Head rotations, bar reading and bring on the prism flippers

Head rotations
Last week, for the first time, I had a completely stable percept while doing my head turns. I couldn't believe it!  I thought I was suppressing or something but I wasn't. Both eyes were just heedlessly adjusting to the head movements without error. It must be great to be able to take these reflexes for granted! I had predicted this milestone for the end of April et voila. Another hurdle taken. The reflexes are not equally reliable every day but that, again, is a matter of time.

Speaking of head turns... I'm reading this awesome book called 'Vision Rehabilitation: Multidisciplinary care of the patient following brain injury' which I will review properly later on. It had some interesting things to say about the anatomy of vision and head rotations.

The cortical or supranuclear influence on gaze is carried out by six distinct neural networks: (1) the saccadic eye system directs the fovea from one object to another object of interest; (2) smooth pursuits hold the image of a moving target on the fovea; (3) the vergence system acts to move the eyes in opposite directions (i.e., convergent and divergent) so that the image of a single object in space can be placed simultaneously on the fovea; (4) vestibulo-ocular holds images still on the retina during brief head movements driven by signals of the vestibular system; (5) optokinetic system holds the image still insofar as possible during sustained head rotation or watching a sustained stimulus going by, such as a train; and finally (6) the fixation system holds the fovea in place on a stationary target. These complex supranuclear networks result in eye movements coordinating whole muscle groups. With the exception of the vergence system, supranuclear eye networks mediate conjugate eye movements. Thus, other than vergence system disorders, supranuclear damage does not lead to diplopia, but to restrictions of conjugate gaze, as in loss of upgaze or downgaze.

Misalignment of the two visual axes with complaints of diplopia frequently results with lesions involving the infranuclear portion of the gaze system, including Cranial Nerve III, IV, or VI or the myoneural junction or extraocular muscles they innervate. Intranuclear lesions also result in diplopia. Innervation of extraocular muscles is ipsilateral to the CN nucleus for CN III and VI, and contralateral for CN IV. The infranuclear ocular motor system is a complex motor system requiring the coordination of twelve muscles to move the eyes.

So there you have it then... I've got problems with the supranuclear, ifranuclear and intranclear portions of the gaze system but the head rotations are on their way! :D In my case it was not a traumatic head injury but a combination of uncorrected developmental weakness and bad surgical intervention. The result for the visual system however is the same. I remember a number of ophthalmologists/strabologists giving me some spiel about third cranial nerve palsy 'with unknown cause'. Yeah, sure mate... Unknown cause. After the surgery there was not only horizontal misalignment but also vertical misalignment meaning the stress on that nerve had increased because the muscles had become so much harder to operate. Vertical alignment also meant that now CN IV had become affected. Overall visual stress on the visual system had become too much to bare as some parts of the system had been ignored and neglected whereas other parts had been damaged in surgery.

Bar reading
I'm a bit repetitive in my mentioning bar reading. I just love this exercise. Nowadays I just wake up, eat something and spend an hour or so bar reading until I get tired. Not completely exhausted though. Up until the point that I still got some juice left but it's time to go for some less visually stressful activities as the day progresses. The hardest part about bar reading is to stop and wait until the next day so I can do it all over again. That's just because I love reading too. I've gone from zero pages at the beginning of this year to 14 to 15 pages a day by the end of April. Hopefully things keep progressing at this pace. It's much more fun to read properly and binocularly than to read in a half assed way. The bars keep you tied up in a 'binocular straight jacket' preventing you from falling back to double vision and visual confusion. Reading while experiencing double vision and visual confusion feels like you are hurting yourself and giving yourself a headache on purpose. I've done this many times to study the things I needed to know to survive but it's not the way to live your life in the long haul. When my bar reading juice is up for the day, I resort to text to speech software, audiobooks or other normal day activities which can include less cognitively taxing forms of visual exercise.

Bring on the prism flippers
To enhance the bar reading progress and the elimination of my remaining convergence insufficiency I'm going to start using prism flippers by the end of May. Making it a little harder yet again. Going to the next level. The new normal.

All I ever wanted was to read well and comfortably

And I'll get it.

It took one year and eight months to somehow position my eyes in alignment in a particular stationary position and have my first singled out view in years. Now another one year and eight months later I've managed to stabilize my gaze while moving my body and moving throughout space. I can even maintain a stable world view without 'land slides' because of crippled eye muscles preventing smooth eye movements while doing head turns. It's amazing! My gaze and world remains stable while turning my head in circles up to 1,5m away from my face. Closer fixation is still a bit wobbly and unstable.

I can barely remember anymore how horribly screwed up my vision was 4 to 5 years ago (fortunately I wrote it down somewhere). Granted, it takes a long time but the human body does seem to have this amazing capacity to recover from all kinds of trauma. I never imagined I would see the day I'd have vision like I have right now. It's still hard to contain my impatience and enthusiasm as I get closer to a livable and workable situation.

Traditionally I used to be eso (cross-eyed) but the surgeons put my eso brain in an exo (wall-eyed) body and ever since I've been trying to reconcile the two. As I'm closing into the near distance range, life is about to get a lot more comfortable. Three years is a long time but given the starting point a lot of ground has been covered during that time which makes three years seem like a short time in comparison. Based on that experience I feel confident in saying I will be able to read comfortably by summer 2015. Hell yes, yes, yes! How glorious will that be! Throughout my life I've been a slow starter in learning new skills or abilities (and now it's obvious why) but later on I was often able to overtake most others by keeping at it. I wonder whether I would be able to pull off the same feat when it comes to my vision. Maybe.

The other day my hilarious friend Anja was telling me how easy life actually is for mere mortals if you don't have to deal with all this impaired vision stuff... It did in fact sound pretty great and it seems like I'm going there! Use my vision to work and get some money, use my vision to have fun, use my vision to catch up on reading and learning, use my vision to live. That sounds pretty star dangling awesome. Let's take off the brakes and go to that place. Learning with binocular vision issues is like surfing the internet with a dial up connection: slow and expensive. I'm so ready for a broadband connection... That's all I ever wanted and I'll get it. They've kept me impaired long enough now. 1,5m visual range, come to papa.

Orthoptists vs Developmental Optometrists: What's the difference?

Orthoptists and developmental optometrists both work in the field of diagnosing, measuring and treating binocular vision problems, strabismus and amblyopia. They both use the same vocabulary to describe a problem and even often use the same tools. So why this distinction? I can only speak for certain about the situation in most European countries but I assume this must similar in other parts of the world.

In the wonderful book Suddenly Successful I read a while back a fairly detailed history of this branch of vision care was provided. Somewhere during the first half of the twentieth century 'the great divide' as we know it today came into being. On the one side you had the orthoptists and ophthalmologists who stuck with the primitive idea that strabismus was only treatable by patching and cutting up eye muscles. On the other side of the fence optometrists started experimenting with all kinds of lenses and procedures in order to see how far they could push natural vision improvement through stimulation and training. Particularly in Anglophone countries this approach gained traction making most notably the USA, but also the UK, Canada and Australia, world wide leaders in this approach to solving visual brain problems. I guess this might be one of the reasons why people like Frederick Brock emigrated from Switzerland to the US, although that is just conjecture on my part. Truth of the matter is that to this day most practitioners of Optometric Vision Therapy have strong ties to the US and are often (partly) trained there.

In an average European country, when dealing with strabismus, you are most likely to get in touch with an orthoptist who isn't educated in improving vision through training. Partly because they vastly outnumber their optometrist counterparts and partly because they are supported by the medical system in every single way while optometrists (depending on the country) are forced to work outside of the health care system. It's bad for developmental optometrists but it's mostly bad for the patient. Frankly I don't care who does the right thing as long as it happens. Because optometric vision therapy is administered off the grid it is not reimbursed, it's hard to know whether that provider is actually qualified and most importantly the patient is often not informed about the most cost effective treatment for his condition EVEN IF it is not covered.

I would like to give you some very clear examples of what a huge difference it makes whether you are dealing with either an orthoptist or a hopefully qualified developmental optometrist.

In essence orthoptics is an early less advanced version of developmental/behavioral optometry. I'm not so much going to argue about specific measuring procedures and tests orthoptists utilize. That being said, I know from experience they fail to check for a whole bunch of visual skills but so might many optometrists. No one is perfect. The main reason why orthoptists are ineffective is that when they do in fact detect a number of visual defects they just resign themselves to waiting for it to get worse. Maybe they'll do some patching in between to give you the impression they are doing something about it. However they are not too worried because once it does get bad enough they'll call their buddy eye doctor to perform eye muscle surgery. The thing that makes orthoptists primitive is that they are not doing their job based on the best knowledge available. They don't add  value to the life of their patients.

I was reminded of this fact by a great cartoon a Dutch strab friend of mine made. Yvette (41) made this based on her own childhood recollections. I thought it was so awesome it was a shame to let it go down the Facebook drain. Have a look.

Regardless of the test, which can vary, the results and the way to interpret these results are completely wrong. In Yvette's case the good news is that she spontaneously started seeing things floating during a 3D tech demonstration about three years ago. This incident prompted her to learn more about visual rehabilitation. The rudimentary and underdeveloped sense of stereo depth she discovered that day has been improving ever since. If you don't do it yourself...

Sadly, this skewed way of treating strabismus is not the past. Earlier I wrote about Emily in Austria who is in the possession of written medical records she did have stereo vision as a child and lost it because of orthoptists not doing their jobs and then making it worse with eye muscle surgery. I too have gone down this road because of ignorance and inactivity among orthoptists.

Even more recent I had a Dutch mother named Anoek contact me. Her baby will be one this month. Her daughter developed a squint early on. I told her to have her checked for farsightedness. She went back to the orthoptist in the hospital and asked to look for hyperopia. Her baby was indeed farsighted but this "was completely normal and did not require glasses at this age". The orthoptist even refused to give a prescription when asked. I stayed in touch with Anoek and urged her to get it corrected to avoid visual deprivation regardless of what the orthoptist said. After a while the child started to consistently turn her head because of the uncomfortable visual stress she was experiencing and trying to relieve. Anoek was alarmed and indicated this to the orthoptist. The woman reportedly answered "Don't worry about it. It happens. If it gets any worse we'll correct it with surgery later on. Your daughter can become whatever she wants when she grows up and will live to be a hundred years old." What a blatant lack of understanding of the nature of binocular vision problems, strabismus and amblyopia. Apparently no one in the north of the Netherlands, not even behavioral optometrists, has the skill or balls to do a proper retinoscopy on a one year old and prescribe appropriate glasses. In the end, Anoek and her daughter will travel all the way to Belgium to get a solid prescription from a behavioral optometrist.

How is this possible? I thought we were living in the developed world? Developed for some at least... The costs and opportunity costs of this ignorance and inactivity are huge. Just this week I was talking to my behavioral optometrist about this situation. Isn't it ironic that I'm about to fall out of the social security system while cleaning up their mess and they are still getting public health care money while causing huge damages by not doing their job? He started singing the Belgian national anthem. It was a witty retort although Belgium is by no means the only country throwing money at people who don't deserve it.  Too bad recovering from strabismus and strabismus surgery while being a 'strabismus journalist' is likely to be the least lucrative job ever. :D However I knów that the true added value of my websites far exceed whatever many vision care professionals are doing simply because it is centered around the crucial idea of neuroplasticity. If you infect people with the idea it can be done, it can be done. I always liked the idea of going all in and beating the odds, but I never expected to have to do it in this venue. Who would have expected vision care, and by extension life, was such a rigged game for strabismics?  I'm still overtaken by surprise every day.

Vision therapy progress in numbers and charts

November 29th, 2010: 14 degrees* ESO**, no fusion, no stereovision

April 7th, 2011: 8 degrees ESO, peripheral fusion, no stereovision

September 28th, 2011: 4 degrees ESO, peripheral fusion, upcoming central fusion, no stereovision

March 29th, 2012: 3 degrees ESO, peripheral fusion, central fusion, no stereovision

September 6th, 2012: aligned eyes, peripheral fusion, central fusion, double vision in daily life is gradually declining, no stereovision

May 2nd, 2013: aligned eyes, fusional area expanding, double vision usually absent, no stereo vision

October 3th, 2013: aligned eyes also increasingly while being in motion, double vision almost entirely absent except during reading, no stereo vision (even though I read a stereogram correctly 'by chance' so maybe I'm close)

April 1st, 2014: aligned eye posture increasingly solid; remaining convergence insufficiency while reading (double vision); stereo tests reveal latent ability to perceive some kind of depth but no conscious stereo vision; need for more speed, accuracy and consistency in ocular motor skills to fully unfold sensory modalities

* 1 degree = 1,75 prism diopter / 1 prism diopter = 0,57 degrees
**ESO= esotropia= cross-eyed as opposed to EXO=exotropia= wall-eyed

What I am going for! Original image taken from
'Association between reading speed, cycloplegic refractive error,
and oculomotor function in reading disabled children versus controls'

Check-up 8 (After three years and three months)

Apparently these check-up meetings are turning into happenings. Last time there was one intern present, this time there were two. I like an audience as much as the next guy. Progress remains consistent making these meetings very pleasant. My doc pointed out to the students I once had to convince him to take me on as a patient but that now he fully encourages me to go on as progress keeps on producing itself. Now it's just a fun fact.

Both eyes are still farsighted (around 2,5) with some evolution when it comes to the astigmatism in my left eye. The angle of my astigmatism shifted from 60' to 45' before and now seems to have moved again to 30'. Seems like eye movement control is not the only thing that is leveling out towards optimal function. 

Ocular motor control keeps improving. I now can take on most binocular eye postures with the exception of some extreme angles. Now it comes down to more speed, accuracy and consistency. When making circles with my head the world is ALMOST entirely stable. Almost. I'm guessing in a month or two it will be.

My main priorities are further facilitating convergence and by extension reading. That's always been my main motivation to begin with. Learn how to read and you will be forever free. As I acquire more visual stamina and freedom of action, I also want to work on getting up earlier in the morning without having it affect my vision. Meanwhile I'm also working on my overall posture. Sit straight, walk straight, act straight, ... As all this motor stuff is leveling out towards proper function, the sensory stuff is starting to make sense.

We did some polarized stereo gram tests. One out of two answers correct. Then we did his big stereoscopic test in his fancy apparatus and asked me which balloon was farthest and which was nearest. I knew the answers but I didn't consciously SEE stereo though. It's weird. He said that many people can intuitively give these answers before they consciously have stereo vision. Vision in both eyes is good and motor skills are totally approximating what they should be for stereo vision to take place, so why not!? Every check-up we're getting a little closer. Nice to have these precursors

Most people my optometrist takes on as patients walk through the door in my current condition. This is what he considers doable. So now I have reached a doable initial patient level hahaha. That's great. Give me one more year or even two and I'll nail this. I sort of have a fiscal cliff hanging over me starting September 2014 and will need to find a way to bridge that gap.  Education, health care and social security are universal in Belgium, unless you have a visual brain injury. Although I basically don't have rights, I've been very lucky still. For every guy who makes it out like me, there must be a 1000 guys in prison. Anyway, stay calm and talk sense into people. Where there's a will, there's a way!

PS: I also asked him to explain how to test for eccentric fixation and anomalous correspondence and what tools he uses. People often don't get a conclusive answer on whether they have it or not. With his tools, the names of which he wrote down for me, he says he can test it conclusively. I'll try to explain this in a separate blog entry.