VT Works

As we round the bend in this sequence of activities, a few things come to me as important points to consider when working through Wachs Mental Minus; the first being hierarchy. For most patients, this sequence of accommodative challenges seems to be at the upper end of the hierarchy, meaning it may not be a “day one” activity. Not to suggest that it couldn’t be, but please consider the idea that there may be more appropriate activities for understanding feeling tone, accommodative posture, and SILO which would, in turn, serve as the foundation for the discussions involved with Wachs Mental Minus. The second thought is to consider the benefit of real space accommodation versus simulated space accommodation. In our everyday lives, we accommodate all day long through real space and whether we know it or not, we are constantly building, calibrating, and re-calibrating our sense of space and the associates spatial maps. Building these skills through simulated space (lenses) is great, but to truly achieve a skill that is owned, we need to make it real enough to use and transfer into their everyday life. Remember, also important here is the “Where Am I?” and the “Where Is It” challenges which are resolved through our manipulation and understanding of real space, so always consider incorporating aspects of real-space types of training into your Vision Therapy program. They, too, have incredible value.

Part Five – Clear – Remove Lens – Keep Blurred

Before you ask, let me say unequivocally “yes”, things just became much more difficult. For the first time in this sequence, feeling tone is the skill needed for a patient to find success with this activity. Without it, true success would seem to be rather difficult, if not impossible. So as a Vision Therapist, we need to feel confident our patients both understand feeling tone and are able to use and control it to accomplish some level of control with their accommodation prior to beginning this level.

Our setup for Level Five is unchanged – comfortably seated, Harmon’s distance, translucent patch, age appropriate sized font.

As an aside, if your session programming is such that this level is your first activity of the day, it may be advisable to briefly revisit one of the previous levels as a warmup as well as to review feeling tone within the accommodative system. This is done simply to help your patient to re-access their newly developed skills, as well as to feel and find success.

For the first step of this activity, the patient places the lens in front of the un-occluded eye (identical positioning as before) and works to clear the letters. Once the letters are clear, we usually will ask the patient to hold the lens in place and share feedback on what they are doing to accomplish clarity. Questions to consider might be:

• How long did it take for the image to become clear?
• What did you have to do/change to make the image clear?
• Do you think you would be able to undo it (relax accommodation) if asked?
• Are you able to describe the feeling associated with making the image clear?
• If asked, do you think you might be able to recreate this feeling without the help of the lens?
• How would you describe the level of difficulty?

There are many more ways, and many different ways, to communicate the emphasis of the activity. The overarching goal here is to build patient awareness of what they are doing to change the picture, to identify areas or skills they would like to change in order to make this a more smooth and accomplishable goal, and to build the knowledge that they are making the change, not the lens. All the lens does is create a visual conflict for them to resolve.

Once both you and the patient are confident they have a good understanding of what’s happening, they should be instructed to remove the lens while holding on to, or maintaining, their accommodative posture. Effectively, we are asking patients to be in control of the change that is occurring rather than allowing the lens to be the determining factor. After a few seconds, the lens can be placed in front of the eye once again. If this is done correctly, the patient should experience blur while the lens is not in front of their eye, and immediate clarity will be experienced when the lens is placed back in front of their eye.

As always, the Vision Therapist might want to observe pupil response, movement of the eye under the patch, and well as inquire about the patient’s current awareness of SILO. In my experience, this tends to be the level whereby patients will inadvertently alter their working distance, with most moving closer to the target making it appear larger, as a means for finding success. When this happens, usually a “did you change something?” is enough to call their awareness to the reduction in working distance, and almost invariably, they will self correct. As the activity is repeated with the other eye, any differences in performance and/or ability should be noted and addressed in future sessions.

The last piece of awareness that becomes important in this level is helping patients understand where they are looking in space. This is purely a Z-axis challenge. Bringing this concept into their awareness seems to help both with making the skill repeatable, but also helps with transferring the skill into their everyday life. For me, this is a “can you be aware of the changes in space?” question. How does the space change when you make the image clear through the lens? Do you need the lens to make that change or can you make it on your own? Can you use the spatial cues to make it happen more successfully? Even if your patients cannot articulate their answers well, you asking the question will help them to build the awareness and solidify the skill!

Level Six is Blur-Insert Lens for Immediate Clarity

Stay Tuned!