VT Works

The overall goal of Wachs Mental Minus seems to be to achieve an awareness, regulation, and control over the focusing system. More broadly stated, the patient needs to be able to maintain visual clarity of their world, no matter the accommodative demand, through the flexibility, stamina, and strength found in their accommodative system. Any anomalies, inadequacies, or inefficiencies may result is such symptoms as headaches, eye strain, squinting, and even an occasional experience of double vision. Obviously, all of these symptoms have undesirable consequences.

Many times, when viewing Skeffington’s Circles, it seems we become comforted by the idea that the “What Is It?” circle only involves accommodation. The “Where Am I?” and the “Where Is It?” circles seem to be a bit more complex when we consider body awareness, motor development, and even Z axis dynamics, so the idea that the Identification Circle is ‘easier’ might be an easy leap to make, but not so fast. When recalling that no skill in the visual system exists in a bubble, or to be a bit more cliche’, everything affects everything, we will quickly realize there is more to “What Is It?” than a patient’s ability to clear a lens. A lot more. We will dive deeper into this when reviewing Part 7 – the Bi-Ocular Phase.

Level Three – Don’t Clear

As a deliverer of Vision Therapy, there seems to be activities where our observations are more important, and some where those observations may take a bit of a backseat to the patient’s self assessment. It can be a delicate balance, and one where the therapist/patient relationship becomes a key factor in deciphering the patient’s true skill level. Truly, level three of Wach’s Mental Minus creates such a situation, as it actually asks the patient to effectively do nothing, and call it a success. At the risk of sounding cynical, this may be the level where some Vision Therapists get tripped up, as in certain circumstances, there can be a fine line between actively inhibiting a response and simply having no response. This is why constant communication with our patients is experience key.

For level three, our setup remains the same – comfortable posture, one eye occluded, Harmon’s distance, and age appropriate text.

As an aside, I received an email after posting level one asking why I suggested using “age appropriate font” rather than a more standard 12 point font to keep things consistent, and my answer is simply to neutralize the demand as much as possible. Generally speaking, most first and second graders use a larger sized font in the classroom, so my goal is remain in step with their current levels. Decreasing the font size will both increase accommodative demand (remember, size matters here) but also has the potential to become defeating if we push them too far out of their comfort zone. Obviously, this detail may vary office to office and doctor to doctor, but this is where my current logic falls. As they progress through the activity, we may consider a font size change, but at the beginning it’s important for me to start where they are.

Once we have confirmed our patient’s setup is optimal (posture, distance, etc.) the first step of this level is to have the patient place lens in front of their non-occluded eye, preferably at a similar distance to that of the lenses of their eyeglasses, imagining they were wearing some. The instructional set is fairly straightforward – “try not to let anything change” – remembering, of course, that our brain’s primary signal to accommodate is blur, and the lens may cause enough of a disruption that the patient accommodates before they are able to inhibit the action, so we should be watching for it. The higher the power of the lens, the higher the level of visual conflict is created, the more inhibitive control the patient will need to call up to achieve success. If a patient seems to be having trouble, an emphasis might be placed on how their eyes feel before looking through the lens, followed by asking if they are able to maintain that feeling no matter which lens we use. As with most levels in Wachs Mental Minus, feeling tone is key.

As the Vision Therapist, two key elements to watch for are pupillary response, as the pupil will constrict with accommodative stimulation (minus lenses) and dilate with accommodative relaxation (plus lenses). The second factor to pay attention to is the action, or inaction, of the eye under the translucent occluder. Because accommodation and vergence are intricately connected, when we move accommodation, vergence will secondarily respond; meaning, the eye under the patch will move. If the patient is successful in resisting an accommodative response, neither a pupillary response nor a movement of the occluded eye should be observed when the lens is placed in front of the non-occluded eye. The same holds true when the lens is removed – we should observe no changes. The process can be repeated on the other eye with a goal of equal levels of control and regulation from one eye to the other.

For a long time, this level of Wachs Mental Minus was confusing for me. Why would we want our patients to find success in making nothing happen? What I came to realize after some time is the need to control our inactions is just as important as the need to control our actions. After all, what would good fixations look like if we couldn’t make them stay still? Active resistance to change and movement through a controlled inhibition is a skillset unto itself.

Stay Tuned for Level Four – Clear and Blur at Will