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Vision Therapy vs. Education of the Visually Impaired
Vision Therapy from a Certified Optometrist
Vision therapy, also known as visual training, vision training, or visual therapy, is a
group of techniques attempting variously to correct or improve presumed ocular,
oculomotor, visual processing, and perceptual disorders." [1] Vision therapy encompasses
a wide variety of non-surgical methods[2] which some have divided into two broad
categories: 1) orthoptic vision therapy, also known as orthoptics, and 2) behavioral vision
therapy, also known as behavioral or developmental optometry.[1]
Orthoptics aims to treat binocular vision disorders such as strabismus, and diplopia. It is
practiced by optometrists and ophthalmologists, as well as orthoptists and occupational
therapists under the guidance of some ophthalmologists and pediatric ophthalmologists.
Behavioral vision therapy is practiced primarily by optometrists who specialize in this field.
It treats additional problems including difficulties of visual attention and concentration,
which may manifest as an inability to sustain focus or to shift focus from one area of space
to another. The ability to shift the focus of visual attention from one place in space to
another affects many aspects of life including reading, most vocations and most
avocations. Eye doctors may also prescribe vision therapy to sufferers from eye strain and
visually-induced headaches. However, not all such therapy is limited to disorders of the
visual system. Professional athletes, for example, may use vision therapy to enhance
sensitivity to peripheral vision on the playing field or increase responsiveness to fast
moving objects.
History
Various forms of visual therapy have been used for centuries.[3] The concept of vision
therapy was introduced in the late nineteenth century for the non-surgical treatment of
misaligned eyes. This early and traditional form of vision therapy is what is now known as
'orthoptics.' Collaboration of some eye care professionals with educators and
neuroscientists produced an expansion of vision therapy into the treatment of other eye
teaming (binocular) deficits (the use of the flow through the right and left eyes
simultaneously to the brain) as well as dysfunctions in visual focusing, perception, tracking
and motor skills.
As a result of this expansion and ensuing confusion over what the term "vision therapy"
includes, there is some controversy as to the use of vision therapy for individuals with
learning disorders.
Although ophthalmologists and orthoptists often perform several components of visual
therapy, most non-strabismic VT is performed by optometrists.[3]
Indications
There is widespread acceptance of orthoptic therapy indications for convergence
insufficiency. Patients who experience eyestrain, "tired" eyes, or diplopia (double vision)
while reading or performing other near work, and who have convergence insufficiency may
benefit from orthoptic treatment. Patients whose outward drift occurs at distance rather
than at near distance are less ideal candidates for treatment.
Major optometric organizations, including the American Optometric Association, the
American Academy of Optometry, the College of Optometrists in Vision Development, and
the Optometric Extension Program, support the assertion that vision therapy does not
directly treat learning disorders, but rather addresses underlying visual problems which are
claimed to affect learning potential.[4]
Advocates cite a number of indications for the use of vision therapy. Some assert that poor
eye tracking affects reading skills, and that improving tracking can improve reading.[5]
Efficacy
In 1988, a review of 238 scientific articles was published in the Journal of the American
Optometric Association defining vision therapy as "a clinical approach for correcting and
ameliorating the effects of eye movement disorders, non-strabismic binocular
dysfunctions, focusing disorders, strabismus, amblyopia, nystagmus, and certain visual
perceptual (information processing) disorders." The paper concluded, "It is evident from
the research that there is scientific support for the efficacy of vision therapy in modifying
and improving oculomotor, accommodative, and binocular system disorders, as measured
by standardized clinical and laboratory testing methods for patients of all ages for whom it
is properly undertaken and employed."[6]
A 2005 review concluded that "small controlled trials and a large number of cases support
the treatment of convergence insufficiency. Less robust, but believable, evidence indicates
visual training may be useful in developing fine stereoscopic skills and improving visual
field remnants after brain damage. As yet there is no clear scientific evidence published in
the mainstream literature supporting the use of eye exercises in the remainder of the
areas reviewed, and their use therefore remains controversial."[7]
Convergence insufficiency is a common binocular vision disorder characterized by
asthenopia, eye fatigue and discomfort.[8] Asthenopia may be aggravated by close work
and is thought by some to contribute to reading inefficiency.[1] In 2005, the Convergence
Insufficiency Treatment Trial published two large, randomized clinical studies examining
the efficacy of orthoptic vision therapy in the treatment of symptomatic convergence
insufficiency. Although neither study examined reading efficiency or comprehension, both
demonstrated that in-office vision therapy was more effective than "pencil pushups" (a
commonly prescribed home-based treatment) for improving the symptoms of asthenopia
and the convergence ability of the eyes.[9][10] The design and results of at least one of
these studies has been met with some reservation, questioning the conclusion as to
whether intensive office-based treatment programs are truly more efficacious than a
properly implemented home-based regimen.[11]
In 2006, noted neurologist Oliver Sacks published a case study about "Stereo Sue", a
woman who had regained her stereo vision, absent for 25 years, after undergoing vision
therapy. The article was published in The New Yorker magazine, which is not peerreviewed, very few details were given of the exact therapies used and the article
discussed only one case of stereo rehabilitation. Caution should therefore be advised in
interpreting Sacks' conclusions.[12]
Controversy
Other than for strabismus and convergence insufficiency, the consensus among
ophthalmologists and pediatricians is that visual training lacks documented evidence of
effectiveness.[3][7] In 1998, the American Academy of Pediatrics, American Academy of
Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus
issued a policy statement regarding the use of vision therapy specifically for the treatment
of learning problems and dyslexia. According to the statement: "No scientific evidence
exists for the efficacy of eye exercises ('vision therapy')... in the remediation of these
complex pediatric neurological conditions." [13] More recently, in 2004, the American
Academy of Ophthalmology released a position statement asserting that there is no
evidence that vision therapy retards the progression of myopia, no evidence that it
improves visual function in those with hyperopia or astigmatism, or that it improves vision
lost through disease processes.[14]
Optometrists take a slightly different view. In 1999 a joint statement by the American
Academy of Optometry, the American Optometric Association, the College of Optometrists
in Vision Development and Optometric Extension Program Foundation reported: "Many
visual conditions can be treated effectively with spectacles or contact lenses alone;
however, some are most effectively treated with vision therapy....Research has
demonstrated that vision therapy can be an effective treatment option for ocular motility
problems, non-strabismic binocular disorders, strabismus, amblyopia, accommodative
disorders (and) visual information processing disorders."[15]
Although skeptics assert that vision therapists may have a financial bias in proclaiming the
efficacy of the practice[16], proponents and advocates of vision therapy claim that other eye
professionals have a similar bias in rejecting its claims.[17]
References
1. ^ a b c American Academy of Ophthalmology. Complementary Therapy Assessment: Vision
Therapy for Learning Disabilities. Retrieved August 2, 2006.
2. ^ Aetna. Aetna Clinical Policy Bulletins: Vision Therapy. Retrieved August 2, 2006.
3. ^ a b c Helveston EM. "Visual training: current status in ophthalmology." Am J Ophthalmol.
2005 Nov;140(5):903-10. PMID 16310470.
4. ^ "Vision, learning and dyslexia. A joint organizational policy statement of the American
Academy of Optometry and the American Optometric Association." J Am Optom Assoc.
1997 May;68(5):284-6. PMID 9170793.
5. ^ http://www.childrensvision.com/vision_therapy.htm
6. ^ The 1986/1987 Future of Visual Development/Performance Task Force. "Special Report:
The efficacy of optometric vision therapy." J Am Optom Assoc. 1988;59:95-105. PMID
3283203
7. ^ a b Rawstron JA, Burley CD, Elder MJ (2005). "A systematic review of the applicability and
efficacy of eye exercises.". J Pediatr Ophthalmol Strabismus 42 (2): 82–8.
8. ^ Bartiss M. "Convergence Insufficiency." eMedicine.com. Retrieved August 2, 2006.
9. ^ Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, Borsting E, London R,
Wensveen J; Convergence Insufficiency Treatment Trial Study Group. "A randomized
clinical trial of treatments for convergence insufficiency in children." Arch Ophthalmol. 2005
Jan;123(1):14-24. PMID 15642806.
10. ^ Scheiman M, Mitchell GL, Cotter S, Kulp MT, Cooper J, Rouse M, Borsting E, London R,
Wensveen J. "A randomized clinical trial of vision therapy/orthoptics versus pencil pushups
for the treatment of convergence insufficiency in young adults." Optom Vis Sci. 2005
Jul;82(7):583-95. PMID 16044063.
11. ^ Kushner BJ. "The treatment of convergence insufficiency." Arch Ophthalmol. 2005
Jan;123(1):100-1. PMID 15642819.
12. ^ Oliver Sacks (June 19, 2006). "A Neurologist's Notebook: "Stereo Sue"", The New
Yorker, pp. 64.
13. ^ "Policy Statement: Learning Disabilities, Dyslexia, and Vision". American Academy of
Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American
Academy of Ophthalmology. (September, 1998).
14. ^ "Complementary Therapy Assessment: Vision Training for Refractive Errors". American
Academy of Ophthalmology (2004). Retrieved on 2008-04-09.
15. ^ "Vision Therapy a joint organizational policy statement". American Academy of Optometry
(1999).
16. ^ Worrall, RS; Nevyas, J; Barrett, S.. "Eye-Related Quackery". Quackwatch. Retrieved on
2006-08-02.
17. ^ Cooper, R.. "Why would some ophthalmologists and their organizations claim that vision
therapy doesn't work?". VisionTherapy.org.
http://en.wikipedia.org/wiki/Vision_therapist
Vision Education from a Teacher of the Visually
Impaired (TVI)
Compensatory or Functional Academic Skills, Including Communication
Modes
Compensatory and functional skills include such learning experiences as concept
development, spatial understanding, study and organizational skills, speaking and listening
skills, and adaptations necessary for accessing all areas of the existing core curriculum.
Communication needs will vary, depending on degree of functional vision, effects of
additional disabilities, and the task to be done. Children may use braille, large print, print
with the use of optical devices, regular print, tactile symbols, a calendar system, sign
language, and/or recorded materials to communicate. Regardless, each student will need
instruction from a teacher with professional preparation to instruct students with visual
impairments in each of the compensatory and functional skills they need to master. These
compensatory and functional needs of the visually impaired child are significant, and are
not addressed with sufficient specificity in the existing core curriculum.
Orientation and Mobility
As a part of the expanded core curriculum, orientation and mobility is a vital area of
learning. Teachers who have been specifically prepared to teach orientation and mobility
to blind and visually impaired learners are necessary in the delivery of this curriculum.
Students will need to learn about themselves and the environment in which they move from basic body image to independent travel in rural areas and busy cities. The existing
core curriculum does not include provision for this instruction. It has been said that the two
primary effects of blindness on the individual are communication and locomotion. The
expanded core curriculum must include emphasis on the fundamental need and basic right
of visually impaired persons to travel as independently as possible, enjoying and learning
from the environment through which they are passing to the greatest extent possible.
Social Interaction Skills
Almost all social skills used by sighted children and adults have been learned by visually
observing the environment and other persons, and behaving in socially appropriate ways
based on that information. Social interaction skills are not learned casually and incidentally
by blind and visually impaired individuals as they are by sighted persons. Social skills must
be carefully, consciously, and sequentially taught to blind and visually impaired students.
Nothing in the existing core curriculum addresses this critical need in a satisfactory
manner. Thus, instruction in social interaction skills becomes a part of the expanded core
curriculum as a need so fundamental that it can often mean the difference between social
isolation and a satisfying and fulfilling life as an adult.
Independent Living Skills
This area of the expanded core curriculum is often referred to as "daily living skills." It
consists of all the tasks and functions persons perform, in accordance with their abilities, in
order to lead lives as independently as possible. These curricular needs are varied, as
they include skills in personal hygiene, food preparation, money management, time
monitoring, organization, etc. Some independent living skills are addressed in the existing
core curriculum, but they often are introduced as splinter skills, appearing in learning
material, disappearing, and then re-appearing. This approach will not adequately prepare
blind and visually impaired students for adult life. Traditional classes in home economics
and family life are not enough to meet the learning needs of most visually impaired
students, since they assume a basic level of knowledge, acquired incidentally through
vision. The skills and knowledge that sighted students acquire by casually and incidentally
observing and interacting with their environment are often difficult, if not impossible, for
blind and visually impaired students to learn without direct, sequential instruction by
knowledgeable persons.
Recreation and Leisure Skills
Skills in recreation and leisure are seldom offered as a part of the existing core curriculum.
Rather, physical education in the form of team games and athletics are the usual way in
which physical fitness needs are met for sighted students. Many of the activities in
physical education are excellent and appropriate for visually impaired students. In addition,
however, these students need to develop activities in recreation and leisure that they can
enjoy throughout their adult lives. Most often sighted persons select their recreation and
leisure activity repertoire by visually observing activities and choosing those in which they
wish to participate. The teaching of recreation and leisure skills to blind and visually
impaired students must be planned and deliberately taught, and should focus on the
development of life-long skills.
Career Education
There is a need for general vocational education, as offered in the traditional core
curriculum, as well as the need for career education offered specifically for blind and
visually impaired students. Many of the skills and knowledge offered to all students
through vocational education can be of value to blind and visually impaired students. They
will not be sufficient, however, to prepare students for adult life, since such instruction
assumes a basic knowledge of the world of work based on prior visual experiences.
Career education in an expanded core curriculum will provide the visually impaired learner
of all ages with the opportunity to learn first-hand the work done by the bank teller, the
gardener, the social worker, the artist, etc. It will provide the student opportunities to
explore strengths and interests in a systematic, well-planned manner. Once more, the
disadvantage facing the visually impaired learner is the lack of information about work and
jobs that the sighted student acquires by observation.
Because unemployment and underemployment have been the leading problem facing
adult visually impaired persons in the United States, this portion of the expanded core
curriculum is vital to students, and should be part of the expanded curriculum for even the
youngest of these individuals.
Technology
Technology is a tool to unlock learning and expand the horizons of students. It is not, in
reality, a curriculum area. However, it is added to the expanded core curriculum because
technology occupies a special place in the education of blind and visually impaired
students. Technology can be a great equalizer. For the braille user, it allows the student to
provide feedback to teachers by first producing material in braille for personal use, and
then in print for the teacher, classmates, and parents. It gives blind persons the capability
of storing and retrieving information. It brings the gift of a library under the fingertips of the
visually impaired person. Technology enhances communication and learning, as well as
expands the world of blind and visually impaired persons in many significant ways. Thus,
technology is a tool to master, and is essential as a part of the expanded core curriculum.
Visual Efficiency Skills
The visual acuity of children diagnosed as being visually impaired varies greatly. Through
the use of thorough, systematic training, most students with remaining functional vision
can be taught to better and more efficiently utilize their remaining vision. The responsibility
for performing a functional vision assessment, planning appropriate learning activities for
effective visual utilization, and instructing students in using their functional vision in
effective and efficient ways is clearly an area of the expanded core curriculum and
adapting the environment in regards to color, contrast and lighting. Educational
responsibility for teaching visual efficiency skills falls to the professionally prepared
teacher of visually impaired learners.
Bringing together all of these skills learned in the expanded core curriculum produces a
concept of the blind or visually impaired person in the community. It is difficult to imagine
that a congenitally blind or visually impaired person could be entirely at ease and at home
within the social, recreational, and vocational structure of the general community without
mastering the elements of the expanded core curriculum. What is known about
congenitally blind and visually impaired students is that, unless skills such as orientation
and mobility, social interaction, and independent living are learned, these students are at
high risk for lonely, isolated, unproductive lives. Accomplishments and joys such as
shopping, dining, attending and participating in recreational activities are a right, not a
privilege, for blind and visually impaired persons. Responsibilities such as banking, taking
care of health needs, and using public and private services are a part of a full life for all
persons, including those who are blind or visually impaired. Adoption and implementation
of a core curriculum for blind and visually impaired students, including those with
additional disabilities, will assure students of the opportunity to function well and
completely in the general community.
The components of the expanded core curriculum present educators with a means of
addressing the needs of visually impaired children with additional disabilities. The
educational requirements of this population are often not met since the lack of vision is
considered "minor", especially when the child is severely impacted by cognitive and
physical disabilities. Each area in the expanded core curriculum can be further defined to
address the educational issues facing these children and assist parents and educators to
fulfill their their needs.
This expanded core curriculum is the heart of the responsibility of educators serving
visually impaired students. These areas are not adequately addressed by regular
classroom teachers, nor should they be, for this is the core curriculum that is essential only
to blind and visually impaired students, and it epitomizes their "...right to be different..."
http://www.tsbvi.edu/Education/corecurric.htm