Improvement of accommodation and vergence amplitudes is not enough

I was going through my things and found a piece of information I vividly remember reading and highlighting two years ago. I was very excited to see something I already intuitively grasped written in the 'Optometric Clinical Practice Guidelines ' for dealing with 'Accommodation and Vergence dysfunction'. What an emotional moment it was. I was excited and somehow releaved... I was not going completely insane. At the same time I felt cheated by every doctor I had ever seen and a lot of work was left to be done under difficult circumstances. But at least someone in the world knew what they were talking about and that's something. It's amazing... All this information is freely available online and no one seems to care about it!

Two years later I'm still excited about this paragraph. Maybe even more so because that ultimate 'goal of vision therapy' as it is described has come a hell of a lot closer. To simplify, by vergence is meant the ability to move your eyes towards and maintain appropriate posture and by accommodation is meant the ability to manipulate the shape of your eye lens with the help of tiny little muscles in your eye. It's all managed by the brain and these visual abilities have to be performed at the same time at a level adequate for comfortable vision. It all has to happen in one synchronized motion or things get messy. Back then things were very messy. Vergence was all messed up by strabismic brain development and surgical intervention. Accommodation was all cramped up too. Constant double vision, poor and inconsistent performance of the visual system and wasting massive amounts of energy. This is one of those things that if you try harder, it will get worse. Once you stop trying so hard and relax, things will start to fall into place. These visual problems are not rocket science... You just have to detect them, explain them to the patient/parent and make sure no one gets in the way of recovery. In the search for solutions the right kind of motivation is important. You have to really care. You have to handle the problem as if it is YOUR problem. Clearly that kind of motivation is often lacking these days...

When talking about 'vergence and accommodation dysfunction', it's important to note that we haven't even scratched the surface of what happens when your brain develops amblyopia. We're just talking 'simple mechanics' for the moment. (If amblyopia were to occur or has occured because of lack of prevention or binocular treatment a lot can still be done and the American Optometric Association guidelines for Amblyopia are pretty neat too.)

To get back to my excitement... Lately I often use the phrase 'my vision is leveling out'. By this I simply mean that I possess the reflexes to maintain eye alignment and a clear image the overwhelming majority of the time. Also while doing funky head turns, running, playing basketball, ... The whole caboodle. Until I get really, really tired or tense. Let's say that if vergence scored 20/100 on a random, relative scale two years ago, it now scores 100/100 in comparison. I just about get by for simple, daily living. I have more control over accommodation too which is great for the syncing up process, although my prescription has not radically changed.

Alright, so from the inside of my head the visual dysfuction is less blatant than it was two years ago. Mostly undoubled vision unless you put me in a stressful situation (like reading more than 20 minutes haha). BUT as the paragraph states 'Improvement of amplitudes is not sufficient'. 'The goal of vision therapy is to establish automated, effortless accommodative and vergence responses under any stimulus condition.' 100/100 is not enough. To be comfortable you need 'visual reserves'. You need more than just getting by. You need 200/100. You need to be able to maintain visual performance when things get tough. Not only that, you need it so you can actually focus on seeing rather than trying to see. As my VT friend Matan told me earlier, the most profound changes don't result from improved eye movements. The most changes happen when you can execute those flawlessly and effortlessly. Then the perceptual and cognitive gates really start to open up. Based on the rather radical changes that have already been achieved over the last 3 years, I don't see why that final goal would be out of reach. Ahhh man, this stuff is so exciting and it's basically just a matter of time at this point!

In a following post I'll try to explain how the aperture rule or its computerized equivalents of cross eyed 3D pictures and parallel viewing stereograms are useful in cultivating 'visual reserves'.

Matan Drumer on living with and overcoming Convergence Insufficiency

Previously I wrote about how lately my situation more resembles a Convergence Insufficiency profile rather than a manifest strabismus profile. Most of the time my eyes are grossly aligned and I'm aware of both images although I do have some remaining surround suppression. My cyclopean eye is also still somewhat positioned to the right side of my head. Traditionally I used to be an alternating esotrope with a dominant right eye but after some surgeries the situation has gotten a lot more complex. For the moment the issue most impeding me from being more functional and productive is the inability to comfortably converge causing me to have double vision while reading and making it a highly stressful activity.  I've been in this VT game for a while now and I am not worried that in time with the proper lifestyle this will improve and can be remediated.

Looking through both eyes but being unable to sustain convergence... That sounds like the situation my VT friend Matan Drumer (31) experienced before entering VT. Matan entered VT  at the age of 27 after figuring out CI was the thing keeping him from reading properly and advancing academically. It's impressive he was able to pinpoint the problem and take constructive action towards a solution. That's always the first step. He engaged in an intensive year of visual training followed by another year and a half of less intensive training. The changes he describes are profound and encouraging!

How did his life improve?
1. Before starting Visual Training he used to be tired all the time. This is not the case anymore.
2. He could not pass his driving test. He would lose concentration because of the abnormally high amount of physical exertion needed to coordinate his eyes and see. Using his mirrors correctly and figuring out his relative position to other vehicles seemed impossible. Joining traffic and changing lanes was very risky. He felt like a gambler while driving. No longer.
3. Previously studying had not seemed sustainable and he was forced to pause his studies. After his reading improved by ameliorating eye teaming, he was able to resume them.
4. He feels a lot more comfortable in social situations now. He feels like he can be more open en relaxed around people because he feels more in control of his body and can anticipate and read others' intentions better.

He emphasized that improved ocular motor and muscle control is only the start of a series of amazing changes. Once he learned to operate his eyes and eye muscles correctly and effortlessly, the perceptual changes were intense and overpowering. He feels most people, even practitioners in this field, often don't really understand how visual improvement goes beyond motor and perceptual changes and into the functional and social realm. 'It feels like an awakening.'

Nowadays he still experiences (visual) ups and downs. There are days when Matan feels really sharp and it's easy to read. He confided that it feels like taking a drug. 'It's as if everything is "flowing". My reactions are fast. My thinking is quick. It's really cool.' On the bad days things are harder but never as hard as they have been before VT. I once asked Susan Barry the same question about ups and downs. She said 'I still have good and bad vision days. Only now the bad days are good and the good days are very good.' 

On the topic of stereo vision Matan is less clear. He thinks he had some stereo vision before VT or at least some of the time. He has always viewed the world with both eyes but that might have made bad eye coordination all the more confusing. He is however positive that VT has enhanced his stereo vision and his ability to navigate space allowing him to get his driver's license.

Naturally I was curious about what exercises he had done to accomplish all that. He talked a little bit about the famous Eccentric Circles and the Aperture Rule. Incidentally I myself have rediscovered the Aperture Rule this week and am enjoying the exercise much more as 'perfect execution' (who are we kidding :)) gets closer and closer. Knowingly he added that in many cases the 'how' you do a VT exercise is more important than the 'what'. I couldn't agree more.

Experiences and stories like these will certainly keep me going for another year as I eliminate my residual CI. As ocular motor skills keep improving, all these great improvements Matan is talking about might be just around the corner!