Looking back at 2013 and looking forward to 2014

Entered 2013 barely able to align my eyes in resting position and ended the year with the ability to calibrate eye alignment while moving with increasing accuracy. Double vision has been eliminated in daily life EXCEPT when trying to read. However, also while reading I can see the images coming closer to each other than before. During 2013, I have consolidated my transition from manifest strabismus to intermittent strabismus (Convergence Insufficiency). Remaining stumbling blocks towards achieving a workable vision level are improving convergence, sensory fusion and ultimately stereo vision.

I'm starting to feel a lot safer after three years of damage control and can feel victory approaching. I have managed not to lose my mind, not to snap under the pressure and secure much needed support for my recovery. If all goes well, I can finalize this ambitious project by tackling aforementioned challenges during the upcoming year and I will, for the first time ever, experience a visual system adequate for reading, learning and just plain living. A lot of opportunities will open up themselves simply because my brain will be able to seize them. The first subtle functional benefits are starting to kick in. Slightly better reading, less motion sickness, an easier time using electronics, ... Good changes are coming!

But for now, the show must go on! All my energy, time and attention will still be aimed at molding my biology into the shape it was supposed to have if it wasn't for adverse outside interference. I have lost twenty years and I'm not looking to lose any more time than necessary. Soon I will be able to give tDCS a try in adjunction to Vision Therapy. Can't wait to report on it. From what I hear, it's a major game changer. Sounds like 2014 is gonna be the year! Happy holidays everyone!

FAQ: "When is strabismus surgery necessary? What should I be vigilant about before going through with it?" - A guide based upon what I would have wanted to know before undergoing eye muscle surgery

NOTICE: Because communication and collaboration between ophthalmologists/strabologists and developmental optometrists is generally poor, it's hard to know whether one is getting the appropriate information or advice. Having suffered from strabismus for twenty years during which I have undergone three strabismus surgeries and more recently three years of Vision Therapy, I feel like my ideas might be useful to many who are struggling to make the right decision.  I am not an optometrist or vision care professional but under the force of circumstances I have become well-read on the subject. Moreover, during this time, I have had lots of contact with other adult patients and parents of cross-eyed children.  This blog entry is not clear cut advice, but it definitely contains elements to consider before undergoing eye muscle surgery and I hope it will lead to more informed decisions and a better life for everyone involved.

I'm not an anti-surgery zealot but it is safe to say that nowadays it is widely overused as a treatment for strabismus, often not in the patient's interest. Even though often called a 'routine procedure' by surgeons, strabismus surgery is a serious life changing event. In order for the outcome to be beneficial, a cost-benefit analysis has to be made based on ALL available information. The effects of surgery are not easily undone so you want them to be positive. First of all you should be aware of all strabismus treatment options, which is often the first major stumbling block in dealing with the vision care sector. SURGERY IS NOT THE ONLY OPTION.

But once knowing the various options, who to believe? What to decide? I will try to be as objective as possible and give you my view on several strabismus situations one might encounter.

INTERMITTANT STRABISMUS/ PHORIAS
NEVER get surgery if your eyes are aligned some of the time but alignment can not be sustained during visually taxing tasks like reading. Nothing good will come of it. Take your healthy eyes and eye muscles and improve your vision and eye teaming skills through visual training until you are able to maintain eye alignment 100% of the time, also while reading. This can often be achieved in less than one year.

MANIFEST STRABISMUS/TROPIAS
INFANT:  In case of strabismus, it is often said that 'the sooner the surgery, the better'. This makes sense because in that case the baby will adapt more easily to the new artificially manufactured eye posture. But on the other hand, given the fact that an infant can adapt so easily it might be worth considering to avoid the surgery all together and opt for strengthening the visual system through stimulation. Infants are very malleable and have tremendous rebound capacity even when born cross-eyed. I would like to refer you to an earlier blog entry on this topic titled 'I have a cross-eyed infant/child, what the hell am I supposed to do?'. Stimulation can include visual training and life style changes, Syntonics and physical therapy to aid with sensory motor development.

That being said I understand it sometimes feels 'impossible' to parents, especially when their child was born cross-eyed. It's like it was always been this way and all around they get told it's not possible to change the situation. As I see it, those children are born into a more difficult 'visual position' and it might be more challenging but they have the potential to develop normal vision like everyone else. The prevailing negativity among many vision care professionals often doesn't help in moving towards that goal. Because other options are not offered or insufficiently tried (patching by itself is not a worthy equivalent to proper Vision Therapy), parents often feel like they have to act NOW and agree to surgery.

In theory, it sounds good. The child is still young and then at least cosmetically the issue is off the table. However, strabismus is NOT a cosmetic issue, it's a functional issue. So if you agree to surgery, keep in mind you will have to stimulate the child's brain and teach him to use both eyes together. Surgery should always come with recommended follow-up Vision Therapy. After rearranging the mechanics, you need to provide the little brain with 'driving instructions'. Vision develops throughout childhood and its development has to be monitored carefully, especially in children starting out in a visually precarious situation. Vision development is an ongoing process which often does not easily lend itself to 'quick fix solutions'.

Without these 'driving instructions' the eyes will often revert back to crossing leading to follow-up surgeries. Now, the thing that strabismus has going for it is usually the fact that in essence the eyes are healthy and the brain 'just' needs to learn how to control and use them. So the last thing you want to do is to actually damage the eyes or its surrounding muscles by cutting them up and reattaching them one or several times. So if you were to opt for surgery, and this piece of advice is based on my own personal experience,  I strongly urge you to look for the best surgeon around. Do your due diligence. As in any profession, not all surgeons are created equal. Strabismus surgery is no small matter. Check it out on Youtube if you don't believe me. You don't go in there and come out the next day 'That was fun! What's next!? Otra cosa mariposa!'. A good surgeon will minimize damage and scar tissue while optimizing eye motility and posture which will allow the child to develop his vision further as optimally as possible. If dealing with an honest and knowledgeable surgeon he might admit that in many cases the best way to do that is not to perform surgery at all.

This brings me to another important point. Do not act on the opinion of one eye doctor or surgeon alone. Make sure to get the opinion of someone qualified in visual neurorehabilitation or vision therapy too. Sometimes these people are hard to find but it's well worth it.

CHILDREN: For somewhat older children the same cost benefit analysis applies, with the difference that the child can to some extend choose or be compelled to cooperate in his own rehabilitation. Given the fact they are more or less consciously aware of what is happening I would rather try VT over surgery. Surgery often has a shock and awe effect by basically creating a dis-accord between the way the brain had developed so far and the new eye posture which is hard to predict. Surgery comes with certain risks and afterwards Vision Therapy will most likely still be necessary. Everyone reacts to surgery differently but you want to keep in mind visual rehabilitation is harder if the muscles have been cut up and reattached.  Children still have very plastic brains and a surprisingly resilient body so you want to take advantage of that and thoroughly try Vision Therapy before resorting to surgery. In the long run, the functional benefits of good binocular vision are invaluable.

TEENAGERS are often more self-aware and motivated to straighten their eyes. If I would have been told of the option of VT when I was a teenager I would have grabbed it with both hands and would never have let go. Another important thing to mention is that vision development should get precedence over school work regardless of age. If there are just not enough hours in a day or it's too stressful, you take care of the vision issue first. Vision is a prerequisite for good school performance so you want to start with that. First things first.

I had my surgeries at the ages of 16, 18 and 19. The third one was to make up for the second one and after that I was STILL not properly informed about all my options. These are delicate ages to get into the surgery adventure without knowing about visual rehabilitation and I was getting very, very desperate. I hope you read this before that happens. My esotropic brain underwent severe shock and awe after being forced to deal with an exotropic-ish eye posture with serious eye motility restrictions. I could not even maintain a stable gaze anymore and experienced constant double vision. My functionality suffered tremendously and I had to 'relearn' a lot of things. The consequences of those interventions are felt to this day. This is why I feel very strongly about informing patients of their options.

So ADULTS, when do you decide to go for surgery?
With the help of prism glasses surgery outcomes can be more or less simulated in advance (same goes for children and teenagers by the way). 

1. If with the help of prisms you can achieve binocular sensory fusion in the brain, your problem is to a great extent of a mechanical nature. Two options come to mind.
- Get an appropriate pair of prism glasses which stabilize your gaze and allows for sensory fusion on a cortical level. The prism glasses function like crutches to artificially compensate for poor eye alignment. While using this kind of help, it is advisable to engage in visual rehabilitation and gradually decrease your need for these 'crutches'. It will take a while but if the prism glasses are fairly comfortable this allows for a gradual transition without 'shock and awe'.
- Try to fix the mechanical eye muscle problem by means of surgical intervention. If you achieved good sensory fusion with the prisms, a mechanical change through surgery might just fix the problem. In theory this sounds good and it can work. Much depends on the surgeon and on how well the surgery went. Have you not only have achieved eye alignment but is eye muscle damage minimized and eye motility optimized? You don't want an 'aligned' eye just pointing forward unable to move appropriately and function in accordance with the other eye. Depending on the patient, this might lead to very annoying double vision. That being said, I personally know someone who experienced fusion through prisms, underwent eye muscle surgery by a very good strabologist and came out with full blown stereo vision. I have heard similar stories over the years with the appropriate amount of jealousy. ;) This is to say the 'shock and awe' effect is not always negative but you need a really good surgeon and in my opinion it's much more of a gamble than the prism + VT approach. Vision training might still be advisable after surgery. I have not gone into the financial costs of either option but if you do your research you will find that surgery is not only riskier but also more expensive.

2. Adults with stong suppression of one eye who don't achieve immediate sensory fusion with prisms.
In this case the problem is not 'merely mechanical' and eye muscle surgery without Vision Therapy afterwards won't really improve your vision. So let's look at the options.
- You could, depending on your priorities, want to get cosmetic alignment at all costs without regard for functional vision and undergo surgery thinking that then at least you have already fixed the mechanical and cosmetic side of things. Problems with this approach might be that this is unlikely to stick if not structurally accommodated by the brain through vision therapy. Again, the risk of irreversible eye muscle damage should be considered along with other risks such as post-op double vision. You always want to remember that the problem is not really situated at the eye level but at the brain level so surgery will not solve the brain problem and might actually damage the eye muscles which weren't really the problem in the first place.
- You could go down a less intrusive road of Vision Therapy focusing on gradually teaching your brain to point your eyes correctly and then gradually break through suppression in order to achieve sensory fusion and stereo vision. This is probably the less expensive and less risky road of the two, EVEN if not covered by health insurance. Outcomes will likely be better and more durable.

3. Adults whose suppression has been broken, experience double vision daily and don't achieve sensory fusion but rather superimposed images through prisms.
This is a red flag and a behavioral/developmental optometrist should be consulted asap. Double vision has serious implications for quality of life and should be treated by neuro-rehabilitative methods without additional damage to the eyes or eye muscles. If no comfortable situation can be achieved with prisms, surgery will not be beneficial. In this case surgery is only a 'good idea' to make up for previous surgery debacles which should not have happened to begin with. So step away from the surgeon!

In this case the seriousness of the situation should be understood and every action should be aimed at improving rather than deteriorating this brain injury. Visual rehabilitation should take priority because otherwise the downward spiral will not be sustainable over the long haul. Vision Therapy programs should be aimed at resolving double vision through eye alignment, eventually leading to sensory fusion. Vision therapy will be less difficult, but not easy, without recent surgical trauma.

CONCLUSION
It would be unreasonable to completely discard the uses of eye muscle surgery since every case is different and requires a different treatment strategy. Nonetheless, surgery should be a measure of last resort. Many other more structural, less risky approaches should be tried first: Vision Therapy, Syntonics, ... A good indication of how binocular vision problems (strabismus) and amblyopia (lazy eye) are brain problems, and generally not eye muscle problems, are recent studies using tDCS (transcranial Direct Current Stimulation) to promote fusion in the visual cortex in conjunction to vision therapy. It seems like a very promising method aimed at dealing with the real cortical problem rather than the cosmetic surface. It is also less invasive and risky than surgery, however crazy that may sound. More on this later.

So to sum up, I'm not saying 'don't get surgery under any circumstances'. I am just asking you to carefully weigh pros and cons and to not blindly follow one doctor or be pressured into surgery. Strabismus treatment or the pursuit of good functional binocular vision is more than just a medical issue. It's also an educational, academic and work performance related issue. This makes it a socio-economic and ultimately democratic issue. Do we really want to provide good functional vision care and thus provide people with equal opportunities?  Or do we just want to pretend to care and provide half measures leading nowhere but more medical bills and repeat cosmetic surgeries?

LAST WORD
"If you make something a little bit better, people might pay you for it; they may not. But if you make the world (or people's lives) a radically better place, the money is going to come find you, in a fair and elegant way." - Astro Teller

The content of this blog is based on twenty years of unpleasant experience and much hard work to undo past mistakes. If this and other blog entries helped you to avoid making similar mistakes and you can afford it, show some love by donating a few bucks. Thank you! 

Vision Therapy Loading

'Loading' is a term used in Vision Therapy meaning the unconscious application of visual skills consciously acquired during therapy while doing other activities. The idea is to not only be able to point your eyes at the same place at the same time but also be able to do it by default in daily life. In other words, integrate visual skills that so many take for granted but that strabismics have mastered only after x amount of training. Personally it took me one year and eight months just to align my eyes in a rested position and now another year and four months later I can increasingly accomplish this feat also while moving and doing things. However long it took, it's exciting. Tracking cars while walking, tracking birds, being able to sit through an evening and make saccades from face to face without having them go double or being completely exhausted afterwards and so on. This is just the beginning!

Needless to say I wasn't in great shape when I started VT because of a number of reasons I won't go into right now. At the age of 21, I was completely burned out, fighting a serious infection I still haven't gotten completely rid of, etc... So in case anyone was wondering, if not handled right strabismus has the potential to grow into a 'full blown' brain injury even though no one in your environment might realize or accept it. That's the dangerous part. Managing other people in this situation took up all my time and energy which wasn't particularly helpful. I had to rest a lot after going in the red for a very long time and ever since 'energy management' has been an important factor in my VT. I'm still not at a normal 24 year old functional level but it's getting better. Dealing with all the exterior and interior constraints, I have found a way to live my life allowing me to recover my vision which isn't evident at all. You have to be patient with people even though they are hurting you, sometimes without knowing it. Fortunately the storm died down over time. My life consists of rest, visual and physical training and productive activities like there are writing this blog. As time goes by the portion dedicated to resting is slowly declining and time to work is increasing. Later on in the process, work and visual training will start overlapping and then I will be in 'the safe zone'. Workable vision will allow me to gain more independence so I won't have to rely on other people to do the right thing.

Using these hard earned new visual skills and keeping in mind energy management, I've been able to enjoy some good vision  therapy loading activities. It has to be noted that this is written by someone with compromised suppression of his strabismic eye and suppression is even less when I move around. This is relevant because strabismics who are master-suppressors have a hard time knowing whether they are using both eyes while doing activities like these. I generally know when I am using both eyes and I'll explain you why later. If a master-suppressor teaches himself to switch off his suppression more easily, he can do these activities with red green anaglyph glasses as a control to make sure he is using both eyes. I know it might sound weird but I'm way passed shame and I have made public appearances with those anaglyph glasses. You gotta own your issues, I say!

- Running:
To better understand how running might be good vision therapy loading I want to cite one more extract from the book 'The story of the human body'.

Unlike walking, running is a jolting gait that causes your head to jerk around rapidly enough to blur your vision if unchecked. To appreciate this problem, watch a runner with a ponytail: the forces acting on the head oscillate the ponytail in a figure-eight motion with each step even as the head remains fairly still— evidence of unseen stabilizing mechanisms at work. Since humans have short necks that attach to the center of the skull base, we cannot flex and extend our necks to stabilize the head as quadrupeds do. Instead, we evolved a novel set of mechanisms to keep our gaze steady. One of these adaptations is enlarged sensory organs of balance, the semicircular canals of the inner ear. These canals function like gyroscopes, sensing how fast the head pitches, rolls, and yaws and then triggering reflexes that cause the eye and neck muscles to counter those movements (even when your eyes are closed). Since bigger semicircular canals are more sensitive, animals like dogs and rabbits whose heads encounter lots of jiggling tend to have larger semicircular canals than more sedentary animals. Fortunately, the skull preserves these canals’ dimensions, so we know that they evolved to be much larger relative to body size in H. erectus and modern humans than in apes and australopiths. One more special adaptation for damping your head’s jiggling motions is the nuchal (neck) ligament. This strange bit of anatomy, first detectable in early Homo but absent in apes and australopiths, is like a rubber band that connects the back of your head to your arms along the midline of your neck. Every time your foot hits the ground, the shoulder and arm from that side of the body fall just as your head pitches forward. By connecting the head to the arm, the nuchal ligament allows your falling arm to gently pull your head back, keeping it stable.

In short, my vision does get blurry and my gaze doesn't remain all that steady. Those reflexes aren't functioning all that well because of my abnormal visual history which includes a few teenage strabismus surgeries. However, this has increasingly been improving. First while walking and now also while running. Another test I use to check these reflexes is to simply make circular movements with my face and see whether things start jumbling around or not. The disturbing 'landslides' are making way for an increasingly stable world.

I've always been a very good runner until this strabismus brain injury became an increasingly serious problem. So a few weeks ago, I got carried away a bit and violated my usually cautious energy management ideas. Sure enough, that  infection started showing its head again and I had to ease off... Generally though, I do get that 'post-exercise high' again rather than mind crushing exhaustion so I'm on the right track.

- Basketball
With regards to the energy management issue I have found basketball an excellent VT loading activity. In my neighborhood there is a public basketball court so I go there to throw some baskets. This might come as a surprise for a strabismic but I never was particularly bad at football (soccer) or basketball. In this respect too, I'm curious to see what might happen over the next few years.

This is my favorite VT loading activity because it has all the elements you want to incorporate: unexpected movement, physical interaction with objects, reflexes and hand eye coordination. I know I am not suppressing while playing because when the ball comes to me from the side it is sometimes doubled. Extreme sideways viewing, especially on my right hand side, is still somewhat of a weak spot. I also notice it in more subtle ways which are hard to describe. Movement really takes away more of the residual suppression and after a while I do get tired so then it gets harder to single out my vision or see clearly. When that happens I just call it a day and go home. The work you do one day will pay off over the next couple of months and years if all goes well, so I go home satisfied knowing I am one day closer to normal functioning. The best thing about basketball is that it makes me realize that I move my eyes in sync unconsciously and I am starting to take 'not having double vision' for granted.

- Balance Board
Something I also do, but less frequently, is balancing on a bongo board. It took a while to get it down but now I can keep my balance. That doesn't necessarily mean it's helping my vision yet. There's so many things I can do by circumventing my bad binocular vision. It's fairly 'easy' to keep balance when keeping my head steady, so now the trick would be to execute circular head movements while standing on the board without falling and having my vision go double. That's the definition of loading, I suppose. Once you can do a combination of skills reasonably well, add one!

- This list is not finite
Any activity allowing you to incorporate good eye movements without having your vision go double or jittery while moving and without collapsing of exhaustion are good VT loading activities. It's no rocket science as long as you have some way to know you are not suppressing. That might be an issue for some strabismics. It's really fascinating how every strabismic is different, even though we 'are the same'. We are pursuing the same goals but often travel by different roads.

Aside from these activities and regular VT exercises, visual hygiene at all times is important of course. I'm enjoying tons of audio books lately. Thank god for the English language and all the great material that becomes available once you master it. Personally, I have always valued intellectual achievement over physical achievement so not being able to read well and have it gradually taken away even more over the years was devastating. But when considering this from a (visual) neuroscience point of view, the distinction between physical and intellectual achievement is thin if not nonexistent. That reminded me of something Steve Jobs, known for his frantic integration of hardware and software, once said: 'If you really care about software, you have to care about hardware.' When it comes to the human body, our hardware (body and brain) IS the software. By doing these gross motor exercises I'm working my way up to finer eye movement tasks such as reading. I often wonder how easy graduating from Uni must have been without uncontrollable double vision. Can't wait to really enter the zone.


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Book Review: 'The story of the human body: Evolution, Health and Disease' by Daniel E. Lieberman - Strabismus from an evolutionary biology point of view

Note:

This review contains two sections. The first half of this article reviews the book from a general perspective while the second half deals with the book's implications to vision care and strabismus in particular. Each can be read separately according to your interest but of course you are more than welcome to read the entire review. Enjoy!

"Nothing in biology makes sense except in the light of evolution." ,- Theodosius Dobzhansky

In the first half of the book Lieberman kicks off with a detailed history of how we got to be Homo Sapiens and how every mutation came into being and why. Oftentimes it was climate change or some other major event our hominin ancestors managed to survive at the time. It also magnificently reveals why we are the way we are and why we move the way we move. I leave it up to you to read the book if you want the full story on that. What stood out to me is how seemingly random it all happened and how the evolution of the modern human was not inevitable. It's like we 'won the lottery'. I will leave the philosophical debates up to you, but if you can't handle the fact that we are bipedal primates the book is not going to be much fun for you.  A great quality of his narrative is that he doesn't try to oversell and clearly states what actually can be known by examining the evidence and what are merely hypotheses. For instance, one of the many cool fun facts is that even though Neanderthals have died out, 5% of the DNA we carry has Neanderthal origins due to interbreeding. Also notable, and something every human ought to know, is the fact that we are a genetically homogenous species and apparent differences in looks are literally only skin deep.

In short, it's been an interesting last 6 million years and you are the result. Compared to the entire duration of human evolution, the agricultural revolution and later the industrial revolution are merely blinks of the eye. Agriculture was only invented around 11,000 years ago.  Farming is often viewed as an old-fashioned way of life, but from an evolutionary perspective, it is a recent, unique, and comparatively bizarre way to live. This new cultural revolution occurred for good and valid reasons and were mostly beneficial at first. The best way to investigate the effect of past events on the human body is by comparing bodily remains of hunter gatherers and early farmers. Initially height and health of farmers increased. Later on, because of various reasons one of which is population increase, farming was still a boon for the human species as a whole but became a mixed blessing for the individual. Over time farming exposed people to dangerous situations like famine, living of solely one crop and a much higher rate of infectious disease due to higher population and animal densities. In other words, the unfortunate irony of agricultural intensification is that even though farmers produced more food overall, the energy available for each child to grow diminished, probably because they were spending relatively more energy fighting infections, coping with occasional shortages of food, and toiling long hours in the fields.

Ever since the agricultural revolution culture has undergone increasingly rapid change to this day. Through cultural evolution rather than natural selection we have learned how to cope with many of the unfortunate side effects of our new farming life style. The book goes on to describe the industrial revolution and  how new divides between our biology and cultural evolution came to be and how medical advance often spectacularly helped mitigate the effects of many mismatches. The author also provides interesting insights in how the modern food industry originated and works. We are further removed from our 'normal' habitat than ever before and without looking at our own biology through an evolutionary lens we are unaware of the possible risks this entails. Not because I consider something 'normal', it is actually normal. Humans have a habit of making new habits without even knowing it. In fact, cultural evolution is taking on such speeds that what was normal to my grand parents and even parents is vastly different from what I consider normal. Increasingly we are creating novel environments for which our ancient genes did not evolve. Even though natural selection is still ongoing, there is no way it can keep up with the blistering pace at which our environments are changing. However smart we are, or we think we are ,we are still a bunch of monkeys whose proliferation and cultural development got 'out of hand'. Now, the good news is that at this time in history we can start relearning some of our monkey ways to combat health problems our body is developing in response to this profoundly new and weird environment. How awesome is that!

We therefore have much to gain by using the lens of evolution to consider shifting gene-environment interactions that have occurred since the Paleolithic ended. How well do the genes and bodies we inherited from our early modern human ancestors fare in the novel environments to which we subject them? And how can an evolutionary perspective on these changes be of practical use?...

The emerging and important new field of evolutionary medicine proposes that,despite much progress since the Paleolithic, we have become like that (out of place) animal in some respects. As innovation has accelerated, especially since farming began, we have devised or adopted a growing list of novel cultural practices that have had conflicting effects on our bodies. On the one hand, many relatively recent developments have been beneficial: farming led to more food, and modern sanitation and scientific medicine led to lower infant mortality and increased longevity. On the other hand, numerous cultural changes have altered interactions between our genes and our environments in ways that contribute to a wide range of health problems. These illnesses are mismatch diseases, defined as diseases that result from our Paleolithic bodies being poorly or inadequately adapted to certain modern behaviors and conditions....

The most basic interactions between culture and your body’s biology are the ways that learned behaviors—the foods you eat, the clothes you wear, the activities you do—alter your body’s environment, thus influencing how your body grows and functions.

To be clear, this book does not propose to resort back to our caves and give up advances that have allowed people to survive throughout human history. Today 800 million people are often still struggling to get sufficient food. Yet at this time the number of obese people world wide has exceeded one billion. Affluence seems to have its own risks since we did not develop to deal with abundance and nowadays healthy food is more expensive than junk food. So those of us fortunate enough to live in the developed world are developing all kinds of new problems. Because people have no idea anymore about what is 'normal' our daily activities and foods without moderation can lead to debilitating illnesses.

Another application of evolutionary medicine is to recognize that many symptoms are actually adaptations, thus helping doctors and patients rethink the way we treat some illnesses and injuries. How often do you take an over-the-counter medication at the first sign of fever, nausea, diarrhea, or just aches and pains? These discomforts are widely regarded as symptoms to alleviate, but evolutionary perspectives indicate that they can be adaptations to heed and put into service. Fevers help your body fight infections, joint and muscle pains can be signals to cause you to cease doing something harmful like running incorrectly, and nausea and diarrhea assist you in purging harmful bugs and toxins.

Quick fix solutions can be great when dealing with acute health problems, but we could do a far better job in preventing most of those ailments to begin with. Lieberman does not discard the impressive medical advances accomplished during the last centuries and how they enable us to survive acute health problems. He just points out we can have best of both worlds. If we start being aware of the risks of some modern behaviors and know how to manage them adequately we could be much better off. When illness logically finds you because of the way your biology interacts with some behavior or foods, many doctors often deal with the symptom, rather than come up with a structural solution, starting costly negative feed back loops aggravating the problem in the long haul. While as a matter of fact some ailments can simply be prevented or treated by changing behavior.

(Some medical treatments) are not so much solutions as Band-Aids that treat only the symptoms of mismatch conditions. Such palliative responses can create a problem, because treating the symptoms rather than causes of mismatch diseases sometimes provokes a pernicious feedback loop, which I term dysevolution, that allows the disease to persist or even intensify. ...

Many medications are available for treating hypertension, but the best treatment is also the best form of prevention: good oldfashioned diet and exercise. Therefore, like cavities, high blood pressure is a common case of dysevolution because even though we know how to lessen its prevalence, our culture creates and passes on the environmental factors that cause the condition and keep it common. As chapters 10 through 12 explore, similar feedback loops help explain the incidence of type 2 diabetes, heart disease, some forms of cancer, malocclusions, myopia, flat feet, and many other common mismatch diseases.

To get the full benefit of the illuminating descriptions of mechanisms through which very 'normal' or common behaviors might contribute to those ailments I recommend for you to read this book. When reading some books I really feel privileged to acquire the knowledge offered by that particular book and this is one of those books. I'm happy to have learned this information so I can make informed decisions in the future. Nevertheless I will come back to myopia later in this review.

Towards the end the author points out this shift in health care is not going to be easy. It's very profitable to sell comfortable objects and foods we instinctively 'can't get enough of'. Moreover, the medical system is skewed in such a way that it promotes all kinds of accommodating gear, medication and expensive surgeries. Behavioral change is much less profitable and harder to sell. One often has to be really well-informed and have a healthy dose of skepticism towards doctors to find out about more structural long term solutions. Clearly this is no different in the vision care business. In the final chapter, he proposes various policy adjustments and how he thinks they would play out in trying to improve general prevention efforts taking into account our ancient cravings for comfort and 'unhealthy' foods and our new environment. Sadly much money is being spent on keeping negative feedback loops going rather than preventing them from occurring. Preventive medicine is not only the best kind of medicine, it's also the cheapest kind.

The dramatic successes of pediatrics during the twentieth century prove that preventive medicine really is the best medicine. My (the author's) grandfather (who was a doctor) died in the early 1980s, but I am sure he would despair at the state of preventive medical care for children today in the United States. The majority of American children still get regular checkups, inoculations, and dental care, but 10 percent of them don’t because of poverty and poor access to health care. The percentage of low birth weight babies, now 8.2 percent, has not declined in decades and in fact has been rising recently, even though low birth weight substantially increases a child’s risk of dozens of short-term and long-term health problems. In 1900, Americans were, on average, the tallest people in the world, but today they tend to be shorter than most Europeans.

STRABISMUS CONSIDERED AS A MISMATCH DISEASE

"It is virtually impossible to see how biology works outside the context of environment.", - Robert Sapolsky, Stanford University

To me binocular problems or strabismus are one of the most clear cases of a mismatch disease. I have a very hard time believing one could have genes that predispose you 100% to be cross-eyed. I have some papers lined up about strabismus and genetics but I doubt that they will be very earth-shaking in that respect. Even if there is such a thing as a 100% genetically predisposed strabismic, it will be a small minority among the actual strabismics.

A good point about using an evolutionary perspective is that when studying a phenomenon we shouldn't compare someone with a particular disease to a supposedly healthy person who grew up in an industrial environment. To really get an idea of what is 'healthy and normal' we should try to learn from the bodily evidence that our paleolithic ancestors left us. That would be a whole other story since nothing in biology makes sense unless seen in light of evolution.

For instance, the visual system must have evolved over millions of years in order to make us excellent hunter gatherers. Distinguishing colors, having a good panoramic overview of landscapes, judging distance, interacting vigorously with the world resulting in an agile and flexible visual system. I'm working on a blog entry on 'loading', meaning the application of learned visual skills during Vision Therapy in real life activities. I think hunting and gathering would be an excellent form of 'loading'.

Knowing this, writing and reading are a fairly 'risky' new behaviors and was only invented 6,000 years ago. In his book 'The Mind's Eye' Oliver Sacks ponders the question how we managed to invent script, reading and writing from a neurological perspective. He proposes that we didn't evolve to read and write but rather that we 'recruited' brain areas that evolved for other practical uses which eventually enabled us to invent something completely new by combining them. I am the first person to marvel at such ingenuity but advanced behavior like reading are are not really 'normal' in the evolutionary sense of the word. Obviously the benefits of reading outweigh the risks and it has brought us plenty of good. Nonetheless reading could be even more beneficial to mankind if we learned how to manage the risks it brings to the human visual system. A problem can be caused by environment and behavior so it can also be solved by environment and behavior such as visual training.

The author did mention the myopia epidemic that sweeps the globe as a result of intensified reading and electronics use. He clearly understood the idea of how and why vision changes. But I would almost say myopia is a 'beneficial' adaptation to our new environment which in general leads to easier reading, higher income and more socio-economic success. So it is clear our new environment brings out more myopia in those genetically predisposed to it and cultural innovation like glasses and invisible contacts help them cope. However, extreme myopia too can be managed through accommodation training and life style changes.

That being said, Lieberman didn't seem to realize there are far more crippling and fundamental evolutionary vision mismatches in our day and age. Myopia is basically cramping of the ciliary muscle in the eye making it hard for one to adjust his eye lens. My point being that the problem is situated 'mostly in the eye', which is just the tip of the iceberg of the visual system. Things do get much worse when novel environments inhibit normal binocular brain development and vision development goes rogue. In fact people who are genetically predisposed for clear viewing at mid and long distances often experience visual overload when they try reading at a young age without appropriate glasses. This often leads to amblyopia and/or strabismus. These are brain disorders. The brain is the core of a person so you don't want to mess with that or more trouble is in store for you and society. Without managing those risks associated with long hours  of short distance viewing, people with a good 'hunter gatherer vision' predisposition undergo abnormal vision development because of cultural pressures and can eventually even be excluded from society of it. I often mention the added risk of strabismus for farsighted people or hyperopes but myopes can also be at risk.

Frankly, I have a very hard time believing that one could develop strabismus when having to live a hunter gatherer life style. Vision Therapy actually includes training many basic visual skills that would be crucial to hunting and gathering. Even if you were 'born cross-eyed' one would have to grow out of it and strengthen the visual system similar to Vision Therapy. Now, THAT is a really interesting evolutionary mismatch that affects one in five people. Taking into account both those who are suffering from manifest and intermittent strabismus. We consider this the new 'normal' but if we start using our brains we can reinvent what's normal and drastically reduce binocular vision problems. It will not only be better for our health and productivity but it will also be cheaper for society in the long run. I am not the first one to notice or realize this by the way. Look at this excerpt from 'Optometric clinical practice guidlines for the care of patients with accommodative and vergence dysfunction' by the American Optometric Association.

 In previous generations, when survival depended on the ability to hunt, fish, and farm, the visual system had to respond to constantly changing, distant stimuli. Good distance visual acuity and stereoscopic vision were of paramount importance. Today, the emphasis has shifted from distance to two-dimensional near vision tasks such as reading, desk work, and computer viewing. In some persons, the visual system is incapable of performing these types of activities efficiently either because these tasks lack the stereoscopic cues required for accurate vergence responses or because the tasks require accommodative and vergence functioning that is accurate and sustained without fatigue. When persons who lack appropriate vergence or accommodative abilities try to accomplish near vision tasks, they may develop ocular discomfort or become fatigued, further reducing visual performance.

Accommodative and vergence dysfunctions are diverse visual anomalies. Any of these dysfunctions can interfere with a child's school performance, prevent an athlete from performing at his or her highest level of ability, or impair one's ability to function efficiently at work. Those persons who perform considerable amounts of close work or reading, or who use computers extensively, are more prone to develop signs and symptoms related to accommodative or vergence dysfunction.

Symptoms commonly associated with accommodative and vergence anomalies include blurred vision, headache, ocular discomfort, ocular or systemic fatigue, diplopia, motion sickness, and loss of concentration during a task performance. The prevalence of accommodative and vergence disorders, combined with their impact on everyday activities, makes this a significant area of concern.

As I see it, strabismus is a mismatch disease to be monitored and treated when the visual system exhibits deviation from its healthy developmental trajectory. Often children develop strabismus and the suppression of one of both eyes as a temporary adaptation helping them cope with a stressful visual task in the here and now but when this way of seeing persists over the long haul it will have serious drawbacks. If not treated, vision imbalances in the brain will often lead to imbalances in body posture. Examples of these are people tilting their head in odd angles, turning their body to one side, cramping facial muscles in an attempt to compensate for their unstable vision. Another indication that strabismus doesn't just magically appears but it develops in response to environmental demands. Sadly today most doctors still don't understand this and keep the negative, expensive feedback loops going. Strabismus is curable and when talking about accommodative strabismus it is downright preventable.

Earlier passages from the book mentioned in this review definitely apply to the vision care system or, as I like to call it,  the strab-business. The medical system is skewed towards treating the symptoms (eye muscle surgery, ADD medications, ...) rather than causes and it will take a while before people's minds can be changed and we can fully enact this paradigm shift. Strabismus is not so much a medical mystery anymore,as it is a structural social problem. Sure, we don't know every little detail about strabismus (even though we know a lot already) but that shouldn't stop us from using common sense and do the right thing. Not treating strabismus based on what we already know about the brain and only fiddling with its aesthetics leads to what Lieberman calls dysevolution. The word is very accurate in describing the process. It's very cruel to subject children or adults in need of vision help to dysevolution especially when it can easily be avoided. When someone suffers from a disease we don't know how to cure, it's a tragedy. But if someone suffers from a disease we know how to prevent and cure, it's a disgrace.  The majority of vision care professionals can do better and should do better.

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FAQ: "I have a cross-eyed infant/child so what the hell am I supposed to do?!" - A guide based upon what I would have wanted my parents to know twenty years ago

NOTICE: I am not an optometrist or vision care professional. However, I have a lot of experience in dealing with strabismus and am well-read on the subject. As an independent patient who has no stake in your choice of practitioner I feel it is my moral duty to warn parents about possible pitfalls in the vision care system. Moreover I feel like I can lend special insight into a strabismic child's situation and visual development for two reasons. I used to be a strabismic child myself and after much trial and error in dealing with the medical system am only now undergoing healthy visual development as a conscious young adult. I don't want to imply I know thé truth about strabismus because it is a highly complex condition and every brain is different. Still I feel like my thoughts can be of great value to parents or fellow strabismics.

THE IMPORTANCE OF GOOD BINOCULAR VISION AND STRABISMUS TREATMENT
When babies are born with crossed eyes people often think the child is 'born with strabismus'. That's only half of the truth. Some sort of primitive vision already develops to some extent during pregnancy but more than anything else children are born with a 'clean visual slate' even if the eyes physically look crossed at birth. Vision develops as the infant's brain develops. I won't say genes don't play a role in the development of a person and the brain because they do, but very few diseases are truly 100% genetic. At least as important, if not more important, in the building of the brain and visual system are experience and environment. The great thing about that fact is that you as a parent can take action to improve your child's experience and in doing so improve the development of the visual system.

"A child is not born into the world with all of their vision skills in full operation. Rather, a child is born with the proper tools allowing their vision to interact with their environment in a meaningful way. It is the quality of this interaction that will ultimately determine the extent and ability of the child’s vision development. 

Vision is our dominant sense. There is more central nervous system area representing vision and related movement behaviors than with any of our other senses. Our vision system, although extremely complex, has the potential to operate effortlessly. Other areas of a child’s development, including language, curiosity, imagination, social skills, emotional development, fine and gross motor skills, and cognition depend upon how vision develops. It is as if vision is the rudder guiding the entire ship of a child’s development. 

When the child later enters this world fully prepared with well developed vision skills, then the process of learning is supported. When vision skills are not well developed, then learning is encumbered. Children not succeeding in school have been studied closely and were found to have a higher incidence of poorly developed vision skills compared to children succeeding in school." 

From 'Fundamental vision development in infants' 

In short, vision problems are functional problems and not merely cosmetic ones! 

THE VISUAL SYSTEM: My own simplified and intuitive schematic
The visual system is a system. The organism, your child, already has the tools to develop good vision. It is your job to create the conditions under which this system can thrive by using the limited amount of energy your child has for vision development at any given time as optimally as possible. It's not surprising then that developmental optometrists often use words that resemble engineering lingo like degrees of freedom, stress, strain, load, plasticity, ... There are things you can do that are constructive and there are things that can be destructive such as, in extreme cases, child abuse. The fact that you are reading this blog entry clearly indicates that you are of the constructive kind.

There are far more detailed and accurate representations of the visual system out there but my simplified version is more accessible and just as effective in telling you what you need to know.

Based on my experience I would, for our purpose, divide the visual system into three parts.
1. Mechanics of the eye: flexibility of the eye lens and just general eye health.
2. The eye movements: alignment, ability to track, to execute saccades, ...
3. Processing of the visual input by the brain which in turn will determine many aspects of life and behavior.

Enlarge to learn about important pitfalls in the vision care system

BUILDING THE VISUAL SYSTEM

One of the keys to building a better visual system is to avoid bottle necks and (visual) overloads. One visual skill supports the other and if you try too much at once the whole structure collapses.

Looking at my schematic, it is important to realize that only number 1. can be aided by optical correction (glasses). So in order to avoid a bottle neck in the system this is to be your first priority. Save the organism's energy by giving the child the best refractive correction. This way, energy that would be wasted by not having glasses can be relocated to number 2. and 3. Often getting the right kind of glasses already gets you half way through solving the problem.

Once you checked that box and your child still seems to be having inconsistent eye movements you will have to make sure the brain gets better at executing those movements. Basically the movements will have to be done more efficiently and get less energy consuming in order for your child to advance visually (and in life). This can be accomplished through Vision Therapy. There are many aspects of vision that are learned. With the proper environment and adequate vision stimulation, vision can be guided to assume its proper role as the dominant sense.

"By three months of age infants have begun to incorporate a time for exploring and a time for playing. Optometric vision therapy will best be included during this time. It is important that the activities be carried out while the baby is happy and free of the desire to satisfy a particular need. Optometric vision therapy, while the infant is hungry, sleepy, or unhappy is of little benefit. An ideal time usually occurs just after the baby’s bath.

The true change in vision behavior will come about by doing the activities on a regular basis as opposed to doing them for long stretches only intermittently.

The optimal situation in optometric vision therapy occurs when a parent recognizes the underlying visual skill that is being emphasized in the activity. Next the parent can see the potential to develop the same skill with other similar but distinct activities that their baby engages in naturally."

These excerpts are taken from a valuable paper called: Infant Vision Guidance: Fundamental Vision Development in Infancy. The best thing about this paper is that it outlines a number of procedures one can do at home to encourage visual development in infants so don't fail to read it. Also take a look at this great piece on the 'Three Keys to Effective Strabismus Treatment'. Vision is a sensory motor process so do not only focus on the eyes, overall motor development is crucial. Some parents whom I've talked to also seem to be getting great results with physical or chiropractic therapy as a supplement to Vision Therapy. Do consult with a developmental optometrist to know whether this might be appropriate. This article is no replacement for professional guidance but the more parents know and understand about what they are doing, the better!

The American Optometric Association recommends a comprehensive vision exam for ALL children at the following ages:
- 6 months
- At 3 years of age
- Every 2 years thereafter
Children who are found to be at risk for visual problems may be examined annually.

It is important to also emphasize that Vision Therapy is NOT age restricted but naturally takes a different form for older children and adults than for infants. If you want to know more about possible Vision Therapy procedures for older children or adults, learn about red green anaglyph glasses, prism flippers, accommodative flippers, the brock string, eccentric circles,  monocular fixation in a binocular field exercises, simple visual attention exercises, light therapy, stereograms, ... Once you understand the principle of red green anaglyph glasses the possibilities are endless as exemplified by anti-suppression tetris and 3D gaming. Especially when dealing with children I would nonetheless recommend involving a professional to oversee and measure progress.

BE A SCIENTIST
My final piece of advise would be: think like a scientist. After reading this you already know a whole lot but it's important to realize this is a process you need to monitor. Make observations, learn, give up on flawed ideas, readjust, improve, persevere without pushing your child too much and use common sense. The developmental optometrist is there to help and advise you and measure progress but you are in a much better position to see how your kid's vision is evolving on a day to day basis. Speaking of scientists, reading or listening to the book 'Fixing My Gaze' by neuroscientist Susan Barry will go a long way towards understanding strabismus and what your child is experiencing.

A LAST WORD
If you have enjoyed or benefited from this and other blog entries, consider donating an amount as small as 5$ through the Paypal donate button. It's just the best feeling in the world to know your work is being appreciated. In addition, I can use some encouragement and financial support to do an even better job and get through my own visual rehabilitation. In a sense this article adds more value to people's lives than the overwhelming majority of eye care professionals who are misinforming and mistreating patients while being paid for it.  Even though I learned about these pitfalls in the strab-business the very hard way, I love working on vision related subjects and a little help would go a long way toward advancing my work of proliferating Vision Therapy as a vital treatment option for strabismus and amblyopia.

Last but not least, share this article on your favorite social network and give it a +1 on Google if you think other parents should be warned about these life altering pitfalls in the vision care system.

Thank you for reading and good luck in solving vision problems!

Convergence Insufficiency, new glasses and gravity

Recently a fabulous piece of research titled 'Association between reading speed, cycloplegic refractiveerror, and oculomotor function in reading disabled children versus controls' by Patrick Quaid and Trefford Simpson came to my attention. It, as many other optometric research, confirms in immaculate detail the importance of vision in reading and learning. It's great to see such valuable research being done by passionate optometrists on a voluntary basis. You heard that right,  for ZERO of your preferred currency! It does not take millions of $$$ to see the truth and change lives for the better.

In this research paper Patrick Quaid mentioned an interesting model he previously published in 2010 and which perfectly embodies my intuitive experience.

Original model did not include my yellow progress report

Because I have been using Optometric research as a mental anchor over the last few years in order not to lose my mind midst all the visual confusion I understood the fancy words. If you don't grasp some of them, it is a testament to your sanity so don't worry about it. Alright, hang on. I'm getting to my point.

Convergence Insufficiency

I started out almost exactly three years ago in what I would call a functionally blind state. Because of the steady degradation of my vision throughout my youth with as icing on the cake a total annihilation of any binocular skills through eye muscle surgery during young adulthood, I was left with just visual acuity. The lack of extra ocular muscle function resulted in constant double vision. I could use my vision not to bump into things but that was sort of it. I was in total shut down... Couldn't get through the day anymore, infections, ... One year after the last surgery I found out about VT and insisted on starting training however hopeless the situation seemed.  It took one year and eight months just to single out my vision briefly. As that ability improved, I could do it longer and longer and nowadays also while moving. Today I experience no more double vision unless when put under visual pressure such as reading engagements. Even though having traditionally been an esotrope and having an esotrope's brain, the surgery put me in an exotrope-ish body. In fact, there wasn't much of a coherent system when it came to my eye movements anymore. My eyes totally got out of control and the angle of my eyes depended on the viewing direction (position of gaze) among other things. Now, the beauty of my current situation is that I have gone from manifest constant strabismus and double vision to a more intermittent form of strabismus called convergence insufficiency (CI). Having put in ungodly amounts of effort and patience this is nonetheless already a great achievement even if it comes after three years of intense focus.

Where does this leave me in terms of managing my expectations and action plan? 
My initial goal of improving my vision was being able to read better. Once I found out about Susan Barry's Fixing my Gaze, I realized I was missing out on even more! One of the typical characteristics of CI is that it interferes with academic performance and reading. I can't begin to describe how bad things were before my newly found CI state... No one has any f*cking idea how 'simple' accommodative strabismus can grow into a full fledged brain injury when left untreated or badly treated. CI is still quite inhibiting but at least I know it is often treated in less than a year. If I can obtain the visual stamina to converge my eyes flawlessly while reading texts for extended periods of time I'm golden. Learn to read and you will be forever free. In terms of the above pyramid I have made it onto the 'fusional vergences' stage, which are the finer eye movements helping you to sensory fuse the percepts of each eye. I am pretty sure that sooner or later I will be experiencing stereo vision but, instead of frantically focusing on that more distant objective, I prefer to focus on ever improving convergence which will allow me to read more comfortably. It would be great to finally be able to fully indulge in my many interests. Nothing is more frustrating than having to refrain from learning and be condemned to mediocrity because of a failing vision care system. It's quite ingenious how OMDs take out their opposition by ruining their functional vision. Sadly for the ones who did this to me, three year into this quagmire I'm more hopeful than ever and have got the mental juice to take this to the very end. As Canadian optometrist Charles Boulet offhandedly said recently: 'Vision care is fundamental to human growth and freedom. As basic as shelter and food.' I can wholeheartedly confirm this is true while gearing up to eliminate  this remaining, 'milder' form of CI strabismus over the next year!

New Glasses

During my last two check-ups the astigmatism value of my left and traditionally lazy eye had changed and there was a need for better optical correction. I considered getting Shaw lenses for a while but since it's a hassle to import them into the EU and my anisometropia and consequently aniseikonia problem is limited, I settled for standard Essilor lenses. (Again, if you didn't get some of that... Good for you!) I didn't go for the overpriced 'anti-fatigue' and '360' options because I'm not sure whether these innovations would actually contribute to or rather confuse my  visual system. Having done my homework on this, I am convinced the Shaw Lens is an innovation which truly adds value to binocular vision and is even used to treat amblyopia without patches. Whether other companies are just applying some new technologies without a clear purpose or they too are actually 'getting it', I don't know. So in the end, I kept it simple by choosing standard lenses. Both of my eyes have a +2.5 spherical value with a pinch of astigmatism to my left eye. A nice touch however are the rimless frames. I like them. Stylish and great for letting your peripheral vision have a go without restrictions.

Note to self: upload a better picture

Gravity

I went to see the movie 'Gravity' in 3D with my brother. As my brother is my binocular guinea pig, he could tell me this was one of the better made 3D films he had seen up until now. Cinematographers are getting the hang of it maybe. Even though I didn't see any 3D yet,  I've made some interesting observations about myself. I'm not suppressing because occasionally the view went a little double around the edges. Then I would pull myself together and consciously make it single again. In my defense, it was late. Aside from that, my brain is picking up on something. I might not consciously be aware of any stereo vision yet but it feels more intense inside my head. When those bolts and space objects flew all around, it FELT different from a normal 2D movie. I found myself flinching at times, thinking stuff was going to hit me in the face. It might just be the monocular cues but I did FEEL like it was something more though... No matter, time will tell.

Vision Therapy Comics

It would be more funny if it wasn't so painfully true! Thanks to The Upturned Microscope for letting me use one of his characters.

Batman parodies

Jules from Pulp Fiction has strong opinions... :)

 Bane too.

A few good men

Also see:
- Vision Therapy Posters

Things I'm starting to enjoy lately

For one, it is getting easier to compare prices in the supermarket. I also started to like watching people go by juxtaposed to a stationary background. Moreover, there's a special kind of joy to tracing a moving car with your eyes while being in motion yourself. It's amazing you and the car are in motion and you can adjust your eyes as for it not to go double! I'm sure many of the visually spoiled out there don't even think about things like that, but there's more!

I'm starting to understand the concept of sightseeing I think. I have done my share of traveling before but I never really enjoyed views that much. I liked traveling because of different reasons. Now I can point both of my eyes at the things I am looking at and, even though I don't really see any 3D yet, it already feels different. It's different from my 'old 2D'. Somehow it's more overwhelming. Seeing is starting to be a pleasure. Not every second of having my eyes open implies suffering. My new appreciation for my undoubled vision extends to renewed appreciation for the environment that surrounds me. It also struck me that many people experience their first stereo moment while looking at unusual objects or scenes. Additionally, Oliver Sacks wrote about how detrimental being in a confined hospital room for several weeks had been for his sense of stereopsis. So why not get out there?

Since Brussels hosts most EU institutions and 25% of Brussels' population is of muslim origin, it is home to one of the most diverse populations in the world.

People of foreign origin make up nearly 70% of the population of Brussels, most of whom have been naturalized following the great 1991 reform of the naturalization process. 32% of the inhabitants are of foreign European origin, and 36% are of a non-Western background mostly from Morocco, Turkey and Sub-Saharan Africa. Among all major migrant groups from outside the EU, a majority of the permanent residents have acquired Belgian nationality. -  Wikipedia

With its three language communities (Dutch, French and German) Belgium as a country wasn't lacking in diversity to begin with. I moved to Brussels in a terrible state and haven't had much of an opportunity to get to know it. In another attempt to combine strab-business with pleasure, I decided to go sightSEEING regularly.

Taking the metro is starting to get much more pleasant for me. Because of my improved vision I feel much more in control already and am starting to feel less motion sick. I'm also getting to understand why one can enjoy people watching. Especially with all this diversity it is fascinating to just listen to and watch people in Brussels.  Moreover, it's fun to stand at the back of a carriage and take in the entire trains interior view and see the movement in comparison to its surroundings.

I don't even have to go far to see some interesting things. Who needs Paris or Rome when you have Brussels?

The horses on top of that monument for instance did something funny to my vision I can't really put my finger on. It wasn't 3D though... It's like you are somehow opening the perceptual gates by aligning your eyes. It doesn't happen instantaneously but if you keep doing it over an extended period of time things will start a-changin'. I often must look like a 5 year old watching the Lion King for the first time, or at least I do on the inside. I enjoy the view but it quickly drains me. So when I'm running empty I take the metro home. I always make sure to have a fairly easy exit strategy so it remains a positive experience and doesn't become a drag. Anyways, no one ever said you couldn't bring some culture into the strab-business. ;)

How to use 3D gaming in Vision Therapy at extremely low cost

How much as the strab-business might stink, there has actually never been a more hopeful time for strabismics. Neuroscience and technology are maturing to a level at which it is possible to introduce 3D technology and touch screens into the treatment of binocular problems. Thanks to a VT friend of mine named Aaron I learned how to install real games and more importantly apply 3D visual outputting to them. Because of my visual problems I had to let a lot of my geeky pursuits go in remission but stuff like this sure does revive my enthusiasm. I will try to explain how to get this stuff running on your computer for Windows users (although it must be pretty similar for other platforms I reckon).

Visual requirements:
I would say it is advisable that you have sufficient motor control over your eyes as to align them while playing the game. I have reached that visual level now and use the game to achieve better anti-suppression, more sensory fusion and hopefully in time some stereo vision. Aaron said it greatly helped him improve his stereo skills because it is engaging and the graphics are nice and more outspokenly 3D than real life experience. Combining business and pleasure is what we are going for here, as a complaint of VT patients often heard is the tediousness of VT procedures. Although boring repetition is certainly necessary while building very basic visual skills it is nice to add some juice to the mix later on. Depending on your level and your own feel you will know whether it's too soon or not.


The game Aaron proposed is called Trine 2. It has two advantages:
- It's not a first person game, meaning that you are looking at your character from the side. In my opinion it allows for more relaxed gaming and more time for your vision to adapt. Remember that you want to reap a double benefit: perceptual learning and some fun without overwhelming your vision completely. Being killed from the side seems more zen than having it done to you head on. Attacks on your person in first person might leave you more frustrated with your visual skills than anything else. On top of the side view, the game is set in a mythical environment with dreamy music in the background which also helps.
- It has a free demo!

System requirements (for Windows):
OS: Windows 7 / Vista / XP
CPU: 2.0 GHz CPU (Dual Core recommended)
RAM: 1 GB
HDD: 1.5 GB
GFX: ATi Radeon HD 2400 or NVIDIA GeForce 7600 or better (Shader Model 3.0 needs to be supported)
DX®: 9.0c Audio: DirectX 9.0c compatible

Important: Trine 2 may not run on Intel graphics solutions form 2004-2009. The game does run on new (2010-) Intel HD Graphics 3000 or better.

How to get the game?
Sign up for and download Steam. Once you did, this download manager will allow you to download and install the game.

How to get the game to play in 3D?
There are many different kinds of 3D technology which are all intended to supply each of your eyes with a slightly different image. The one that is cheapest and doesn't require extra tech equipment is red/cyan based 3D. The only things you need are very low cost red/cyan glasses and a 3D driver on your computer capable of outputting red/cyan graphics.

For you to know which 3D driver you can use, you need to find out what kind of video card your computer has. Learn how to do that here.

- If you have an NVIDIA video card it is possible your computer already has standard 3D support. Go to the NVIDIA control panel to check out the keyboard shortcuts. Normally CTRL + T will enable stereoscopic viewing if the game supports it which, in the case of Trine 2, it does. If 3D is not supported by default you can download a 3D driver designed by NVIDIA to go with your particular video card.

- In case you use an Intel HD Graphics solution (or other) you can download the iZ3D driver here. Select Anaglyph and download the driver.

Once you downloaded and executed the software it will show you the keyboard shortcuts you need to turn on and adjust the 3D graphics according to your needs. More divergence, more convergence... Whatever is most comfortable for you to start building more visual skills and better fusion. In case you only see red or cyan, you are suppressing. In my experience movement helps with anti-suppression and so it is too in playing this game.

If you get tired of playing the free Demo you can buy the game for a few bucks. In any case, this allows you to try 3D gaming at virtually no cost if you already have a pretty good computer. Cart board glasses and that's it basically.

I hope this explanation is clear enough in order to make 3D technology accessible for visually impaired people. The result of your endeavors should look like this:

Vision Therapy Posters

'Keep Calm and Carry On' was a motivational poster produced by the British government in 1939 several months before the beginning of the Second World War, intended to raise the morale of the British public in the aftermath of widely predicted mass air attacks on major cities It had only limited distribution with no public display, and thus was little known. It was believed there were only two known surviving examples of the poster outside government archives until a collection of 20 originals was brought in to the Antiques Roadshow in 2012 by the daughter of an ex-Royal Observer Corps member.

Time to bring out this iconic poster once more! Too many children with visible and invisible vision issues are going undiagnosed or are being misdiagnosed with behavioral problems. Even in case they are diagnosed with the correct binocular vision issue, they are often left untreated or mistreated. Curable eye teaming and perceptual problems are jeopardizing their future. People seem to like those retro looking posters so get them into your doctor's offices, schools, optician's stores, hospitals, ... Automatically people will be drawn to them and upon reading ask themselves the right questions.

PDF version

PDF version

PDF version

The PDF files are meant for easy printing. If any of you come up with other good slogans or completely different format ideas, let me know!

PDF version

Also see:
- Vision Therapy Comic