the index finger held up in the line of vision of the picture on the wall. Miller calls this problem "convergence insufficiency," which is the inability of the eyes to coordinate with each other to see an object.

To treat this problem, behavioral optometrists might have a person come to the office for weekly therapy, with "homework" assignments designed to reinforce what is learned in the optometrist's office.

"Depending on the problem and how significant it is, vision therapy could be done in as little as four to six weeks or as long as a year," says Miller, executive director of the College of Optometrists in Vision Development, in St. Louis, which certifies behavioral optometrists.

A typical homework assignment for a person with convergence insufficiency might be to hold a pencil at arm's length and focus on the tip, gradually moving it toward the nose. "At some point as you move it closer the image will break into two," Miller explains.

But through repetition, the person will gradually be able to hold a single image of the pencil tip all the way until it reaches the nose.

Problems like convergence insufficiency may be complicated by activities of modern living -- long hours of television viewing and staring at a computer terminal. And behavioral optometrists say many vision problems stem from the failure of our eyes to evolve beyond the more primitive functions for which they were designed, to meet the demands of our up-close visual world today.

"We have a vision system made for farmers and hunters being used in offices with no windows and no opportunities for focusing at distance," Miller says. "We are a near-centered society, but we have not evolved our vision system to adapt to that."

Vision and Learning

Twenty-two years ago, Marjie Thompson of San Diego took her 12-year-old son Scott to see behavioral optometrists at the San Diego Center for Vision Care. Despite the fact that Scott had nearly perfect eye exams since he was small, optometrists there found he had problems with eye coordination, focusing, and the ability to visually pick out specific words or symbols -- say, on a blackboard -- when they were surrounded by other words and symbols.

Fourteen hours of therapy later, Thompson says, her son's reading level increased by six years.

The case is an example of the way that behavioral optometrists are extending the principles of their field to areas not typically associated with optometrists.

Stephen Ingersoll, OD, of Bay City, Mich., says that understanding the way the eyes develop throughout childhood to work in coordination with the developing brain and body has profound implications for education, especially for how children learn to read.

Take the exercise requiring you to name a number that comes three before 97. Ingersoll says the task draws on the ability to visualize a sequence in your brain -- a skill that begins developing in infancy when the eyes first receive images and becomes more sophisticated the more one learns and experiences.

This task of "visual thinking" is critical in reading, learning, and navigating the world. "Children who are early successes in school and reading are kids who use visual thinking to remember the look of words," Ingersoll says.

But children with problems learning to read may not have developed that skill yet. Instead of visualizing a word in their brain -- for instance, the word "because" -- some children may use a different part of their brain to hear the word. Consequently, they are liable to spell it the way it sounds -- bekuz -- and may not recognize it when it is spelled correctly.

Ingersoll says the eyes are critical in overall development of physical and motor skills that allow us to move and react appropriately in response to the world around us.

"There is a connection between physical development and mental development, and it runs right through the visual system," he says.

For this reason, he says, the failure to develop visual thinking may be at the root of problems experienced by children with attention deficit disorder. Lacking a highly developed ability to form visual images that allow them to think about and respond to all the stimuli in their environment, they are easily overwhelmed and may never master the "multitasking" skills that adult life demands.

"Visual learning allows us to think our way out of the here and now," he says. "Visually incompetent children exist in the here and now and lack the ability to see future consequences of current actions."

Because of this, Ingersoll is critical of the widespread use of Ritalin to treat attention problems, which he says forces the brain to "weed out" competing stimuli in order to help the child concentrate. What should be done instead, he says, is exactly the opposite: retraining children's eyes and brains to more competently respond to the environment.

In addition to his practice as an optometrist, Ingersoll helped found a charter school called Livingston Developmental Academy, in Hartland, Mich., which incorporates principles of behavioral optometry in educating learning-disabled children.

Field Has Its Skeptics

Ophthalmologist Donald Schwartz, MD, OD, says there is little proof that behavioral optometrists can accomplish what they claim. By going beyond how the eyes receive images and delving into areas of how the brain perceives and organizes those images, they are entering a field more appropriate to neurologists, psychologists, psychiatrists, and educators, he says.

When it comes to treating children with learning disorders, Schwartz says their claims could mislead parents.

"When a child is failing in school, parents are anxious to grasp at anything that might help their child improve," says Schwartz, spokesman for the American Academy of Ophthalmology and clinical professor of ophthalmology at the University of California, Irvine.

But Miller says the field is not an alternative to the care that ophthalmologists and optometrists typically provide, and that behavioral optometrists do not deny the importance of standard care involving corrective lenses.

He estimates 3,000-5,000 people nationwide practice behavioral optometry. Insurance coverage is limited, and the cost of therapy is typically $75-$125 an hour, Miller says.

He advises people with vision problems that don't respond to conventional care to be persistent. "Don't take the answer that nothing more can be done as the final answer," Miller says.

Marjie Thompson seconds that sentiment. Recently she helped found Parents Active for Vision Education, or PAVE, an organization that promotes the principles of behavioral optometry for children with learning problems and helps parents find behavioral optometrists. It can be reached at (800) PAVE-988.

"Parents are going through the same thing I went through 22 years ago," she tells WebMD. "The reason is that people are just not aware that these problems are identifiable and correctable."

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