VT Works

OK, friends. We are approaching the home stretch!

By this point in the sequence, hopefully we have a reasonable sense of our partient’s abilities. It is worth noting that in most cases, the seven levels of Mental Minus are not completed in one or even two sessions. My comfort level, and please alter anything I write to match your own model, has been to work through one or maybe two levels per week with corresponding home assignments as the patient’s performance dictates. A phrase Dr. Harry Wachs often used was ensuring the patient “owned the activity”, which for me is the key. Asking or assuming a patient can truly own an activity after 10-15 minutes of work seems to be a bit ambitious. If you consider it takes most toddlers several weeks to learn to walk efficiently at a time in human development when our brains are the most pliable, expecting an older child or an adult to own a new skill after one session to me seems a bit unrealistic. They may have a splinter skill to succeed at a particular level, but truly owning the skill means they should be able to perform the given task whenever and however they are presented a challenge, without obstacle or hesitation. For a parallel, think of walking. Most of us don’t sit in our chairs preparing to walk across the room by thinking “this time I’m going to put one foot in front of the other” – we just walk. We own the skill and can perform it without challenge at any time of the day or night. Owning visual skills should be treated with the same measurement.

Level Six – Blur – Insert Lens – Immediate Clarity

As mentioned in the previous levels, this level creates a fairly high visual demand for the patient, so it may be advisable to briefly review a previous level to allow the patient the opportunity to call up the skills needed to find success.

Our setup here is consistent with previous levels – comfortably seated, Harmon’s distance, translucent patch, age appropriate sized font.

To begin this activity, we ask the patient to place the lens in front of their non-occulded eye and clear the target while paying attention to the changes needed and the associated feeling tone. Once they have a good sense of this, the lens is removed and the patient should, again, clear the target.

Without placing the lens back in front of their open eye, the patient is asked to recreate the previously identified visual posture without the benefit of looking through the lens. If done well, the patient should report the target becomes blurry. For me, this tends to be a place where discussions of the Z-axis are important.

“Where are you looking?”

“How much closer/farther did you have to move your focus?”

“Does your visual space change when you work on this level?”

“Can you maintain complete awareness of the space between your eyes and the target? Including peripheral awareness?”

“Does your awareness of your visual space change (better or worse) as you work to reposture your focusing system?”

Once the patient has an increased level of awareness, the lens can be placed in front of their open eye. If they have achieved a successful visualization of where they were looking and how to revisit that posture on their own, the target will immediately appear clear in the lens.

As the Vision Therapist, when observing your patient work through this activity successfullly, you should observe none of the changes previously discussed. The addition of the lens should not create a pupillary response, nor should you be able to observe movement with the occluded eye.

Work at this level should continue until the patient can find and maintain proper visual alignment given the power of the lens being used. It is important to repeat this exercise with many individual powers of lens to ensure the patient truly understands how to move and hold their visual posture – effectively “owning” it.

As the Vision Therapist, if you need to troubleshoot when your patient is not finding success, here are a few suggestions:

• Consider the skills needed for your patient to find success. If they are struggling, ask yourself if you have covered everything – feeling tone, spatial changes, SILO?
• Does a different power of lens change the outcome for the patient. Although counterintuitive, less power is not always easier. Sometimes, bigger changes are easier to reproduce so higher powers are better. As your patient fine tunes their system, lower powers can be introduced.
• Have we moved too fast? Please please please…don’t consider it a failure for you or your patient if you need to back up to a previous level. Sometimes review is what is needed to help a patient own a skill. There is nothing wrong with identifying the need to remediate. Remember, babies will fall down hundreds of times before they walk successfully, and sometimes crawling is just easier. Nothing wrong with it.
• Consider peripheral awareness. Many times when patients are working hard on an activity, they tend to “look hard”, or visually tunnel. Although understandable, it’s not the most effective method. As they work on this level, remind your patients to find a balance between working intently and looking soft, with full peripheral awareness. Remember, the “Where Am I?” and the “Where Is It?” systems are still to be given full consideration here, even though we are not working on them directly.

Stay Tuned for the Finale – Bi-Ocular Lenses