VISUAL ABILITIES, VISION THERAPY,

and the

MYTHS OF 20/20 VISION

  


If your child is struggling with reading even though you know he or she is smart and does well verbally, it could be the result of a hidden and undetected visual skills deficiency. Poor visual skills are the most overlooked reasons why a child struggles in school. 

Your child may have 20/20 eyesight with or without glasses, but poor visual skills. The difference is critical. An eye exam by most eye doctors and all school vision screenings ignore 9 out of 10 visual abilities necessary for a child to achieve full potential in school. Very few eye doctors have the interest or specialized training in detecting and treating these visually related reading problems. Don't assume that all eye exams are the same. 

Hidden visual difficulties are common. According to the American Optometric Association, almost 1 out of 4 children suffer from inadequate visual abilities. While many of these patients have refractive error (nearsightedness, farsightedness, or astigmatism) commonly treated by glasses or contacts, some have additional problems in the functioning of the vision system that are most appropriately treated with optometric vision therapy. About 40% of all Americans have functional vision deficits. Children with vision disorders rarely complain or tell others, because they don’t even realize they have a problem. 

About 75% - 90% of what children learn in the classroom comes through their visual system. A study has shown that 80% of children who are reading disabled have a deficiency in one or more basic visual skills. What is ironic is that most of these children passed the annual school vision screening or the pediatrician’s eye chart. 

It is rare for eye doctors to test for more than eye health and the presence of refractive error. This means an exam by the eye doctor may only test for eye disease and the ability to see 20/20 size eye chart letters, with or without glasses. Although it is very important to test and to treat these two concerns, it is the basis for the "most dangerous assumption" a parent can make regarding a child's visual system. This assumption is that the 9 other visual abilities vital to reading achievement are optimally developed. This assumption holds true in about 4 out of 5 cases of all children and therefore causes no problems. Perhaps this is why the assumption is so common.

"Perfect" 20/20 eyesight merely means you can see something 20 feet away. Eyesight and vision are vastly different. Vision is the ability to take in information through our eyes and process the information so that it has meaning. Eyesight has little to do with how the brain is integrated; information is processed, or is understood. The ability to understand and interpretation what is seen is referred to as visual perception. Visual perceptual skills are one of many factors important to successful learning.  

Visual perceptual disorders are associated with glitches in the neural pathways that connect the eyes and the brain. The visual system itself is estimated to interconnect to 65% of the brain. So if you were to change how the visual system functions, this will change the way that the brain processes information.

Unfortunately pediatricians, teachers, psychologists or reading tutors and most eye doctors are not trained to diagnose, recognize or treat learning related vision disorders. The academic curriculum is designed on the assumption that children possess certain visual abilities, as well as other skills, by certain ages. Is your child truly visually ready for school?
 

THE VISUAL ABILITIES 

The Visual Abilities are the skills which give us the power or means to take in information through our eyes. The visual sensory system is considered to be composed of 20 visual abilities. To simplify, these skills have been grouped into 11 separate abilities and divided among 3 categories.


VISUAL ACUITY 

1. Visual acuity - the sharpness of sight. Visual acuity is what is measured by the Snellen "Eye Chart" at school, the pediatrician’s office, or the eye doctor's office. Optical aberrations such as nearsightedness, farsightedness or astigmatism reduce visual acuity. Eye diseases such as cataracts, glaucoma or retinal degeneration can reduce visual acuity. Eye diseases have not been found to cause learning difficulties. Fortunately eye disease is rare in children.
 

MECHANICAL SKILLS

These are neuro-muscular abilities controlled by the muscles inside and outside the eye networking with the brain. 

2.  Accommodation - the ability to change focus, as well as maintain focus in order to see clearly at different distances. 

3.  Binocularity - the teaming of the two eyes together so they can converge and point to the same place when reading. 

4.  Ocular Motor Fixation - commonly referred to as eye "tracking". This is the eye's ability to direct and coordinate movement as it quickly and voluntarily shift from one target to another.

5.  Eye Hand Coordination - the ability of the visual system to steer fine motor movements as in handwriting.
 

PERCEPTUAL SKILLS 

These visual information processing skills allow the brain to organize and interpret information that is "seen," and give it meaning. 

6. Peripheral Vision - the ability to see or be aware of what is surrounding us, our side vision. 

7. Visual Form Perception – consists of four visual abilities called figure-ground, form constancy, visual closure, and visual discrimination. Figure-ground is the ability to recognize distinct shapes from their background. Form constancy is the ability to recognize two objects that have the same shape but different size or position, identify or recognize a symbol or object when the entire object is not visible. Visual discrimination is the ability to discriminate between visible likeness and differences in size, shape, pattern, form, position, and color.

8. Spatial Relations - the ability to judge the relative position of one object to another (directionality) and the internal awareness of the two sides of the body (laterality). These skills allow the individual to develop the concepts of right, left, front, back, up, and down.  

9. Visual Memory - the ability to retrieve or remember a picture in the mind that has been seen in the past. 

10. Visualization - the ability to create or alter new images in the mind. 

11. Visual-Sensory Integration - the combining of visual information with movement, touch, balance, hearing, and other sensory data. 

The following are explanations of these visual abilities. Also included are common symptoms caused when these abilities have not developed adequately. If your child has any of these behaviors, he or she may have a hidden visual skills problem totally unrelated to good eyesight. This may cause your child to struggle unnecessarily with a vision related learning or reading problem. Single instances of these symptoms may be seen in almost any child. Only when these symptoms are repeated can the assumption be made that there is a visual skill inadequacy.

It must be kept in mind that visual problems can exist without signs or symptoms, because a child or adult who avoids use of his/her eyes enough will not be subdued by a visual skills inadequacy. These are most often the students who because they are very intelligent and excellent "listeners" can absorb the information necessary to score well on tests. Furthermore, children who experience visual difficulties most often do not realize it is abnormal; therefore, they do not complain and rarely tell anyone. It can be helpful to ask your child if she/he is having these symptoms, or you may have him/her check off this list too.
 

1. ACUITY 

Visual acuity is "sharpness of sight". It is measured by the Snellen Eye Chart. Reduced visual acuity can result from myopia (nearsightedness), hyperopia (farsightedness), astigmatism, or an eye disease such as retinal degeneration, glaucoma, or cataracts. If my exam reveals significant nearsightedness, farsightedness or astigmatism, glasses to compensate these optical aberrations will be recommended. But contrary to popular belief getting and wearing glasses prescribed, rarely eliminates a reading problem with school age children. Numerous research studies have shown very little correlation in improvement in reading after correction of nearsightedness, farsightedness, and astigmatism unless the amount is extremely high. Reduced visual acuity can lead to:

2. ACCOMMODATION (eye focusing) 

Just as a camera must be "refocused" to take clear pictures at different distances, so must the human eye accurately adjust to create clear images for different viewing distances. This occurs in the human eye as a result of a change in curvature of the lens inside each eye. This ability to change the shape of the lens of each eye to focus at different distances is called ACCOMMODATION.

This focal change is a result of a change in contraction of the internal eye muscle. To see clearly far away, we relax accommodation. In fact, when the human eye is looking at something 20 feet away or further, no work is required of this focusing adjustment system. However, to see clearly closer than 20 feet, accommodation must be activated. The closer the target we point our eyes at to see, the more accommodation must occur.

Accommodation is usually rather well developed by age three. This function then begins to deteriorate very slowly starting at about 8 years of age. By about 42 years of age, we need reading glasses or bifocals to replace the lost focusing. Normal developed accommodation allows clear, automatic and effortless focusing when pointing the two eyes from across the room to a word on a page 14 inches from the eyes. This focal change is usually instantaneous and we are not aware of it.

Unfortunately, many children never fully developed this automatic focusing ability. You my be able to lift a chair with one hand for a few seconds, but does that mean you can hold it at that height for thirty minutes? NO! Likewise, a child may be able to focus long enough to read a few lines of print, but he may not have developed enough focusing stamina to complete many pages of reading effortlessly. Excess energy must now be spent during reading in an effort to compensate for the dysfunctions and to keep the print clear. This extra effort is most often involuntary and without the child being aware of it. This is energy that could have been used towards the mental processing necessary to extract and retain meaning from the printed page. This reduces comprehension. 

Other symptoms of accommodative insufficiency are:

These last three symptoms occur because the person with accommodative insufficiency has to consciously or unconsciously work so hard to get the focusing muscle to keep the print clear, that the focusing muscle often spasms and over focuses. When he shifts his eyes from the page to across the room, the focusing mechanism inside the eye is very sluggish to change. The board at school is therefore blurry.
 

3. BINOCULARITY (eye teaming ability) 

There are no parts of the body which must work together with more precision than the eyes. The two eyes and all their 12 reciprocating muscles work as a team so that both eyes point precisely at the same object (or the same word or letter in the case of reading.) When both eyes are accurately aimed at the object being viewed, the information coming from the two eyes will be combined in the mind as a single image. When we read, the two eyes must converge such that both eyes point at the same place on the page. Some people never developed the ability to effortlessly converge.

About 10-15% of children have poor eye teaming abilities. In these children and adults, the eyes do not automatically and easily coordinate together. This creates stress and also reduces comprehension. In some children it is so poorly developed that words "go double." The eyes are not crossed but slip almost imperceptible amounts when reading and the child sees the words "run together." This would certainly make someone want to avoid reading. Eye teaming difficulties often result in the loss of binocularity. Since the visual system is more efficient having one eye work alone rather than two eyes working against each other creating stress, the visual centers of the brain will often ignore input from one eye. In this situation, the person is only using one eye. Tests are performed to check for the "suppression" of vision. Symptoms of poor eye teaming are:


4. OCULOMOTOR - FIXATION 

Fixation is the ability to direct and maintain steady, central visual attention on a target. This basic skill is developed in infancy and refined through the early years. Ocular motor skills are neuro-muscular control skills developed to point the visual system on target and move it to either follow a moving target or jump from one object to another. The infant reflexively turns the entire upper torso toward the direction of a noise, and then gradually learns to turn only the head to guide the visual system. Through the toddler years the individual refines this movement system by learning to use eye muscles to replace head movement - an achievement important in visual readiness for school. Eventually vision becomes the dominate sense. 

When reading a line of print in a book, our eyes need to make many small changes in position to move the eyes to the end of the line and to make the long return sweep back to the left to start the next line. Each eye must make quick and accurate "jumps" from one group of letters on the line to another set of letters. Some people call these eye movements "tracking." People need precise eye movement and fixation whether they are keeping their eyes on the ball in sports or looking from word to word when reading. Unless eye movements are accurate, mistakes will be made. This observation is based on a simple fact: if you are not looking directly at something, you cannot really see it. When reading, it normally takes only five or six eye movements per line before you get to the end of the line. Some persons make twelve or fifteen fixations per line, many of them inaccurate because of under or overshooting the target. If eye movements are slow, clumsy, or uncoordinated, and the eyes jump, miss, or lose their place on all instructional materials, then the information obtained by the child will be reduced. Symptoms of poorly developed oculomotor (eye tracking) ability can include: 


5. EYE HAND COORDINATION 

Eye Hand Coordination, also called visual motor integration, is the ability of our eyes to guide our hands. There is more to eye-hand coordination than coloring, cutting, writing, and catching a ball. This coordination demands more than a normal eye and a normal hand. Proficiency in this area is dependent upon the combined use and practice of the eyes and hands as paired learning tools. From constant use of the eyes and hands to feel, explore and inspect a child’s world, the child realizes that what he sees and touches are the same. The use of actual manipulation is no longer necessary to identify something. Inspection can then be accomplished using vision in order to determine size, shape, orientation, location, and distance. This skill is developmentally essential and preparatory to both reading and writing. Practice must start at a very early age and develop through thousands of opportunities during the first 8-10 years. In the preschool child, it is quite normal for movement and touch cues to reinforce eye aiming (hands guiding the eyes). By 1st grade he should developmentally shift the relationship so the eyes guide the hands. Every child is expected to come to the classroom ready for the writing task, a very advanced act of visual-motor integrations.

Signs and symptoms of poor eye hand coordination are: 


6. PERIPHERAL VISION 

Peripheral vision allows you to stand at one end of a room, stare straight ahead at a point and without moving your eyes up, down, left or right, detect other parts of the room.  

Nearly all sports demand good, if not superior peripheral visual awareness. Studies dating back to 1941 concluded that athletes had larger vertical and horizontal visual fields, than non-athletes. All ball sports require the player to localize a ball moving in their periphery quickly in order to make appropriate movement responses.  

All eye doctors are aware of the visual field reductions caused by glaucoma, stroke, head trauma, or brain tumors. These are called pathological visual field defects. In 1936, Dr. Thomas Eames, a physician at Boston University, reported in the Journal of Educational Research that many children with learning disabilities had smaller visual fields than children without learning disabilities. In my office, every person gets their visual field size tested. It is not uncommon for the visual field of some youngsters to be only one inch across! Trying to read with such constricted visual fields is comparable to reading with a drinking straw over each eye. This tunnel vision effect often explains why a child looses place easily, skips words or whole lines and can’t seem to relocate the target.  

Recently, the effect of stress on vision was confirmed in a series of studies by Mark Anderson, Ph.D., of Beloit College and Jean Williams, Ph.D., of the University of Arizona. Their studies found that stress directly affects the peripheral field of vision, thus reducing how much we see. They discovered that as the degree of stress increased, so did the likelihood that an individual’s field of vision would contract when required to respond to a visually demanding task. The most visually demanding and stressful tasks appear to be school work in general and reading in particular. It is difficult to say whether the academic stress that these children were under caused the visual field constrictions, or vice versa.

A child who has reduced peripheral vision may have the following symptoms: easily distracted, decreased attention span, poor comprehension, poor eye tracking, poor athletic performance, and/or clumsy; falls and bumps into things often. School activities such as reading, writing, and copying from the board can also be adversely effected.


7. VISUAL FORM PERCEPTION  

Four visual abilities are part of visual form perception. These are figure-ground, form constancy, visual closure, and visual discrimination. Figure-Ground is the ability to recognize distinct shapes from their background, such as objects in a picture, or letters on a chalkboard. Form Constancy is the ability to recognize two objects that have the same shape but different size or position. This ability is needed to tell the difference between "b" and "d", "p" and "q", "m" and "w".  Visual Closure is the ability to identify or recognize a symbol or object when the entire object is not visible. An example would be a design that is half completed. Visual Discrimination is the ability to discriminate between visible likeness and differences in size, shape, pattern, form, position, and color. Such as the ability to distinguish between similar words like "ran" and "run". 

A child who has a Visual Form Dysfunction may have the following symptoms:

8. SPATIAL RELATIONS  

This is the ability to judge the relative position of one object to another (directionality) and the internal awareness of the two sides of the body (laterality). These skills allow the individual to develop the concepts of right, left, front, back, up, and down. This ability is needed in reading and math.  

The development of orientation starts in the prenatal period stimulated by gravity reflexes which help the fetus orient in utero. This development continues through varied learned experiences in our lives. Interferences in movement activities involving vision and neuromotor relationships limit the development of orientation.  

At three years old, or even younger, a child should have grasped the concept of top and bottom, and right side up or upside down (even though still looking at books upside down). Until a preschool child is introduced to the world of letters and numbers, an object is the same no matter which way it faces. Learning numbers and letters is the first time in his life that the directions of objects are important. When the letter p points to the left, it’s a q, and when a d points to the right, it’s a b. A four-year-old child will reverse his shoes as he tries to put on his own shoes. Some four to five year olds may print numbers and letters from right to left. At these ages, this is a normal stage of developing orientation in children.  

When a child is mature enough, usually by age six, he should be able to have an internal awareness of the two sides of his body. The primary method by which a child learns how to distinguish between his right and left is through bi-lateral integration/ gross motor coordination. Bi-lateral Integration/ Gross Motor Coordination is the visual guidance of body movements and the coordination between both sides of the body. Walking, running, swimming, and riding a bike are all activities that develop a sense of balance and lateral awareness.  

Although most children master the concept of directionality by age 8, this confusion in orientation may continue in some people all their life. Reversal errors that persist beyond second grade are considered abnormal and are usually associated with reading disabilities. The specific causes of these errors remain controversial. Several possible factors have been identified and include laterality and directionality, visual form perception, eye-hand coordination, visual memory, and language deficits. If necessary, a vision therapy program will include specific procedures to reduce the tendency for “reversals”.  

The following are symptoms and signs of a visual-spatial dysfunction: 


9. VISUAL MEMORY

Visual Memory is the ability to recall and use visual information from the past. This skill helps children remember what they read and see by adequately processing information through their short-term memory, from where it is filtered out into the long-term memory. Children with poor visual memory may:

While there are good spellers who do not have good visual memory, good visual memory can be a real asset to spelling. The person who can easily remember the picture of a word as it is correctly spelled and can then write down what he is seeing in his mind has a real advantage over the child who has to try to spell each word “as it sounds”. An example of spelling a word as it sounds would be “enuf” for enough and “nashun” for nation.

Because it is frequently possible to develop a child’s visual memory, this ability can then be used by the child to spell even if he has been unable to master phonics or cannot “hear” the spelling of the word in his mind. As the number of words which the child can spell through memory increases, the ability to recognize those words when reading also increases. 

10. VISUALIZATION

Visualization is the ability to create and manipulate mental pictures of an object or concept on the basis of past visual experience and memory. It is essential in reading and playing sports.

When reading, a good reader will create mental images. Remembering pictures is much easier than remembering sounds or words. Good comprehension and understanding are dependent upon good visualization. For instance, if a child is reading a story about Africa in which a lion was chasing a zebra, it would be better to understand and remember the story if he could create a picture in his mind of the lion and zebra. Visualization is also important for good listening skills. If a student cannot visualize what is being heard, then auditory input has very little meaning. One cannot listen effectively if visualization is not taking place.

Symptoms of poor visualization are:

11. VISUAL-SENSORY INTEGRATION  

After visual data is gathered, it is processed and combined in the brain with information from hearing (auditory-visual integration), balance (gross-motor/bilateral integration), posture, and movement (visual-motor integration). This process is called visual-sensory integration. Underdeveloped visual skills do not stem from improper parenting. They are more the result of conditions we do not yet understand well. Heredity, genetics, nutrition, environmental toxins, stress, problems at birth, or insufficient sensory stimulation has all been blamed. Poor visual abilities occur without regard to race or socioeconomic status. 
 

WHAT CAUSES POOR VISUAL SKILLS 

Underdeveloped visual skills do not stem from improper parenting. They are more the result of conditions we do not yet understand well. Heredity, genetics, nutrition, environmental toxins, stress, problems at birth, or insufficient sensory stimulation has all been blamed. Poor visual abilities occur without regard to race or socioeconomic status. 


VISION THERAPY

The good news is that the visual abilities necessary for optimum reading are LEARNED skills. This means that they are developmental in nature and can be improved through an optometric specialty called vision therapy.

As defined by the American Optometric Association, optometric vision therapy is a treatment plan used to correct or improve specific dysfunctions of the vision system. It includes, but is not limited to, the treatment of strabismus (turned eye), other dysfunctions of binocularity (eye teaming), amblyopia (lazy eye), accommodation (eye focusing), ocular motor function (eye tracking), and visual-perception-motor abilities.

Please note that scientific research has not proven that vision conditions such as nearsightedness, farsightedness, astigmatism, and presbyopia can be successfully treated with optometric vision therapy. My optometric vision therapy program does not treat these vision conditions.   

Optometric vision therapy is based upon a medically necessary plan of treatment which is designed to improve specific vision dysfunctions determined by standardized diagnostic criteria. Treatment plans consist of a set of procedures that are individualized and prescribed by an optometrist to teach a patient how to improve a weak or nonexistent visual skill or processing skill through the use of lenses, prisms, occlusion (eye patching), special computer programs, and other appropriate materials, modalities, and equipment.

Vision therapy is best explained as a learning process where the visual system is trained to respond and adjust to visual material, such as print, in the appropriate manner. Through various standardized vision therapy procedures, the visual system and the visual control centers of the brain learn a new habit of how and when to respond. During therapy, a therapist will help the patient become aware of his weak visual ability; teach him how to improve this visual ability; and have him practice certain procedures until his visual system automatically functions efficiently. Some individuals refer to vision therapy as “physical therapy for your eyes".

The vision therapy program that Dr. Toler may prescribe is an individualized treatment plan. Dr. Toler will estimate the length of the program, which can typically range from 20 to 45 sessions. These one-on-one therapy sessions are done in the office with a vision therapist. The optimum frequency is two office sessions per week with a day between. Home activities are recommended for days that therapy is not scheduled.  Patients, who regularly practiced their home activities at least two days per week with their twice a week in-office therapy sessions, generally make the progress as expected and in many cases are able to shorten the estimated length of their treatment.

Vision therapy is not a direct treatment for dyslexia, learning disabilities, or attention deficit disorder. However it does treat vision dysfunctions that are often mistaken for these problems. For an individual who is Learning Disabled, Dyslexic, or has Attention Deficit Disorder, he/she faces yet another obstacle when poor visual abilities are present. People with learning problems may require help from many disciplines to meet the learning challenges they face. Optometric involvement constitutes one aspect of the multidisciplinary management approach required to prepare the individual for lifelong learning.
 

BENEFITS OF VISION THERAPY 

The goals of vision therapy are to improve the patient's visual function, relieve associated signs and symptoms, meet the patient's needs, and improve the patient's quality of life.  

Probably the most commonly asked question is "Is the improvement that comes with therapy permanent?" Therapy gains do remain! One research study indicated that over 98% of gains made in vision therapy remained when retested 1 year later. This study did of course take into account the gains expected by 1 additional year of maturity. Our own retesting experience has demonstrated that these skills typically do not deteriorate, but continue to improve. In a long term research study, patients who were treated with vision therapy for a poor eye teaming ability remained symptom free with normal clinical findings when retested 5 years later.  

In a questionnaire given to parents after vision therapy, one of the common changes reported is that the child is able to stay on task. The child’s concentration has improved because their visual system is working more efficiently. The second most noted change is how much faster a child does an activity. Vision therapy helps develop processing speed, the speed at which a child performs an activity. Every vision therapy activity constantly encourages the child to handle more information in less time.  An average child after vision therapy has improved his visual processing abilities by 2.9 years. The number one change parents report is an improved self esteem. Through each vision therapy activity that a child has successfully completed, he became aware of what he can do rather then what he can’t do. Children feel good about the improvements that they have made in their visual system.


THE HISTORY OF VISION THERAPY

Physicians in the mid-1800s originally introduced many of the techniques that are used today in optometric vision therapy. Modern Optometric Vision Therapy was pioneered in the United States in 1928 by optometrist A. M. Skeffington.  Dr. Skeffington used the principles of orthoptics (the science of correcting defects in binocular vision without surgery) and expanded upon many of the theories about vision and learning. Throughout the years, vision therapy’s concepts have expanded using principles from psychology, education, neuroscience, physical and occupational therapy sciences.  
 

WHY CAN'T THE SCHOOL TREAT POOR VISUAL ABILITIES?

Just as there are eye doctors who have very little training or interest in detecting or treating poorly developed visual abilities, teachers do not receive training in this specialty. Also, teachers have the education of the class as a whole as their main priority. It would be impossible to single out a child and give him the individual attention necessary for visual skills enhancement. Unfortunately, many teachers are not aware of the help that vision therapy can provide because so few optometrists offer this specialty. 

Numerous parents of students with reading difficulties have been made aware of the services I offer through resource teachers or tutors who have witnessed the improvement vision therapy made in one of their students. Some teachers who are aware of this service would like to refer a child out for these services, but are inhibited by "school politics”. Teachers and administrators have a policy of not referring children to "outside" private sources. It is not because they don't care. 

Public schools, being a tax supported enterprise, consider it a conflict of interest to support private business. Teachers and administrators fear that by recognizing a specific weakness and referring the parents for outside help, the parent may hold the school system responsible for resolving the problem since the school "diagnosed" the problem. With school system budgets across the country strained and hard pressed for funds, the money is just not available to provide the services, in or out of the school. The school and administrators don't want to risk being accountable.


WHAT IF NO TREATMENT IS DONE? 

Parents often ask "If nothing is done, will my child outgrow these reduced abilities?" Accommodation (Eye focusing) and eye teaming don't improve with age. The other visual skills improve with age, but unfortunately not fast enough to catch-up with children of the same age who don't have reading and learning difficulties and reduced visual skills. The effect of reduced visual abilities worsens because as the child gets older, school work becomes more visually demanding. The child remains handicapped and educational deficits become harder to overcome. Therefore, early diagnosis and treatment becomes extremely important.
 

GENERAL INFORMATION 

Dr. Toler and the vision therapists work as a team. Before a patient first starts a vision therapy session, Dr. Toler and the therapist will decide what techniques and methods will best help reduce the patient’s visual problem. This is based on test results and the consultation. 

Vision therapy is individually programmed to meet the patient’s specific needs. As therapy progresses, Dr. Toler and the therapist will discuss the patient’s progress and make modifications in the program in order to expedite success. Dr. Toler will see the patient again for a mid-way and final evaluation. The importance of the mid-evaluation is to make certain that visual abilities are improving as expected. The mid evaluation also will indicate what sub-skills need continued work and which ones no longer need emphasis. 

Although improvement in test scores is important, our ultimate gauge of success is the patient, parent or teacher reporting reduced difficulties in reading or learning. This almost always occurs before the mid-evaluation. Unless most of the vision therapy program occurred during the summer, we will have the added benefit of feedback from teacher, parent or patient on school and homework performance. 

For every hour spent on direct vision therapy and contact with the child, the therapist will spend at least 15 minutes programming the activities of the next therapy session. This is similar to the school teacher who plans the next day’s lessons the night before. The result is that no time is wasted during the therapy session figuring out what to do next. 

A frequently asked question is, "At what point in the treatment should results or improvement become apparent?" Based on our experience significant and noticeable improvement has been reported from the parents and/or patient by the mid-way point in about 93% of cases. Even after given this success rate, parents or patients often and understandably ask, "What if no obvious improvement is occurring with my child by the halfway point?" First, I must emphasize that success is dependent on several factors. Frequency of visits is important. If visits are missed and the patient is not doing home activities, it becomes difficult to make gains and permanent changes. Success in a vision therapy program is also highly dependent on the attitude, motivation and hard work of the patient. The therapist merely coaches and instructs the patient on the techniques and activities that the patient performs. It is not necessarily something that is "done to them". If all these criteria are met, and by the mid-evaluation, retest scores have not improved and there has been no noticeable change in the patient, as gauged by the patient, parents, or teachers, then I would recommend discontinuing therapy.  

So often I hear parents say that they can't let vision therapy interfere with their child's baseball or soccer because it’s so important for their child’s self esteem. Vision therapy needs a certain level of priority. If after school activities such as sports, karate, dance or others will keep you or your child from maintaining the minimum frequency of office sessions, the desired results will be difficult to achieve or come very slowly. You may want to reconsider your priorities. Children do not outgrow poor visual abilities. Consider what effect will this have in the future as reading assignments become more difficult, when homework takes longer and the frustration continues to grow?
 

ABOUT DR. ROBERT L. TOLER, O.D. 

Dr. Toler is a native of Rocky Mount, N.C. He attended East Carolina University and graduated from the Pennsylvania College of Optometry in 1982. His clinical internships included Walter Reed Amy Medical Center, The Pediatric Unit of The Eye Institute in Philadelphia and the Gessell Institute of Child Development in New Haven, Connecticut. Dr. Toler completed the post graduate vision therapy courses offered by nationally known vision therapy experts Dr. Kenneth Gibson, Dr. David Cook and Dr. Mitchell Schieman. He is the only optometrist to complete all three. Doctor Toler is board certified as a vision therapy specialist. He is a Fellow of the College of Optometrists in Vision Development. This organization began in 1970 to certify competency in visual testing and therapy, and promote continuing education and research in the treatment of functional visual problems that result in reduced human performance. There are only 9 other individuals in North Carolina who have accomplished this 2-3 year certification process. Approximately 500 optometrists in the United States are certified specialists in the treatment of vision therapy. Dr. Toler maintains a practice in Raleigh and Apex and is staff optometrist with the Department of Corrections. He practices general family eye care but specializes in the testing and treatment of visual related reading disorders. Dr. Toler is a past president of the Apex Rotary Club and is co-scout master of Troop 399.


A NOTE FROM DR. TOLER 

Most of the material in this handout is a combination of material from Dr. Ken Gibson of Appleton, Wisconsin, Dr. David Cook of Atlanta, Georgia and Dr. Mitchell Schieman of Philadelphia, Pennsylvania. All of these optometrists have helped over 300 optometrists in the United States, including myself to become qualified to test and treat vision related reading problems. Because I have such a passion for this specialized area, I have taken the post-graduate courses from all of them. I have combined their materials, techniques and philosophies to produce what my therapists and I proudly consider the best vision therapy program.