VT Works

Last month we reviewed WACHS Mental Minus, a wonderful Vision Therapy activity organized and illustrated by the late and great, Dr. Harry Wachs. Although, many blog posts are my own way of expressing and/or purging ideas floating around in my head, having the opportunity to share this particular activity was fun! Especially enjoyable are the follow-up emails explaining variations others have come up with – proof positive that we all have something to teach, as well as something to learn!

In completing that series of write-ups, the “Where Am I?” and the “Where Is It?” questions were mentioned often. Although not directly related to that series of activities, the awareness of these factors remain important in our patients’ finding success in tnderstanding where to look, and so we keep it alive in our conversation. Not wanting to leave that concept dangling, I would be remiss if we didn’t at least try to share some ideas on how to work that aspect, too.

As always, these activities are offered as a means of sharing my methods, with the understanding that they may not work for everyone, but are hopefully a welcomed form of sharing. Surely, there are other methods available, and those methods are just as valuable as mine. My hope is simply to offer some framework for my use and understanding of these activities.

So here goes:

Part One – Fixation and Awareness

Unlike Mental Minus, our setup with this activity generally involves having our patients stand. Of course, if your patient has physical limitations, has trouble standing without becoming dizzy, or for some other reason does not feel safe standing for more than a few moments, completing this activity while seated does not make it any less valuable. It is just important for the Vision Therapist to understand the factors that change while a patient is seated – i.e. gravity and relatability to everyday life, come to mind. My general rule of thumb is to always error on the side of patient comfort.

When our patients are ready, we should ask them to stand in a relaxed and balanced posture, with the Space Fixator a little less than a full arm’s reach away. A trick I’ve learned to measure quickly is to ask the patient to extend their arm in front of them while raising their hand (as if to offer me a high five), and the place the Space Fixator against their palm, either by them moving forward or back, or by moving the equipment. Whichever movement you choose to make, it is usually a good idea to have the patient “touch” the Space Fixator before we begin, so they can train/ground their brain as to where the object actually is in space.

This initial level is completed on a monocular basis. There is no directive in terms of which eye should work first; rather, this decision is patient specific and should involve the advice of both the Developmental Optometrist and the Vision Therapist. In most cases, there is no discernable benefit to starting with the right eye versus the left eye, but in with certain visual conditions (i.e. amblyopia), the patient experience of increasing awareness may be improved by starting with a particular eye.

Once the patient is in the correct position, they should be instructed to look at the center dot and maintain fixation on that point for a moment. The idea from here is to build peripheral awareness of the entire circle of dots, and if this step is difficult, the patient can step back slightly, effectively creating more space to work with in their peripheral vision. Once all dots are within awareness, the patient can be asked to move their eye to another dot on the circle, and again call into awareness the rest of the dots in the circle. Depending on the level of difficulty this activity presents for each patient, this portion of the activity (building awareness) can be moved through quickly, or relatively slowly. To start, we may want to ask our patients to move to the cardinal positions first (3 o’clock, 6 o’clock, 9 o’clock, and 12 o’clock) and then progress into the diagonals.

Once we have built solid awareness of all dots in the circle, the patient might be asked to move their eyes in a measured, accurate, and/or rhythmical fashion around the dots. Each movement should be preceeded by a concentrated peripheral awareness of the next dot the patient intends to move to so the saccade can be accomplished with little to no overshooting or undershooting. Essentially, it becomes “peripherally locate where you want to go next – and move”. Some patients may be inclined to move their head during this activity, which we want to discourage. To add difficulty, when appropriate, we can ask our patients to maintain full awareness of not only all the dots in the circle, but of the entire room. We can also start calling out different clock positions, asking our patients to move their eyes to the corresponding dot.

This activity can be repeated with the other eye open and experiences can be compared. Ideally, the Vision Therapist asks questions like:

• How did you do?
• How would you compare your experience from one eye to the other eye?
• What might you change next time?
• What are some activities you do everyday where this new skill might be important?

Ideas for making this activity more difficult mgiht be asking the patient to stand on a balance board, introducing some low level yoked prism, and even dynamically walking a few steps back and a few steps forward while completing the activity.

Remember, although the upcoming levels may provide a greater challenge, the entire goal of this activity is to help our patients understand how to become aware and remain aware of their peripheral vision. Since every subsequent level, and many other VT activities build upon this awareness, the beginning of this sequence becomes one of the most important steps – not just for this activity, but in most VT skills, including when we begin to address the “Where Is It?” question.

Stay tuned for Part Two!