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.

Book Review: The woman who changed her brain - Barbara Arrowsmith Young

To give you an idea of how mind-bending this book is I will start out by telling you the following... Even though I sort of knew what to expect because of the references to this story given in the book 'The brain that changed itself' I read earlier and watching a TED talk given by author Barbara Arrowsmith Young, I continuously thought to myself 'this is so important! people need to know this! this can alter and save tons of lives!' while listening to this book. So after listening to the book once, I listened to it again, summarized and basically studied it.

Just as our brain shapes us, we can shape our brain. This book is about a woman who saved her own life doing 'just' that. This is all the more amazing if you know she did it in a time neuroplasticity wasn't even an established fact among neuroscientists. Through her own compelling autobiographic view along with many case studies the author describes a dozen neurological deficits, more commonly known as learning disabilities, and how to remediate them with cognitive exercise targeting a specific cortical area. By the looks of it, this book isn't much about vision. However when in a chapter on a deficit called 'motor sequencing deficit' (more on this later) people started describing how by fixing 'the mechanical aspect of reading and writing' they gained stereopsis I was completely sold. If you are familiar with Vision Therapy the exercise she devised doesn't so much impress, but rather the fact that they  'accidentally' acquired it while trying to improve other cognitive skills. Knowing that vision is a sensory and motor processing activity in the brain this makes sense, but you have to be made of stone not to be awed by how the human brain works.

Nowadays neuroplasticity is the latest buzz word but still there is a lot of resistance to change in the realm of education and health care to methods drawing on this idea. Even though we know better now, there is still a lot of neurological fatalism around because people don't know how to practically implement this principle. Sadly a paradigm shift does not happen overnight. Many educators are still telling parents learning deficits are lifelong and suggest compensatory methods rather than nipping the problem in the bud. Compensatory methods don't come close to the functionality of a cognitively repaired brain and just aren't realistic for day to day life. Depending on how severe the deficit(s) is even compensatory methods and unlimited amounts of effort will be of no avail. This will make for a lot of broken dreams and broken lives. Dysfunctional brain patterns won't go away as a child gets older unless addressed structurally through cognitive exercise. If not, they will lead to learning difficulties, job problems, depression, substance abuse, ...

I can relate to this on a personal level. Even though my neurological deficit or functional vision problem differs from the author's neurological deficits, many of the quotes and even life events in this book were familiar. A few piercing quotes:

I was clinging to a cliff by my finger nails and I was asking myself when will I fall and who will catch me? The answers were 'soon' and 'no one'.

I couldn't go forward. I couldn't go backward. There was no place for me in the world.

Many other citations from this book went straight to my heart and hit a home run. Yet in the interest of writing an informative and complete review I will attempt to give a brief overview of the neurological deficits described in this book rather than focusing on its emotional value.

1. Symbol relations problem: Difficulties with relations, abstractions, irony, jokes, grammar, figurative speech, considering alternatives, logic and reason. This results in an overwhelming feeling of uncertainty and problems in communicating thoughts and feelings leading to social isolation. Russian neurologist Luria called it semantic aphasia or a loss of meaning. The problem resides in important association areas of the cortex.
Exercise > Clock exercise
Improvement in this area means things start to make sense and one can connect the dots.

2. Symbolic thinking deficit: Weakness in the prefrontal cortex which is crucial to executive function and judgement. Difficulties with mental initiative, problem-solving, organisation, setting goals, foreseeing consequences, strategising and an inability to learn from past mistakes. A problem located in this 'recruiter of the brain' also means one easily gets distracted. A symbolic thinking deficit can be likened to an army without a general or a company without CEO. Someone with this deficit wants to be independent but is unable to and gets constantly into trouble by making bad decisions.
Exercise > Reading fables and extract meaning and morals/ Problem solving
Improvement in this area of the brain enables one to learn from his/her mistakes and to take initiative. Vital to get anywhere in life.

3. Predicative speech deficit: This deficit makes for a lot of mumbling and an inability to pronounce or write full sentences. Language beyond simple naming is not possible meaning poor or no syntax and consequently an inability to convey complex messages. This cortical weakness not only affects outward speech and writing but also internal speech and ultimately memory.
Exercise > Listening to slowed down speech
Changes will be improved spoken language, richer vocab and understanding. This in turns ends social isolation and makes for a happier and relaxed kid/person.

4. Artefactual thinking deficit (also dubbed 'social deficit'): This deficit finds its root in a weakness located in the right prefrontal cortex. It consists of an inability to read facial expressions and body language and to adjust own behavior accordingly. Someone with this deficit is impeded to learn 'the vocabulary of social movement'. Faulty interpretation of situations and acts leads to what is perceived as asocial behavior but the sufferer is simply unable to pick up social clues. To imagine living with this deficit the author proposes a trip to Japan without previous knowledge of the culture. The difference in social rules and interpretation will soon get you in trouble.
Exercise > Examining narrative art and extract meaning and social relevance. Exercise is similar to the one for symbolic thinking deficits which is also located in the prefrontal cortex but on the left side instead of the right side.

5. Object recognition deficit (prosopagnosia or face blindness is its most well-known form): This deficit includes not being able to recognize friends or family out of context. One might not be able recognize, even in context, the face of a familiar person or be able discriminate between unfamiliar faces. Sometimes someone with this deficit is not even able to distinguish a face from an object. In severe cases that person cannot even recognize himself in a mirror. Often this disability not only limits itself to faces but also to object and places.
Exercise > Find discriminating features of similar but different pictures.

THE BRAIN AND READING:
Reading is a very complex process and many areas of the brain are involved in reading. Being able to read comfortably is not a luxury but without structural cognitive training, poor readers will remain poor readers. Based on her many years of experience and the neuroscientific material available the author has tried to determine which areas are critically involved in reading and what deficits they might produce. This quest has produced three main reading deficits which lead to poor reading performance.

6. A Broca area deficit: Impaired auditory speech discrimination and trouble connecting a symbol to a sound. Improvement will not only result in better reading but also better speech.
Exercise > Discriminate between phonemes and listen to sounds.

7. Symbol recognition deficit (word blindness): Difficulty with visually remembering sight words and a limited visual vocab library.
Exercise > Study Arab or Urdu. It's not about learning how to speak those languages but about remembering the shape of the symbols. This strengthens visual memory and makes reading English or the Latin alphabet comparatively easy.

8. Motor symbol sequencing:  An inability to smoothly track words and sentences with the eyes. This leads to a lot of misreading, being easily tired and quick loss of concentration. Weakness so powerful it can impair speech, spelling and signature. With this deficit speech often does not completely reflect ones thoughts. Those kids write slowly, sloppy and with poor spelling. Needless to say that for those people grades fail to reflect their intelligence.

"Of all learning disabilities treated by Arrowsmith, difficulties with the mechanical aspect of reading are most common and take longest to deal with."

Exercise > With intent to stimulate the left prefrontal motor region they always patch the left eye and focus on writing smoothly (motor skills). Doing this some people with a weaker right eye have acquired stereopsis which is magnificently described in the book. I do have some questions however about what she would suggest in cases of a weaker amblyopic left eye such as myself. But this exercise isn't so much about vision as it is about writing. Seemingly reading and speech just improved along with it. So it influences the visual 'only indirectly' unless you really have a lazy right eye. Regardless of my visual problems my own writing is pretty okay at that so it does make sense.  In the end I wasn't so much impressed with the exercise as with how clearly all those functions and vision are intertwined in the brain.

Personal note: I do have some reading difficulties of my own and clearly no two reading problems are the same. I liked this analytically view of how the brain reads and it confirmed a couple of things for me. It is pretty clear my reading problems are entirely originating from the mechanical aspect of reading. A Broca deficit makes it hard if not impossible to learn a second language so I can erase that from the list. Furthermore I think that symbol recognition is one of the ways I compensate for poor eye muscle control. I need relatively little visual information to recognize a written word, even upside down. So in a sense this is good news. If I keep improving my eye movements, I should be able to overcome this as so many others have. It was also affirming to see that of all deficits described in this book this one takes longest to deal with. The testimonials of this deficit were particularly familiar and poignant from my point of view. I would like give examples but this review will be way too long if I do.

9. Kinestetic deficit: Problems with the mental body map or proprioception meaning that you have trouble knowing where your body parts are in space without visually seeing them. This deficit may for instance also lead to a situation in which one feels pain at the left side of the body but has to visually search for its source. This deficit often causes uncoordinated body movements. In short, it puts you at odds with your own body.
Exercise > Stop visual compensation methods and execute precise movements with eyes closed relying on other sensory input.

10. Primary motor deficit: Interferes with the speed, strength and control of muscle movements. This deficit is more commonly known as low muscle tone.
Exercise > Fast and controlled transitions from one muscle position to another

11.Spatial awareness deficit: Excessively getting lost and an inability to creating mental maps or visualize three dimensional items or situations. This weakness may for instance make it hard to estimate when an approaching car will reach you. A strength in this area enables some Hockey players to mentally visualize the field of players from above and predict their  potential movements.
Exercise > Tracking exercise in a spatial configuration

12. Memory for information deficit: Memory is intricately linked to our identity and allows us to write our own autobiography so a deficit in this area is therefore especially painful. The sieve that is their memory has unusually 'big holes' leading to poor long term retention. In severe cases major life events cannot be remembered, oral instructions can barely be followed and making lists becomes essential to survival.
Exercise > Listen to songs until one can repeat the lyrics. Start out with very easy songs and gradually move on to more difficult lyrics.

13. Quantification deficit: Difficulty with time and numbers. Some people are for instance incapable of differentiating between 8, 80 and 800. Mental math and the relativity of numbers eludes people with a quantification deficit. This causes them to get in financial trouble, be chronically late and be bad at scheduling.
Exercise > Repeated and progressively more difficult mental calculation: addition and subtraction.

14. Auditory speech discrimination deficit: One isn't able to distinguish between similar words and has a hard time discriminating speech form other sounds. With this deficit listening to your own language becomes like listening to a foreign language. You can hear the sounds but it's hard and fatiguing to make sense of them.
Exercise > Listening to speech sounds in unfamiliar languages (Swahili, Kurdish, and Bengali, to name a few). This way listening to the sounds of your own language becomes relatively easy.

Keep in mind that the exercises are brought back to a customized level empowering the student to stimulate the impaired brain area without being overwhelmed. This makes it possible to gradually pursue normal functioning in that area or number of areas. The Arrowsmith program currently assesses and treats 19 deficits so not all of them were explained in the book. Even if they were, this list is not an exhaustive and can be further refined over the years. Nevertheless I am already sure this is the future of education. Aside from just providing content, education should be about making a brain susceptible to that content. Vision therapy is a great example of such cognitive interventions and so is the Arrowsmith program. Once you enable a student's brain to learn, that student will soar on his own.

The Arrowsmith program is increasingly implemented accross Canada and the United States and recently expanded to New Zealand. More information on  http://www.thewomanwhochangedherbrain.com/ and www.arrowsmithschool.org.

Book Review: The Mind's Eye by Oliver Sacks

Oliver Sacks' books are impressive and this one is no exception. He's always willing to go that extra mile in trying to understand the experience of people who are confronted with all kinds of neurological anomalies. One of my favourite Oliver Sacks quotes is very truthful and at the same time marvelously reveals his curious and compassionate attitude towards his patients.

"Classical fables have archetypal figures — heroes, victims, martyrs, warriors. Neurological patients are all of these. ... They are travelers to unimaginable lands — lands of which otherwise we should have no idea or conception." 

In this book Oliver Sacks delves deeper into the phenomena of alexia (loss of the ability to read), posterior cortical atrophy, aphasia (inability to speak), prosopagnosia (face or object blindness), stereo blindness (inability to see depth), his own experience with eye cancer and unilateral blindness and finally various accounts of complete blindness and mental imagery. I am intrigued by all of those conditions and the very diverse ways of neurological adaptation to them. Especially the gift of mental imagery based on visual memories and input from other senses some blind people develop, allowing them to do all sorts of unexpected things, is very inspiring. I personally on the other hand only have first hand experience with stereo blindness making this a rather biased review towards that topic. It is also in this book that he tells us the story of how he met Susan Barry and how they marveled at her discovery of stereo vision later in life which is discussed in more detail in her own book 'Fixing my gaze'. For many strabismic people, including myself, the book 'Fixing my gaze' was a turning point in their lives and propelled them into a stereo frenzy. Aside from Susan Barry's journey from zero to stereo, the chapter also describes Sacks his own experience as a 'stereophile' joining the NY stereoscopic society and experiences of various other people losing and gaining stereopsis and how it affected them. One of these stories confirms everything I've learned so far from many earlier readings but nonetheless it still didn't fail to amaze me.

One has to lose the use of an eye for a substantial period to find how life is altered in its absence. Paul Romano, a sixty-eight-year-old retired pediatric ophthalmologist, recounted his own story in the Binocular Vision & Strabismus Quarterly. He had suffered a massive ocular hemorrhage, which caused him to lose nearly all sight in one eye. After a single day of monocular vision, he noted, “I see items but I often don’t recognize them: I have lost my physical localization memory.… My office is a mess.… Now that I have been reduced to a two-dimensional world I don’t know where anything is.”

The next day he wrote, “Things are not the same at all monocularly as they were binocularly.… Cutting meat on the plate—it is difficult to see fat and gristle that you want to cut away.… I just don’t recognize it as fat and gristle when it only has two dimensions.” After almost a month, though Dr. Romano was becoming less clumsy, he still had a sense of great loss:

Although driving at normal speed replaces the loss of depth perception with motion stereopsis, I have lost my spatial orientation. There is no longer the feeling I used to have of knowing exactly where I am in space and the world. North was over here before—now I don’t know where it is.… I am sure my dead reckoning is gone.

His conclusion, after thirty-five days, was that “even though I adapt better to monocularity every day, I can’t see spending the rest of my life in this way.… Binocular stereoscopic depth perception is not just a visual phenomenon. It is a way of life.… Life in a two-dimensional world is very different from that in a three-dimensional world and very inferior.” As the weeks passed, Dr. Romano became more at home in his monocular world, but it was with enormous relief that, after nine months, he finally recovered his stereo vision.

A reoccurring theme in all things neuroscience is the importance of stimulation and experience which is especially relevant in figuring out treatments such as Vision Therapy for neurological conditions.

"Our face cells (neurons used to recognize faces), already present at birth, need experience to develop fully. It is similar to many other capacities. From stereo vision to linguistic powers, some predisposition or potential is built in genetically but requires stimulation, practice, environmental richness and nourishment if it is to develop fully. Natural selection may bring about the initial predisposition but experience and experiential selection are needed to bring our cognitive and perceptual capacities to their full realization."

Speaking of which... I recently listened to 'The woman who changed her brain' by Barbara Arrowsmith Young who developed and tested many cognitive exercises to treat herself and thousands of others with severe neurological deficits and learning disabilities. Her book and program of brain exercises are wonderful examples of what neuroplastic treatment can offer if only educators and doctors start learning about them!

Youtube Book Review: The brain that changes itself

In 'Fixing my Gaze' Susan Barry describes the marvels that brain plasticity has brought to her life through engaging in optometric vision therapy and overcoming strabismus. It also made clear that vision is not something that can be isolated from the rest of the body or brain, since vision is the major source of sensory input and affects the way we think and everything we do. Neuroplasticity is the new Buzz word and I was wondering how far this principle goes and what implications it has, not only for vision care, but also for other kinds of brain disorders. 'The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science' by Norman Doidge provides many of the answers or partial answers to that question. Even though not dealing with vision as such, sensory plasticity is also covered in the book.



I found out about the book through a Youtube review which can be watched below. The review is thorough but is in no way a substitute for reading or listening to the complete book.

Another video I want to share related to this book is an interview with the author Norman Doidge. Something particularly troublesome to me is when asked whether these discoveries are finding their way to conventional medicine the answer is 'Not quite'... This is really too bad because applications of the paradigm shift discussed in this book open up the possibility of treating people of all ages who are suffering from countless neurological and psychological disorders in new more effective ways and by doing so augment the quality of life of those patients considerably.

This book also reveals once more how much ahead of its time developmental or behavioral optometry really was when developing the practice of visual rehabilitation or vision therapy at the beginning of the 20th century and refining it over the years. I totally recommend this book to anyone interested in the brain and especially to Vision Therapy patients who are doubting or are in need of renewed motivation. Also available on audio book!