Hidden treasures

During my Uni days I lived with a great guy named Dennis. As a child Dennis had gone through Vision Therapy. There are all levels of irony attached to this fact because I underwent the damaging surgeries while living with someone who already experienced the solution to the problem. Apparently we both didn't connect the dots and when looking for counsel from the 'crème de la crème' of Belgian strabology, I bought into the whole 'It's too late, bring out the knives' story I'd been served again and again. We'd never really talked about his VT experience until it was too late and I had read Fixing My Gaze.

Dennis got to be one of the chosen ones who received Vision Therapy simply because his mother was acquainted with someone who'd gone to optometry school and suggested behavioral vision treatment when his binocular and associated problems arose. This fortunate coincidence saved another life. Too bad this kind of life saving interventions depend on sheer coincidence... 

Three and a half years ago, he gifted me two 3D art viewing books he had used as a child as part of his vision therapy. Both books were printed in Germany in the year 1994. One book for cross eyed viewing and one book for parallel viewing. When he gave them to me I thought I'd never have any use for them. They were way, way, way over my head. I couldn't even get my eyes to approximate the correct viewing position, leave alone to construct a 3D percept. 

During a recent bout of cleaning rage I rediscovered these books (among other things). They are great! They are perfect practicing material for my current vision. They fit right in there with the aperture rule, bar reading and computerized cross eyed photography and stereograms. Somehow I prefer these books over computerized pictures. The art is nicer and maybe the lack of back lighting makes it more agreeable.  Maybe I just like books. 

Funny how gifts can appreciate in value as your brain improves itself. I should remind myself of the fact that these pictures, as was bar reading, were off limits just a year ago. That idea and the idea that it's only going to get better should keep moral high. I know the rules of the game now so it's just a matter of strategizing a way out. Childhood and youth might be lost but the future is wide open if I keep it up. 

Early in the day the parallel viewing pictures are more easy. It's fun to do them while doing all kinds of head movements. That only makes me more convinced that autistic people sometimes do weird movements in order to try to get rid of or improve their sensory problems. The body already knows what it needs to do to make it better, but the sensory distortions might be so great there's no quick way out. That's why they act weirdly as to find more comfortable ways of dealing with sensory problems. As the day progresses and I get more into my own, the cross eyed pictures come more naturally to me. I can do both kinds at any time of day but I notice how the level of difficulty changes over the course of day. Sometimes when staring and relaxing I even get this perceived swirling motion in my visual experience of some pictures but then, when I try focus on it, it goes away. 

This kind of stuff really is the last hurdle, isn't it? Integration, stabilization, normalization. Perfecting motor skills to fully fire up the sensory modalities.  It might take another year or even two to really get it sorted but what else can they do to me? I know the rules of the game and will play until the very end. Let's just continue the walk through the belly of the beast and eventually I'll get out. Thanks for the great present, Dennis!

Vision Therapy and tDCS (2): How and what?

First of all I want to thank my buddy Andrew for blazing this trail. I knew about TMS and tDCS but I was not planning on trying it myself anytime soon. That was until he figured out what supplies were needed and had successfully tried it on himself with promising results. I'd like to refer to some of his blog entries to get you more acquinted with his DIY vision therapy tDCS adventures.

- http://vtwithsyntonics.blogspot.be/2013/11/167-session-tdcs-with-syntonics.html
- http://vtwithsyntonics.blogspot.be/2013/12/170-session-tdcs-works-very-well.html
- http://vtwithsyntonics.blogspot.be/2013/12/reddit-discussion.html
- http://vtwithsyntonics.blogspot.be/2013/12/174-session-sensory-fusion-driving.html
- http://vtwithsyntonics.blogspot.be/2013/12/178-session-what-tdcs-seems-to-do.html

He even made a video tutorial breaking down what's involved in setting up tDCS.

So I bought a Chattanooga Ionto Dual Channel Drug Delivery Phoresor Device, four 2 by 2 inch Mettler sponge electrodes, a couple of stereo wires and two hair bands. There are cheaper devices but I like to put current through my brain in a reliable manner. It took a while for all that stuff to get here, but finally it did. I bought the stereo wires in a local electronics store and some hair bands in a shop called Claire's. Turns out one never knows when he is going to need French women's accessoires.

Some more interesting resources and tutorials in addition to the research papers I mentioned in the previous entry:
- http://www.jove.com/video/2744/electrode-positioning-montage-transcranial-direct-current
- There's a pretty numerous tDCS community on reddit
  http://www.reddit.com/r/tDCS/comments/1apltw/tdcs_setup/
  http://www.reddit.com/r/tDCS/comments/1procy/chattanooga_ionto_how_do_i_start_using_it/
- Video on the physiological effects of tDCS

- Video on clinical applications of tDCS

Really cool video, check it out.  tDCS approaches to paresis, motor learning, reading, aphasia, visio-spacial neglect, pain, depression, ... Some pretty awesome information in there. On YouTube you can find related videos from that same conference.


What can I say about tDCS after using it for one week?
Because the device has two outlets you can use four electrodes, that is 2 anodes and 2 cathodes, at once. However I thought I'd start slowly and only used 1 anode and 1 cathode this week. The amount of current I applied was 2 mA for 20 minutes twice a day. The 'conventional' idea is that the anode excites the brain region it is placed on and the cathode inhibits the brain region it is placed on. If you wet the electrodes appropriately tDCS does not really hurt. Just some minor irritation on the skin in the beginning of the session and then it fades away.

I tried two kinds of electrode placements this week.
- The anode on the right side of the occipital lobe, that is the right hand side of the visual cortex.
The cathode was placed more or less 8 cm lower almost on the left neck/shoulder. This way I get to excite the visual cortex, hit some of the cerebellum and then the current exits below.
- The anode placed on the right or middle of the occipital lobe as before. Instead of placing the cathode 8 cm down, this time I placed it 8 cm upwards over the top of the head also on the right hand side.

In both cases there is a subtle but noticeable difference. Subjectively the second placement felt a little more intense. It's not a dramatic effect but I feel like tDCS does intensify perception during the session and for a time after the session has ended. At the same time it feels stimulating and relaxing. I had read test subjects sometimes experience an altered sense of time perception. I did in fact feel like I lost track of time and was more focused on what I was doing.  As if I was more 'in the zone' and less distracted. Although I did  not experience things spontaneously getting bigger as Andrew described. I think that because all brains are different, also the strabismic ones, every tDCS experience will inevitably vary. Nonetheless I definitely think it's helpful tool for enhancing behavioral therapies. While stimulating I did a number of VT procedures like the brock string, bar reading, eccentric circles, saccades, tracking, balance boarding or just freely playing with my vision. I don't know whether it has to do with tDCS but this week I made the 'ten pages a day' mark with regards to bar reading. I couldn't do ANY bar reading prior January 2014 so that's nice!

The most salient effect for me was being more relaxed and having more energy this week. I was able to be more productive. I've been able to rise a little earlier without loss of functional vision (as would usually be the case). Those must be the 'connectivity driven remote effects'. You are not just stimulating the areas beneath the pads but entire neural networks.

I'm also going to revisit some of the papers I read because I remember other placements being used to enhance attention and perception. I think it might be useful to stimulate motor areas too, aside from solely focusing on the visual cortex. For instance, placing the anode on the motor cortex and the cathode on the frontal cortex as shown in the Jove video. After all, vision is just as much about motor learning as it is about sensory learning.  

It might be placebo or it might be the arrival of spring, but I don't think so. Next week I will start using both outlets and all four of the sponge electrodes. I'm curious to learn what the effects of tDCS will be over a longer period of time.

Pursuing a higher degree of visual freedom

In my last blog entry I talked about 'visual reserves' and how important this concept is for long term comfort and for VT to be successful. The improvement of eye lens focusing and eye movement amplitudes individually is not enough for it to stick. You need to be able to execute those visual skills simultaneously, effortlessly and automatically.

Another great illustration of this processes by Dr Maino is shown below. Mastering those skills paves the way for further consolidation and visual/sensory development of the brain.

Check out the entire slide show for more informative illustrations like these:http://www.slideshare.net/DMAINO/what-is-lazy-eye.

At this point in time, I feel like I'm oscillating between the orange binocular box and the integration stabilization box. However it's not that clear cut. As you do a lot of integration, stabilization and loading, those skills also keep getting better individually while improved timing and daily application make for even more added value.

When it comes to eye lens focusing (accommodation) and eye movement (vergence), I have clear single vision under relaxed, undemanding circumstances. But that's not enough to live a proper life, so you want to go beyond that. To accomplish that you need to artificially separate the accommodation and vergence distance. 

Nice examples of these are cross-eyed 3D photos and parallel viewing stereograms. In case of cross eyed 3D photos, the vergence distance (the intersection of the visual axes) falls in front of your computer screen whereas the accommodation distance is the actual distance of where your screen sits on the desk. You have artificially dissociated both processes.

On the other hand, in case of parallel viewing stereograms the vergence distance is way farther than the accommodation distance. You have to be able to do some serious visual flexing to accomplish both these artificial situations. This kind of visual gymnastics will grant you some nice 'visual reserves' over time.

A classic VT exercise based on the same principle is the aperture rule. Even though you can in principle do the same thing with a computer screen, I very much like the simplicity of this gadget. It's easy to use and makes you jump through the right hoops in order to achieve the same goal. By adjusting the aperture slide you gradually adjust difficulty and have a frame of reference to keep track of your improvements.

In VT the expression 'degrees of freedom' is used in describing the process of building a stronger and more flexible visual system. I very much like that expression. It's accurate in describing the process and correctly implies that visually impaired people are less free in acting, interacting and participating. It also infers that there are degrees in the way that strabismics are affected and no two strabismics are the same.

Susan Barry once said 'You can control your vision and you are learning how to take control'. It's true but it still sucked at the time. After all this time I've already gone from a situation of constant involuntary double vision to one where I can cause myself to have single or double vision at will. I'm well on my way of eliminating my eye muscle palsy. As I gain more control over my vision, I gain more control over my life. I gain more degrees of freedom.

Why and how can text-to-speech programs be helpful to some strabismics?

It is only recently that I started appreciating the value of text-to-speech programs and there's a couple of good reasons for that.

- Not all text-to-speech programs are created equal. You have to find the right one. I'm not in the business of making publicity for anything but I think the program I'm using deserves to be mentioned. TextAloud is available in English, Spanish and some other European languages. Especially when combined with an optional 'natural voice' it proves to be enjoyable to work with.

- My vision had to reach a certain level for it to be a help rather than another sensory annoyance. Now that to a large extent my double vision has subsided but I still feel like I can't fully enjoy my vision, it can be a nice 'crutch' while keeping me on the road of vision improvement. Previously the sound was just adding to the visual confusion of double vision and making for even more sensory overload. At this point in time I possess the ocular motor skills to align my eyes and execute the saccades for reading even though it's a fragile undertaking. Somehow with the help of text to speech technology the visual pressure of executing the eye movements and simultaneously extracting meaning from the text with vision alone is relieved by the auditive help. My productivity has risen greatly without hurting myself in the form of headaches, jaw cramps, eye strain, ... Essentially I like it because it allows me to do the things I love like learning new things and exploring new ideas while 'looking soft'. This activity is contributing, rather than harming, to my health and vision in the form of visual fitness and sensory integration. Combining the strab-business with pleasure for a change.

 This, ladies and gentlemen, is the beginning of the end of all this misery. Opening up opportunities for a learning disabled brain while allowing it to further heal itself. To me compensatory technology is useful as a means of transition to better vision not as a final solution. Sometimes I talk about VT and about how I want to 'break even'. By breaking even I mean reaching a level of functional vision that allows me to do my thang without regressing. Obviously I have learned and studied before in my life but always at the expense of my health and that vicious circle has to be stopped. I am not quite there yet but this technical aid is giving me an idea of how it must be and I'm loving it. Just being able to be absorbed with a certain subject without suffering. Normal people are so visually spoiled...

Book review: Fixing My Gaze by Susan Barry

After I read 'Fixing My Gaze' for the third time in three years I decided to write a long overdue review about the book that got this whole VT party started. I first read it during the summer of 2010. At the time I was undergoing all kinds of personal, academic and medical crises and I realized I was on my own. So I turned to the oracle that is Google and went looking for better alternatives to help me get rid of my double vision. This time in English. I discovered Vision Therapy. I was already flabbergasted by this whole new universe of useful information on vision therapy related websites which I was reading with great effort. Then I found out about a book called 'Fixing my gaze' and watched some Youtube videos by the author of the book named Susan Barry. So... THERE IS A SOLUTION NO ONE HAS TOLD ME ABOUT?! Aside from the cerebral double vision short circuit all kinds of fireworks were going off in my brain. The situation was bleak but now there were new elements to consider. Quickly I ordered the book and when it arrived I read my way through it in a less quick post-op double vision strab kind of style. This book contained the information I had needed ever since my eyes started crossing at the age of three and it was clear I would have to do whatever it takes to make things right again despite of the twenty year delay and medical mishaps. Denying the information in this book, as some 'VT critics' seem keen on doing, should be listed as a criminal offence. After all, the book only talks about healthy visual brain development and has the endorsement of two Nobel prize winners on the back...

Needless to say this book got me through some grim times. If it was not for the constructive perspective and the better outlook this book provided I might not have been sitting here at all. That's something unusual to say in a book review I guess. Even reading it for the third time gave me another boost of much needed energy. Every time I read it I am relating more to different parts of the book. Partly because of the fact that I was younger back then and partly because my vision has actually changed over the years! Some parts I couldn't relate to simply because of not having had that visual experience. The first time I read it I wasn't just younger, I had the vision development level of a baby. Worse, a visually wounded baby.

Something that struck me every time I read it is the fact that suppression is a more energy consuming way for the brain to see as opposed to normal binocular viewing. These adaptive mechanisms such as suppression are very effort consuming. Smooth binocular viewing is the most efficient way to use cortical real estate. That makes a lot of sense of course. It's just surprising how far some people can get removed from that healthy integrated viewing position. As an eye doctor you got to be very ignorant about what you are doing to have patients end up three or four years of rehab removed from such a healthy situation. Sadly the brain does not adapt overnight but fortunately it does adapt. This is masterfully described  in various passages, notably the one covering 'the lazy eye myth'.

All in all the most touching moments in this book are the ones in which Susan Barry attempts to describe how it feels to see in 3D. Paradoxically, there is no way to describe a qualia as powerful as stereovision with language. This makes it all the more tantilizing!

'Gaining stereovision, I thought, would augment my perception of depth but not change it in any fundamental way. So, I was completely unprepared for my new appreciation of space and for the deep feelings of joy and wonder, the enormous emotional high, that these novel sights gave me. To experience for the first time seeing the most ordinary things in stereo feels like scaling a mountain and witnessing your first mountaintop view.'

Or the description of Rachel, someone who was also previously stereoblind. 'It was as if I had stepped inside a painting that I had spent my whole life observing. I was awed and moved to tears. I never experienced a forest in this way. The depth of space and emotion was overwhelming.'

Being still on the road to such extra ordinary epiphanies, my attention was particularly drawn to the link between motion paralax and stereovision. Aside from monocular cues such as size, shadowing and context, stereoblind people get some added sense of depth from movement. This is called 'motion paralax'. It seems that once you learn how to see binocularly this sense of 'motion paralax' is greatly enhanced on top of the newly acquired stereovision.
'So, my ability to see in stereo also translated to a heightened sense of depth through motion.' 'For me, as well as for many of my formerly stereoblind friends, one of the greatest surprises and delights of our new vision has been this incredible sense of depth while moving.'
This stayed with me because lately when I take my walks it seems something weird is going on while walking. Things sometimes seem to have kind of an aura. Might just be the gateway to stereo, or heaven... Whatever floats your boat.

Before you start saying I'm totally over-the-top... It's not all good. Visual transformation takes its toll and even though I don't have stereovision yet, I can already relate to it 'just' from eliminating my double vision. Because many events that happened earlier in my life are only now showing their long term effects along with the overwhelming and exhausting effects of constant visual transformation I related very much to this paragraph.
'Many days I felt both exhilaration and exhaustion. Most people learn to see when they are infants, at a time in their lives when they are cared for, are free to get cranky, and enjoy lots of naps. I was relearning how to see as a responsible, contributing adult. While I went through all the motions at work, I desperately wanted to be left alone, to be quiet and reverent, to take in one long, delicious look after another. I disappeared on long, solitary walks, I was at a loss as to how to explain this to my colleagues and friends.'
She talks about how this feeling of sensory overload just made her (and others with strabismus) want to be alone. How all the new experiences made her look for more peace. She even describes avoiding the news and instead listening to familiar music. About how the visual transformation is so all absorbing that she had to take on fewer responsibilities at work. I didn't even remember reading that the first time. Now it's so relevant to me.

Another awfully familiar experience is feeling like an idiot while trying to explain what you are doing or what you are going through. You want to tell everyone but the reactions are so mellow that you try to relish small victories on your own or with strab friends on the internet. You want to broadcast that stuff even though the rest of the world already 'got it' at the age of four months.

It's clear vision therapy or any kind of rehabilitation takes ungodly amounts of perseverance, practice and determination. I knew that was going to be the case and I thought 'Bring it on!'. I still think that but now I've got the social scars and a VT legacy to back it up. However great the book might be, it will not save you from that. So the fact that I went 'all in' for such a long time and basically studied my way out of this sorry pickle gave the pages about 'active involvement' in rehabilitation a special flavor.

Having read many other things about vision during my VT time many 'technical' names, VT techniques, the organisations involved, the neuroscientists and optometrists, the history of behavioral optometry and passages about the importance of vision in developmental delays all fit together much tighter. The author also emphasizes that the treatment of strabismus is not unambiguous. I personally too have heard of people who have greatly benefited from undergoing surgery. However, it should be stressed that surgery is certainly not the only way to treat strabismus and that in most cases VT is required or even a combination of surgery and VT. Therefore it is of paramount importance that ophthalmologists and developmental optometrists start collaborating. Hopefully this book contributes to taking away the blinders many eye care professionals and educators are wearing.

Last but not least I don't want to spare anyone the closing paragraph of 'Fixing my gaze'. This is what many strabismics out there have been dying to hear and wonderfully recaps what this book is all about.
'I finally relaxed and thought back at all that had happened. When I first learned about stereovision in college, I assumed that if I could see in 3D, I would be better at threading a needle, parking a car, and hitting a tennis ball. Of course, all of this is true, but I had no idea just how different and how magnificent the world would appear in all its glorious dimensions. Most importantly, I learned that I was not the victim of a visual fate that had been sealed in early childhood. I could rehabilitate my own vision. My newfound and hard-earned stereovision has given me an enormous sense of security, confidence, and accomplishment. It is with a stable, clear, and depth filled gaze that I now encounter the world.'

Session 60: An unconscious reflex to many, a giant leap to a strabismic

Yesterday I had my 60th vision therapy session since I embarked on this mission almost three years ago. Things are as good as can be expected given my history. Expectations have already been exceeded several times and things are still getting better so objectively there shouldn't be any reason I can't get this monkey off my back if I keep strong.

A few examples of how far we've already come:

- After 20 years of accommodative strabismus and 6 years of them with double vision 24/7, I have eye alignment and single vision almost all the time now. This first showed its head in September 2012 and during the past year this has gradually been improving. I never thought I'd see the day! At the same time I know my binocular vision isn't 'locked' yet so I try to adjust my activities in a way that doesn't hurt further development of my vision. I'm not free yet.

- Complementary to this development is a 'vision test' I do frequently. It's a very simple test. Just making circles with my face while try to keep my eyes fixated on a certain point. Ideally the entire landscape doesn't shift in front of your eyes because of poor ocular control. However simple this is for most people, this has been a disaster for me ever since my second strabismus surgery five years ago. Over the past three years the gaze holding while head turning has been getting better and now I can almost do it without my vision doubling up while doing it. No self inflicted 'earth quakes' anymore. Almost. The uncontrollable eye spasms are disappearing. I don't have divine powers of stopping earth quakes but this is pretty freaking close.

- Every ten sessions my Vision Therapist takes out her standardized test box. It's a simple stereoscope like device one has to look into with simple cardboard charts being the tests. There was one particular chart I have never been able to get right. One eye sees a red and yellow block and the other eye sees a yellow and blue block. If you are doing it right you will see a column of thee little blocks, superimposing the yellow blocks. This 'final' chart has been so hard because the blocks are very small and require very fine close range motor control. I expected myself to be able to do it by September and yesterday I did.

My point being that ocular motor skills are still improving and increasingly the 'gaps' are being filled in.

- A cool, albeit modest, real life example of this is a computerized bar game I played last week with some friends. This particular game requires one to find 5 differences between two pictures as quickly as possible. The score depends on timely completion and the game gradually increases its difficulty. Two years ago I was 'like a retard' when playing any kind of game involving quick visual capturing of a situation and reaction to that situation. This became painfully clear when having to do visual assessment tests in order to get a job... This particular bar game required A LOT OF QUICK saccades. Last week my performance wasn't significantly worse than that of my friends. I could physically execute the saccades in order to play the game without any double vision. I mean... Two years ago I was experiencing constant double vision and I was totally baffled by any kind of visual test not concerning studied knowledge. After playing that game for a while I was tired, but what a universe of difference still. It's always good to put this kind of small events like a bar game in this broader perspective. To some people it would be insignificant, but it's huge. This tells me that over the next few months and year things will keep getting better visually. I have the same innate visual capacities as everyone else and however hard they tried to keep me from it, I will develop them.

Related articles on other blogs:
- How about this weather?

The importance of sleep

An excerpt of 'The brain that changes itself' struck me as particularly explanatory of why proper sleep is so important to recover from visual brain damage. It also explains why not getting the amount of sleep needed or interruptions of my sleep don't just feel like a bad day but as a step closer to the abyss. So sleep certainly isn't death's cousin, not sleeping properly is...

Scores of studies show that sleep helps us consolidate learning and memory and effects plastic change. When we learn a skill during the day, we will be better at it the next day if we have a good night's sleep. "Sleeping on a problem" often does make sense.

A team led by Marcos Frank has also shown that sleep enhances neuroplasticity during the critical period when most plastic change takes place. Recall that Hubel and Wiesel blocked one eye of a kitten in the critical period and showed that the brain map for the blocked eye was taken over by the good eye — a case of use it or lose it. Frank's team did the same experiment with two groups of kittens, one group that it deprived of sleep, and another group that got a full amount of it. They found that the more sleep the kittens got, the greater the plastic change in their brain map.

The dream state also facilitates plastic change. Sleep is divided into two stages, and most of our dreaming occurs during one of them, called rapid-eye-movement sleep, or REM sleep. Infants spend many more hours in REM sleep than adults, and it is during infancy that neuroplastic change occurs most rapidly. In fact, REM sleep is required for the plastic development of the brain in infancy.

A team led by Gerald Marks did a study similar to Frank's that looked at the effects of REM sleep on kittens and on their brain structure. Marks found that in kittens deprived of REM sleep, the neurons in their visual cortex were actually smaller, so REM sleep seems necessary for neurons to grow normally. REM sleep has also been shown to be particularly important for enhancing our ability to retain emotional memories and for allowing the hippocampus to turn short-term memories of the day before into long-term ones (i.e., it helps make memories more permanent, leading to structural change in the brain).