tag:blogger.com,1999:blog-28657285357867720932024-02-18T21:02:18.900-08:00Getting past double vision one day at a timeA vision therapy blog, because knowledge and understanding change everythingMichael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.comBlogger167125tag:blogger.com,1999:blog-2865728535786772093.post-8389084811116361272015-06-05T08:10:00.002-07:002015-06-05T08:10:24.619-07:00www.strabismusworld.comThis blog has moved to <a href="http://www.strabismusworld.com/">www.strabismusworld.com</a>. Everything that can be found here can also be found at the new location, as well as new articles.<br /><br />The new site:<br />
- provides more overview and a system of categories.<br />- has a text-to-speech feature when highlighting text.<br />
- contains a YouTube side bar widget with relevant videos and link to the YT-Channel.<br /><br />
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<br />Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-18428842515773191952015-04-28T05:09:00.001-07:002015-04-28T05:17:41.094-07:00Vision Stress Testing: 5K Run<b><i>April 14th, 2015</i></b><br />
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After being out for a couple of years and focusing my energy on my vision, I decided to slowly give running another try. Running is not my main focus but I try to use it as complementary training to my vision rehab. That is, when I feel I can handle it and won't go in overload.<br />
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It's unfortunate that these mistreated vision problems have dragged my physical and neurological condition down to such an extent because I used to be a natural at running. My performance should be peaking rather than dipping right now.
I've never done many races in my life but so far I have done 5K, 10miles (16K) and a half marathon (21K). I decided to do another 5K race in 12 days. I'm looking forward to it but I'm keeping expectations low. I think I can do 23 minutes but we'll just see what happens. If I clock at 25 minutes, that will be alright too!<br />
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Here are some of my previous running results. If I can have the same outcome as in 2012, it is a de facto improvement because my vision (ocular motor control) is much better now than it was back then.<br />
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<b><i>April 28th, 2015</i></b><br />
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I immediately added the results of this year to the image. The race went pretty okay. I started out easy and then, after the 3KM point, deployed whatever energy I could muster. During the last kilometer my vision was getting very shaky. So much so that I barely recognized my awesome friends who were cheering by the side of the road. Fortunately you don't need that much vision to run your longs out. When I arrived I was very dizzy but I fairly quickly recovered my normal (current) level of ocular control. I did not revert to double vision. Running the 5K wasn't the actual challenge. The challenge was to see what would happen afterwards. Would I be able to function normally and get home or not? To my delight I did alright. My nervous system and ocular motor control recovered enough not to be a zombie for the rest of the day. We went to grab some food and we had a nice day without me crashing.<br />
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Nonetheless, it remains interesting to see these time differences. I attribute it to the following cause (but I could be wrong). When I was younger, I would have a very low resting heart rate. When checking my heart rate, doctors would always ask me, 'Do you do any extreme sports?' or 'Are you doing sports on a professional level?'. I didn't. I didn't even run that often. Just when I felt like it, which was usually on Sunday. I was simply physically strong from having to endure academics with limited visual skills. To me, reading is much harder and physically taxing than running.<br />
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Sadly, these days my resting heart rate is not that slow anymore. I have the occasional panic attack and have to <a href="http://vtworks.wordpress.com/2014/01/10/a-sit-down-with-michael-lievens/" target="_blank">endure the stresses of an unrecognized handicap without income replacement or compensation for medical malpractice</a>. The only thing I can do is wait and do my vision rehab which has been a very long and arduous process without breaks. Fortunately, relatively speaking, I can now see light at the end of the tunnel. I was lucky to find enough support and have played my cards flawlessly to get to this point. Now over the next year or so I have to finish it. I think that only after having acquired the security of reliable vision and body performance and hopefully, God forbid, a steady income stream, I will get some peace and might be granted a more slowed heart rate once again. Being more relaxed from time to time helps your body recover and allows you to build reserves. In that case of a slow heart rate, you can elevate that heart rate to a much greater extent when it is actually needed for physical performance. This instead of heart throbbing from being cornered and betrayed or the occasional, and ultimately useless, panic attack when dealing with a visually (and otherwise) unstable world.<br />
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<i><b>Nothing is more crucial to the survival and independence of organisms—be they elephants or protozoa—than the maintenance of a constant internal environment. Claude Bernard, the great French physiologist, said everything on this matter when, in the 1850s, he wrote, “La fixité du milieu intérieur est la condition de la vie libre.” ,- Oliver Sacks</b></i>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com1tag:blogger.com,1999:blog-2865728535786772093.post-6428662460872150262015-04-12T08:22:00.000-07:002015-04-12T08:22:08.655-07:00Aperture Rule: A Vision Therapy empathy top tipAs you might know, at this point my eyes are looking pretty much normal most of the time but the inability to converge consistently remains crippling. It drains and strains a lot. It's like a massive extra backpack I'm wearing, or an invisible barrier between me and the world, preventing me from getting things done more easily.<br />
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Currently, much of the time, I'm living with a male cousin named Thierry (22) and female cousin named Cynthia (26). They are very nice about my peculiar situation and try to understand. I, in turn, am very patient in trying to explain my neurological vision problem even though, after all this time, I'm often fed up trying. By now, however, I am getting quite proficient at linking theory and experience into a coherent narrative. More importantly, they are really interested and concerned on a personal level so it's worth the effort to make them understand more fully. I'm really lucky in this respect because that quality is not something that can be taken for granted. They even defend me and try to re-explain the issue when other people ask them, "What is your cousin doing with his time all day?". They try to grasp and explain the reason why I am seemingly unproductive. Because of the nature of this problem, I know it's nearly impossible for them to understand completely but they are very considerate and do their best. That's a prerequisite for true communication.<br />
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To my delight, Thierry, who is also an engineering student, got so interested that he wanted to perform some of my exercises himself. Earlier we did some trial runs on the <a href="http://livingwithdiplopia.blogspot.be/2015/03/cheiroscope-video-drawing-samples-and.html">Cheiroscope</a> and he was very good at it. His drawings were very stable and deliberate and his corners nice and sharp. That was to be expected. The fact that my drawings aren't stable and deliberate is basically the only reason I didn't end up to be an engineer in the first place.<br />
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Now, what was even more interesting is our experience with the aperture rule. The aperture rule artificially dissociates accommodation and vergence. In other words, it makes it harder to use both of these basic visual functions appropriately to see a single AND clear image. The goal of this exercise is to further automate and incorporate these skills and enable the patient to use them without effort. This is an often re-occuring theme in Vision Therapy. The Rule has 12 levels for convergence and 12 levels for convergence depending on which Aperture plate you use. I, myself, am not super-solid on any level but my best performance, including head turns while viewing, is at level 4 using the double aperture (divergence setting). Generally I am more at ease with the divergence setting but I can only go up until level 6 before the target picture doubles up.<br />
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In the convergence setting (single aperture), I have often trouble keeping a clear and single image regardless of the level. Much depends on my fatigue level but generally there is improvement. When well rested, I can go up to level 6 or 7 when keeping my head still and focusing intensely. With head movements things tend to jump around. After all, this exercise is particularly hard because of the artificial dissociation of accommodation and vergence. It is my dream to be able to do the aperture rule fluently and without too much effort up to level 8 or 9. Well, the higher the better but let's start with that. Good stuff ahead! Can't wait!<br />
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Let's get to my point. I had both Thierry and Cynthia do the Aperture Rule. I got them to do convergence which they could do well, as I expected. They could go all the way up to level 12, albeit with some effort. At the higher levels they started to need some time to fine tune their vision to adjust to the heavy load of seeing both singly and clearly. They started to have the experience of having to work for your vision! <b>They uttered things such as, "I can see it but I can't see it well", or "It takes a lot of effort!". Thierry even said, "You've explained your vision issues so many times but this is the first time I REALLY understand what you were talking about. It must be so exhausting having to work for your vision in this manner ALL the time!" </b>Afterwards he said he was very tired.<br />
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For my part, I told them they were fortunate because in modern life convergence is most important when it comes to completing daily living tasks successfully. My inability to converge is the main reason why I'm out of service.
Then I had them try divergence. They were completely floored. They even had trouble figuring out how to see level 1 correctly. Maybe it was not an inability to diverge but rather an inability to grasp what was expected of them. It's not always easy to figure out the Aperture Rule the first time you encounter it. Nonetheless, Thierry was intrigued. He remarked, <b>"Apparently I have a visual limitation. I don't like it. I want to improve, especially as I want to try and become a pilot later on." </b><br />
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There you have it, people. A Vision Therapy empathy top tip: the Aperture Rule. If you can't shake your vision problem easily or quickly, make 'em join you!Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-9568264185315122382015-03-29T08:01:00.001-07:002015-03-29T09:12:20.291-07:00Cheiroscope: video, drawing samples and implicationsAfter a nice theoretical post, let's get down to the nitty gritty. How can we get a tangible look into how someone perceives his personal space? How can we determine inconsistent perception of space interfering with the construction of solid brain maps?<br />
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As <i>vision writes spatial equations for the muscles to solve</i>, cheiroscopic drawing is an interesting way to gauge the state of ocular motor ability and spatial vision. During cheiroscopic drawing, one's visual system is completely stripped of contextual aids. Broader context often helps strabismics to get around and complete certain tasks by circumventing proper ocular motor movement or spatial vision and by relying on sub-optimal, monocular vision adaptations and other senses. When using a cheiroscope none of that is possible. Your drawing hand and fingers HAS to take its cues from the eyes. The movements of the hand are based on the movements of the eye. If the eyes are positioned well, move together in a smooth and harmonious manner and can maintain a steady posture, you will succeed. If not, you will come up with an inconsistent and skewed drawing. It's that simple. A direct connection. No more adaptations, no more tricks, nowhere to hide from your visual shortcomings. It's a head-on confrontation with your visual limitations but also an opportunity to improve and to chart and compare that improvement over time.<br />
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I made a little, informative video about a cheiroscope that can be used at home. I apologize in advance for the constant movement of the camera. My video recording skills also need more work!<br />
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Here are some more of my practice run results produced by using that device (March, 2015). They are each of them unique and contain small mistakes. The variations in the drawings are variations in my vision and ocular stability. My vision is still volatile and unstable. Yet, it's a far cry from where I've come from years ago. This maze is very detailed and requires a fairly sophisticated level of ocular control on which to base your solution. Merely being able to try this exercise is already a triumph for me.<br />
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<b>Let me show you where I've come from, going all the way back to February, 2011</b>. For that purpose, I will be showing drawings made by me with another type of cheiroscope. <a href="https://www.youtube.com/watch?v=-qR0Uke2XNI" target="_blank">This is a standup variation of the cheiroscope. It is called the Wolff cheiroscope named after Bruce Wolff, OD, who designed it.</a><br />
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Recently, at the VT office, we were comparing some cheiroscopic drawings I had made over the years. These pictures compare the results of the <b>same cheiroscopic drawing exercise</b>. The upper drawing was done on <b>October 16th, 2012</b>. The lower drawing was done on <b>March 16th, 2015</b>.<br />
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The relative position of the drawings is different because of different eye positioning. Also the quality of the drawing itself is markedly different because of improved ocular stability. In 2012 the left hand drawing was so inconsistent that the sun wasn't even staying her box. Hell, there was not even a clear box! And, as someone acutely pointed out, now the suns do have a smiley face!<br />
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What's even more startling is the fact that, <b>on October 16th, 2012, I had already been in Vision Therapy for one year and eight months!</b> Here are two cheiroscopic "Van Orden Star" drawings comparing February, 2011 to October 16th, 2012. The drawn lines should converge onto the highlighted fold. In the first drawing, in 2011, this certainly wasn't the case. I had a considerable vertical misalignment too.<br />
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<tr><td class="tr-caption" style="text-align: center;">Van Orden Star</td></tr>
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Notice that, in the picture with the sun drawings, the upper drawing was drawn on the same day as the lower Van Orden Star drawing. <b>This nicely demonstrates that improvement is relative</b>. On October 16th, 2012, I was delighted about my improvements regarding the "Van Orden Star" drawing. However, the more visually demanding and detailed sun drawing exercise left much to desire. Now, another two years later, the sun drawing too have improved significantly and I will continue to go down this road of more ocular stamina and accuracy. <b>The only thing one can do is to consider his current vision status and keep on stacking incremental improvements to eventually get to a better place in the future.</b><br />
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My primary vision therapy goal is not stereo vision. Stereo vision seems to be a combination of various basic vision skills. Overcoming the crippling legacy of strabismus surgery, which has thoroughly destroyed already ailing basic vision skills, is my primary vision therapy goal. To be specific, I need smooth tracking, reliable saccades and a stable vestibulo-ocular reflex. When I accomplish that, I'm golden. From what I hear, stereo vision will be a nice bonus on top of having these basic visual skills. These basic visual skills by themselves are pretty awesome too though! Without eye muscle surgery, I would already be seeing in stereo! However, as the cards have been dealt this way, these extra hurdles have to be taken. There is no other way.<br />
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Me and my Vision Trainer summarized the current situation as follows. <b><i>"No one would have thought you would have come this far when you walked through the door, more than four years ago, but now you possess the basic visual skills. You can see through both eyes, you start having fairly good eye motility, you have some fusion in polarized targets and you can even figure out depth in tranaglyphs with a reference object like your finger or a stick! You have all the ingredients and now have to go a little furter and combine them into a good menu."</i> </b><br />
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The only missing ingredient is more time and work. I can do that. The cloak of subdued dysfunction is slowly lifting itself. I have mentally prepared myself it might take until January 2017 for me to reach workable levels of vision. After six years, I think, this Vision Therapy thing will start to lose some of its charm. Hahaha. Cheers, everyone!Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-70628323600354988392015-03-14T08:52:00.000-07:002015-03-14T09:14:47.076-07:00The visual system's important role in figuring out where you areDevelopmental strabismics often learn how to suppress sight coming through one eye. Many times they even learn how to alternate between both eyes. This is a useful short term neural adaptation but has many disadvantages in the long haul if not corrected. Having been, and to some extent still being, an alternator, I know how it works in practice and how it feels. If feels like you can shift between two ways of seeing. You are not only switching between your physical eyes but also between two viewing positions in your mind. You litterally have two "mind's eyes". When paying attention to this weird ability and supposing your head/body is a vehicle you are maneuvering, it feels like you can change the driver's seat's position. One moment you are in a normal car. The next moment you are in a Brittish car. <b>You can shift what is called your visual midline (visual midline shift)</b>. When I was younger even colors used to look slightly different depending on which eye I was using! I remember when I was fourteen asking my mom: "When I switch from one eye to the other I sometimes get color changes. Do you also get that?". Reasonably enough she didn't really understand what I was talking about and had a disturbed look on her face!<br />
<br />
In developmental strabismics the act of alternation is often a subconscious one. Because we developed this way we can usually apply it to our benefit as much as possible. It's not optimal but if you master and control it, it can be manageable. For me problems started occurring when, firstly, this learned visual neuro-adaptation started to unravel by itself due to external pressures (because it is not an optimal nor stable neural equilibrium). Secondly, these problems were aggravated when the correspondence between how my eyes moved physically and how my neurology worked was radically disrupted through eye muscle surgery. That is why the first couple of days after surgery I even had to relearn seemingly simple acts such as keeping balance and walking. On the surface I learned quickly but a lot of extra unnecessary baggage had been added to tasks of daily living. I did my best to pick up the pieces and held my own for a couple of years but ultimately it was not possible to just forget about the problem and live a normal life. Untangling this neural and physical dissonance is a work in progress.<br />
<br />
...<br />
<br />
That is why following passages taken from the book <a href="http://www.amazon.com/Vision-Rehabilitation-Multidisciplinary-Patient-Following/dp/1439836558" target="_blank">Vision Rehabilitation</a> strongly resonated with me. These can be found in Chapter 4 on Spatial Vision, written by Robert Sanet and Leonard Press.<br />
<br />
<blockquote class="tr_bq">
<i>"While walking, patients with ABI may demonstrate a shift in visual midline and
altered gravitational sense termed <b>visual midline shift syndrome (VMSS)</b>. These
patients demonstrate balance impairment and associated motor dysfunction, including
leaning, falling, or veering to one side during mobility. VMSS can have an immediate and dramatic effect on the motor dysfunction. </i></blockquote>
<blockquote class="tr_bq">
<i><u><b>The sense of awareness of one’s position in space is predicated on what has been
referred to as “the invariant.” Without having a stable frame of reference of self,
it is impossible to organize space efficiently and accurately.</b></u> As an example, consider
what it would be like to find the location of a specific place on a map using only
the coordinates “two miles west and one mile to the north.” One cannot derive the
answer without knowing the initial piece of information: <b>“From where?”</b></i></blockquote>
<blockquote class="tr_bq">
<i><br /></i><i><b> The invariant provides a stable frame of reference upon which we build spatial
constructs.</b> The mental representation of space, and perception of straight-ahead body
orientation, are related to a number of<b> internal reference frames, including visual, vestibular,
proprioceptive, and tactile information that allow us to build accurate spatial
maps.</b> That is to say, the brain orchestrates movement using a series of internal
models, maps, or schemes of external reality. Even before initiating the movement,
the brain has already taken the visual information, anticipated the consequences of the
movement, and formulated a series of motor actions to accomplish the goal.
The antigravity system, therefore, relies on the integration of many neurological
processes, principally as follows:</i> </blockquote>
<blockquote class="tr_bq">
<i>- <b>Visual system</b> input that aids in the determination of vertical and horizontal
frames of reference, and the perception of self-motion that comes from
optic flow patterns across the retina.</i> </blockquote>
<blockquote class="tr_bq">
<i>- <b>Vestibular system</b> input through the otolith and semicircular canal systems
of the inner ear give information about head position relative to gravity, and
changes in acceleration and deceleration.</i> </blockquote>
<blockquote class="tr_bq">
<i>- <b>Proprioception system</b> input from the stretch receptors in the muscles that
give information on body position.</i></blockquote>
<blockquote class="tr_bq">
<i><b>Visual input to the vestibular and proprioceptive systems that direct movement,
such as when adjusting balance or moving the body and hand to grasp an object or
to catch a ball, is due in large part to subcortical “unconscious” visual pathways.</b>
The automatic, unconscious visual prediction and computation that supports motor
planning and execution of accurate motor movement is often disrupted when patients
experience ABI. This results in visual-spatial confusion and inaccurate visual guidance
of motor movement."</i></blockquote>
This short clip by the BBC nicely demonstrates how disrupting changes to visual input can be for balance and motor ability.<br />
<br />
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<br />
<br />
I particularly like the concept of having a stable frame of reference of self in relation to the environment constructed upon various sensory streams of information referred to above as "<b>THE INVARIANT</b>." Vision plays a crucial role. Simply put, the visual system has four essential questions to answer:<br />
1. Where am I?<br />
2. Where is it? (an object or objects of interest)<br />
3. What is it?<br />
4. What do I need to do or say about it?<br />
<br />
If that primary sense of awareness of where one is in space (the invariant) has become variable because of conflicting visual information due to for instance eye teaming difficulties, the answer to the first question has been compromised. <u><i><b>If the invariable becomes variable, spatial uncertainty is compounded.</b></i></u> This will have far-reaching effects on the visual system's ability to answer question 2 to 4. This interference and uncertainty will negatively impact the ability to oversee situations, interact with objects or find relevant information. Secondly, it will also compromise movements, memory, verbal ability and might cause serious fatigue and mental confusion. In short, without controlled and stable visual input to the brain, the ability to interact and build proper spatial brain maps suffers greatly.<br />
<br />
...<br />
<br />
To get back to my own story... Nowadays my, what is supposed to be, invariant is all too often variable and this has a profound effect on my ability to function. I am physically strong but this leak in the system can throw me off balance and drain my energy without mercy. I like to move but I do it in settings where I can easily retreat when needed. Over time my variable invariant is getting more fixed and coherent. When I have good moments and have relatively high amounts of ocular control, I can see abilities and talents I knew I have had all along flaring up. If I can get my invariable to be invariable more often and hopefully indefinitely, the sky is the limit.<br />
<br />
One example of this is a basketball video I recorded a few weeks ago on "a good eye day".<br />
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<br />
<br />
This is pretty good for having no stereovision. However, I cannot play like this consistently. Same goes for reading performance or any other kind of performance. It depends on whether I have good or bad ocular control that day or that moment. As optometrist Myron Weinstein once said: <b>"Vision writes spatial equations for muscles to solve."</b> Can my brain rely on the visual and proprioceptive input provided by my eyes? Isn't it too exhausting to get my eyes in line? Those factors will determine how variable my "invariable" is at that moment and how well I will perform.<br />
<blockquote class="tr_bq" style="text-align: center;">
<i>"We are never tired as long as we can see far enough" ,- Emerson</i></blockquote>
<div style="text-align: left;">
Fortunately I know I can improve indefinitely, even with damaged eye muscles, and I will. As there is no other option but to do this rehabilitation thoroughly, I should not settle for damage control but I should try to unify these two alternating monocular ways of seeing into one coherent binocular system. This in turn will contribute to my body's sense of position, motor abilities and my ability to construct brain maps of any kind.</div>
<br />
If you are interested in learning even more about strabismus, suppression and brain maps, I had a first attempt at making a watchable video tutorial about this topic. Enjoy!<br />
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<br />Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-77093292850025773692015-03-03T05:56:00.001-08:002015-03-03T05:57:57.628-08:00Jaw clenching, Vision Therapy and earthquake resistant structuresPersonally I learn a lot from reading/listening up on vision rehab and anatomy but I learn just as much from having conversations with other strabismics. I think it's a practice that could be useful to anyone with any problem. Don't compare yourself to people with a very differing, in this case neurological, background. Learn from people who are similar to you and dealing with similar day-to-day problems. What follows is a blog post constructed on this type of conversation.<br />
<br />
<b>PASQUALE</b>: Hi Michael, in many blog entries you mention jaw clenching. I too have said that I engage numerous facial muscles while I try converging and diverging at different targets. It feels like the brain is recruiting other muscles because it still hasn't figured out how to properly use the eye's extra-ocular muscles.<br />
<br />
<b>MICHAEL</b>: I always think of it like learning how to do something with your left arm (unless you are left-handed). First you use your entire arm, often in a contorted way. Then you move on to more specialized movements of the joints and ultimately you can do things smoothly having very fine control over your arm, hand and fingers. Theoretically the potential for improvement is limitless.<br />
<br />
Let's transpose this to the visual realm. At first, when trying to accomplish a visual task, you are doing it very clumsily and inefficiently. Your brain is trying to accomplish a task which requires fine ocular motor skill but it's not succeeding because of a lack of (lasting) control. Because many of us are hardheaded we redouble our effort and adjacent regions and resources like facial muscles are drawn into the process to little or no avail. Not good. Instead of redoubling our effort employing a very limited set of visual skills we should go back to the drawing board and improve and multiply our skills. Technique is more important than 'brute' force.<br />
<br />
The visual system involves six of the the twelve cranial nerves. That's a lot of guns to fire and potentially misfire. When I experience jaw clenching after too much reading or just a visually or otherwise stressful situation, that implies I've gone beyond my current visual skill level and I need to back down.<br />
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<tr><td class="tr-caption" style="text-align: center;">Trigeminal nerve - 5th cranial nerve</td></tr>
</tbody></table>
<br />
<b>PASQUALE</b>: Have you figured out exercises that eliminate engaging other muscles except for those needed to coordinate the various components of the eyes.<br />
<br />
<b>MICHAEL</b>: Well, any activity that encourages 'the eyes', meaning the appropriate muscles and neural processes associated, to do the work without recruiting other muscles. That implies not going too far beyond your current skill level and paying a lot of attention without getting frustrated. For me it means slowing down and lowering expectations while gathering finer motor control. As long as my jaw doesn't clench, I'm in the safe zone. Once I start hurting, I'm overdoing it. It's not always easy to be patient and sometimes there are just visually stressful tasks I have to deal with. Then I'm tired, dizzy and in pain.<br />
<br />
<br />
When thinking about this problem I'm reminded of something I learned about earthquake resistent structures. There's no such thing as a completely earthquake resistent building but you can improve a buildings capacity to withstand external shifts to a large extent. There are various approaches you can adhere to when going about the seismic retrofitting of a structure.<br />
- You can increase the global capacity of a structure. (<b>strengthening</b>)<br />
- You can isolate the foundation so the structure can shake on it. (<b>partial flexibility</b>)<br />
- You can impose intelligent structural changes. Structural vibration control technologies minimize forces and deformations. (<b>flexibility</b>)<br />
The last option implies that various individual parts of the building can move or flex allowing for shock absorption. <br />
<br />
Vision Therapy is akin to a seismic retrofit for the visual system. You make structural changes in how it works and learn how to control and flex individual parts. You learn to lean into a quake rather than stiffening up. That way you can withstand more external demands, with reduced energy drainage and avoid collapse of the structure/system.<br />
<br />
<br />
For me, eye teaming remains a big challenge but I'm getting there. A related challenge is to gain more independent control over vergence and accommodation, i.e. taking on any binocular stance while manipulating my eye lens as I please. Either component should have limited effects on the other one's performance and there should be a certain ease in doing this. Just like using indivudual fingers while playing the piano. An increased 'isolation' of these visual components gives more freedom of movement. To continue the piano anology, you'll be able to play 'visual Mozart' instead of just hitting the keys indiscriminately with all fingers at once.<br />
<br />
As far as particular exercises are concerned, there are plenty of options to choose from if you understand the underlying principle. Magic eye stereograms, prism/spherical flippers, Eccentric Circles, Aperture rule, even just playing freely with your vision, ... Many VT practices are grafted on this idea one way or another. They are looking to improve smooth eye teaming, lens focusing and then increasing skill level by adding more activities (balance, body coordination, cognitive skill, ...).<br />
<br />
In that respect, I particularly liked a quote from the interview I did with Mark last month. It illustrates this point very nicely.<br />
<blockquote class="tr_bq">
<b>MARK</b>:<i> I still have strabismus but I have a greater degree of control. The reduced suppression helps. I can line everything up that I need for stereopsis (fixation on an object, in focus, no suppression, awareness of peripheral vision etc.). It can be an enormous effort but it's like any other form of learning. Repetition is the key and progress, however slow, will be made!</i></blockquote>
The only catch 22 when talking about all this 'control' is that you won't necessarily attain it by going about this like a control freak. Be relaxed, patient but determined.<br />
<br />
<div style="text-align: center;">
<i>One month later... </i></div>
<br />
<b>PASQUALE</b>: It has taken me over eight months to finally feel that my brain can move my eyes with better coordination without trying to recruit a battery of other facial, non ocular muscles. I have gone through an entire slew of other muscles including those around the temple region, jaw, even moving my ears. The worse was when I actually felt my upper jaw putting tremendous stress on my entire skull as if trying to separate one from the other. I have to say that I see more positive progress now that my brain isn't trying to move my eyes through the recruitment of all those other muscles.Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-17402113680905858752015-02-12T12:53:00.000-08:002015-02-14T11:28:23.664-08:00Mark B, strabismic pilot with eyes on the skiesAround a year ago I met Mark B. through our DIY Vision Therapy Facebook group. Every so often he'd post a picture of a little airplane or an air field on his Facebook profile. I thought he must really like planes but since he was strabismic he probably doesn't fly them himself. Turns out I was wrong!<br />
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<b>MICHAEL: Hi Mark, where do you live and how old are you?</b><br />
<br />
MARK: I live in the Brittish midlands, in Redditch more specifically. That's just south of Birmingham. I'm 39 years old and will turn 40 this year.<br />
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<b>MICHAEL: When did you develop strabismus? </b><br />
<b><br /></b>
MARK: As far as I know it's congenital, although the term "strabismus" is relatively new to me. Growing up it was simply a "lazy eye" which was "treated" with eye patches. The patching was a regiment of forced reading with one eye. I don't think the patching did anything to align my eyes and improve the strabismus as such. At the time I didn't really know why I was doing it either. However, clearly the patching helped me keep vision in both eyes (avoiding amblyopia which is another relatively new term for me) so I'm grateful for that!<br />
<div>
<br /></div>
<b>MICHAEL: So just to be sure... You never had eye muscle surgery, right?</b><br />
<b><br /></b>
MARK: No, the patching happened around the age of 5 or 6. Then, I can't remember exactly, maybe around 6 or 7 I had a few hospital visits and had lots of tests. They wanted to do eye muscle surgery but I was horrified and refused! Over time I learned to control my eyes so they looked straight(ish). On the other hand, I also learned to suppress vision in one eye and developed a distinct head-tilt. I'm glad I never went in for the surgery. My parents were cool with backing out of it and never made a fuss about it.<br />
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<b><br /></b><b>MICHAEL: Clever kid, good for you! Did you have a hard time academically? </b><b>What did you study?</b><br />
<b><br /></b>
MARK: I do remember when I was very young, reading was very difficult for me. I had above average intelligence and a very inquisitive nature but I struggled to read words as they jumbled all together. I would lose my place when moving to the next line.
Over time, my reading got better as I learned (as I now realise) to suppress the image from one eye. At school I studied Science and went on to study Physics at university.<br />
<br />
<b>MICHAEL: Cool, what kind of work do you do currently? </b><br />
<br />
MARK: I'm currently working for a water company. It's a great job. It takes me to a lot of different places and I meet a lot of interesting people. I work as a planning and scheduling manager - I've got groups of people dotted around the place who organise crews to go and respond to customer issues and make sure we maintain the pipes and overflows so we don't cause pollution. There's a lot to keep me busy!<br />
<br />
<b>MICHAEL: Sounds like an interesting and useful job! Water is important. How then did you get involved in aviation?</b><br />
<br />
MARK: I started flying a few years ago - just a lesson a month which was very slow going. I've always liked planes and the idea of flying. It was my wife who suggested I should start flying lessons. I never really believed I could afford it or have the ability. I trained for a few years and got my private pilot's licence last year.<br />
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<br />
<b>MICHAEL: That's awesome! What a supportive wife you have! Did you have to pass some sort of vision exam to obtain your licence?</b><br />
<br />
MARK: To get a <i>private pilot's licence</i> you need a <i>class 2</i> medical which involves a reasonably thorough medical examination by an aviation doctor including a "routine eye exam" (basically medical history, no "abnormal" eye conditions, a reasonable level of visual acuity and colour vision although the latter only restricts night-flying).<br />
<br />
Last autumn I got the crazy idea of pursuing a career path in aviation (commercial work or instructing) but for that I would need a<i> class 1</i> medical (thorough examination including very detailed ophthalmology exam, cardiogram, audiogram, blood tests etc.).<br />
<br />
I spent a day at Gatwick airport doing this but failed due to strabismus. The guidelines for a pass on the vision exam are:: -<br />
<br />
(1) At 6 metres:<br />
2.0 prism dioptres in hyperphoria,<br />
10.0 prism dioptres in esophoria,<br />
8.0 prism dioptres in exophoria;<br />
and<br />
(2) At 33 centimetres:<br />
1.0 prism dioptre in hyperphoria,<br />
8.0 prism dioptres in esophoria,<br />
12.0 prism dioptres in exophoria<br />
should be assessed as unfit.<br />
<br />
<b>MICHAEL: I guess they placed prisms in front of your eyes to elicit certain reactions and those were your limits or something...</b><br />
<br />
MARK: I failed due to 8 dioptres hypertropia . My eye positioning was not fixed and would change all the time, even during the measurements. My eyes were just out of my control! They also said it would be very unlikely that I would ever be issued with a class 1 certificate. Nonetheless, at this point I was allowed to renew my class 2 medical (fit to fly - hooray!). That was when I finished my private pilot licence course in Feb 2014.<br />
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<b>MICHAEL: It's too bad you were assessed as unfit for a class 1 certificate! Nonetheless, you seem to be endowed with an analytical mind and can do attitude. A problem needs a solution, right? How did you discover VT?</b><br />
<br />
MARK: I think I learned about VT just by searching the web for 'strabismus cures'. I did a bit of research. I went looking for real evidence on websites that they genuinely viewed Vision Therapy as a serious and effective branch of optometry. I have also seen some websites advertising VT as some kind of miracle cure or pseudoscience which put me off... Anyway, I found several good websites and eventually I also found your blog!<br />
<br />
<b>MICHAEL: I always love to hear that people find my blog! Did you ever read Fixing My Gaze? </b><br />
<br />
MARK: I did, it is a fantastic book! I really like the way it relates to Sue as the person and how she feels and relates to the world rather than Sue solely as the objective scientist. Definitely gave me hope despite years of dogmatic medical opinion that there is nothing that can be done with strabismus apart from cosmetic changes through surgery!<br />
<br />
<b>MICHAEL: When you first found out about VT you experimented a bit on your own, right? </b><br />
<br />
MARK: I did try some VT stuff before I started formal VT appointments but this caused me a lot of frustration. I think I was over stretching myself and trying to work on alignment and fixation without considering the basics like muscle control, attention and posture.<br />
<b><br /></b><b>MICHAEL: Here are some of your group updates from around that time: </b><br />
<b><br /></b>
<i>January 21st, 2014</i><br />
<br />
"Had an interesting couple of days. I'm experimenting with different things myself at the moment before handing over money to somebody who says I will never see in stereo.<br />
<br />
The anaglyph Tetris is going okay but it's hard work. I'm still not fusing both images into one so it's like trying to guess how many columns to move the piece to land it. Interesting though, I thought my left eye wandered upward but it moves slightly to the right as well! I know it's helping me overcome suppression but it is hard!<br />
<br />
I'm having much more fun trying to view 3D anaglyph (blue/red) photos, I'm finding that if I relax my eyes and un-tilt my head (I have a head tilt), I get fleeting moments of 3D vision. I tried to explain to my wife that it's like suddenly looking through a piece of glass in front of your face and everything looks beyond or in front of that piece of glass. Everything looks a lot clearer and sharper as well. Those fleeting moments are quickly lost but will hopefully build up.<br />
<br />
I'm getting brief moments of stereo vision in every day life as well. They're few and far between but getting more frequent. This is going to take some serious time but I believe I will get there!"<br />
<br />
<i>March 26th, 2014</i><br />
<br />
"Last week I felt I was getting somewhere. I worked on some crossed eyes stereograms for a couple of weeks and started to see in 3D in the real world but it was short-lived! I just went back to flat images and vague 'shadows' of the eye that tends to suppress. I'm going to sort out formal Vision Therapy in the next few weeks... I can't do this on my own!"<br />
<br />
<b>MICHAEL: How did you find your behavioral optometrist? You seem to be having very good experiences with the practice you are going to.</b><br />
<br />
MARK: I looked on Google. They are surprisingly hard to find! I think I ended up on the BABO (British Association of Behavioural Optometrists) website <a href="http://www.babo.co.uk/">www.babo.co.uk</a>. Fortunately I found a behavioral optometrist around 40 miles away which isn't too far. I went with <b><a href="https://www.youtube.com/watch?v=qloTmGMdek8" target="_blank">Keith Holland</a> and associates</b> in Cheltenham as it looked really professional and they seemed to genuinely care about what they did. The vision therapist has been working in this field for many years and really takes time to make sure we spend our time productively and focus on the right areas (no pun intended). I really cannot praise them enough and really look forward to our sessions! It is difficult to gauge my own progress as I am, by my very being, subjective but I have really improved my visual range (i.e. movement range of the eyes), ability to focus on specific points and stereopsis when viewing stereograms. I see the Vision Therapist every month and I think I'm due for a review with the optometrist every six months. I have a long way to go but I've definitely got some momentum going here!<br />
<br />
<b>MICHAEL: Yeah, you also went in with some fleeting moments of stereopsis which is a nice starting point! I would sign up for that any day! Here are some more group updates you posted after you officially started VT. I always liked your updates as they are so positive and excited.</b><br />
<b><br /></b>
<i>August 27th, 2014</i><br />
<br />
"Well, I finally had my first appointment with a behavioural optometrist today. I was warned that I might get permanent diplopia (double vision) if VT breaks my suppression but I can't fuse images. That's just something that could happen. The alternative is living with the strabismus which I don't want to do. I should get some news next week about starting proper vision training!"<br />
<b><br /></b><i>
September 15th, 2014</i><br />
<br />
"I started vision therapy today!!! It went really well. The therapist said that a lot of people in my position (i.e. late thirties) find out about VT and start a program having done a lot of research and having a good idea of what it is about. As it was the first session, we covered lots of different things.<br />
<br />
One thing that surprised me was that there was emphasis on balance and perception of surroundings. It had something to do with re-wiring the brain and creating new neural pathways in order to accept 3D vision. For instance, for one exercise I wore a pair of prism glasses which gave me instant double vision (no suppression). I had to look at my hands in front of me (there were four of them) and we went through each one (numbered 1,2,3 and 4!) to make me believe each hand was real. I'm not entirely sure what the purpose of this was but I will ask next time - possibly starting anti-suppression?<br />
<br />
Anyway, I've got an eye-patch and my own brock string with a timetable of daily exercises for next time. I'm working on balance (walking in a straight line with legs crossing in front of each other), eye stretching (patching one eye and fixating to the far ranges of the unpatched eye) to strengthen the muscles and to "convince" the brain that it would be good to start looking in places where I currently cannot, and a brock string. I'm trying to get the "V" shape. I'm sort of struggling so far but I will persevere! There was one brief super exciting moment where we had a go at a polarised stereo pair plate and I could "see" one circle "in front" of the other. I've had brief flashes of 3D before but this was quite controlled. Apparently neurons going into overload and building new pathways when that happens! Looking forward to more of that! Next session in four weeks!!!"<br />
<br />
<i>September 19th, 2014</i><br />
<br />
"Almost a week later and I'm starting to really break things down. The brock string is great. It shows you how things really are. It gives instant feedback on whether both eyes are "switched on" and if you're really fusing/fixating on an object (rather than your brain telling you not to worry about it!).
Doing big eye muscle stretching exercises every day. I think they're helping. I can "fix" a bead on the string after doing stretches. It's just going to take some serious repetition and practice. Onwards and upwards!"<br />
<br />
<i>October 14th, 2014</i><br />
<br />
"I had my second VT session on Monday and we covered loads! I tried brock string with red/green glasses which really helped. It seems to help break the suppression as the two images are clearly different colours. I've now added those to my VT pack. We did some more balance work with prisms to alter my view point. We're working on centering my brain and body. My VT is big on looking at vision as a holistic sum of many parts, not just the eyes!<br />
<br />
Did some more work on the polarised tranaglyph. I'm sort of seeing depth but really struggling without another reference point to compare it to. I've been given some homework to work on hand/eye coordination and estimating depth by threading a straw with a cocktail stick and to keep with the brock string.<br />
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A final thing we did was called the <b><i>"<a href="https://www.google.be/search?q=van+orden+star&es_sm=93&biw=1600&bih=756&source=lnms&sa=X&ei=zLnbVO_jJcL0PJzcgcgM&sqi=2&pjf=1&ved=0CAsQ_AUoAA&dpr=1" target="_blank">Van Orden Star</a>"</i></b> which is a bit like a stereogram lensed viewer where you join opposite sides by drawing with a pencil to where you think they meet. I think it gives an objective visual representation of how you see the world (how your eyes are positioned, that is). One side seemed higher than the other which would make sense. We're going to do it again in a few months to see how I've improved (!).<br />
<br />
In every day life, I'm suppressing less by fixating on objects with my eyes more rather than turning my head. This is bringing on some diplopia but it is completely within my control and is useful feedback on where my eyes are pointing and how far I am off. I'm sure my brain would prefer I didn't do this but it's tough. It's going to have to adapt I'm afraid! I am getting regular flashes of "depth" also - very briefly but more often. I just need to keep pushing myself. Onwards and upwards. This VT stuff really does work."<br />
<br />
<b>ANDREW: Apparently you have some 3D vision and it's gradually getting stronger and stronger. It doesn't seem that you just suddenly *got* it. Some people mention 'layers of depth' in regard to object array auto stereograms without really seeing depth in every day life. It seems like it's a sort of low-level stereopsis. With higher-level stereopsis, I'd imagine that you would see depth exactly as you would Y and X dimensions. </b><br />
<br />
MARK: Yes, the depth I see is something I've discussed a lot with my Vision Therapist. I refer to it as relative depth as I can differentiate between different depth planes in a very real way. They seem nearer or further away. Nonetheless I really struggle with tying that up with their absolute position in space. I think judging absolute positions of objects and the environment by stereoscopic depth perception is a learned skill which most people learn throughout infancy. For us strabismics, however, it's another step in the Vision Therapy chain of neural learning.<br />
<br />
<b>ANDREW: Do you have still have strabismus, i.e. a perceptible misalignment?</b><br />
<br />
MARK: I still have strabismus but I have a greater degree of control. The reduced suppression helps. <b><i>I can line everything up that I need for stereopsis (fixation on an object, in focus, no suppression, awareness of peripheral vision etc.)</i>.</b> It can be an enormous effort but it's like any other form of learning. Repetition is the key and progress, however slow, will be made!<br />
<b><br />MICHAEL: Things seem to be moving in the right direction for you! That was October last year. How have things progressed since then?</b><br />
<br />
MARK: Ever since I started formal Vision Therapy I've been making leaps and bounds of progress. It's been hard for me to judge as things don't happen quickly but I have regained a lot of muscle control and I have a better degree of stereopsis. For example, when I was first assessed, I was shown a stereoacuity test "the fly" which was just a polarized stereogram of a fly. I was asked what I could see and, with my alternating suppressing ways I answered that I could see two slightly different images - it depended on which eye I looked with. <i><b>I had completely forgotten about this when I was shown it again a few weeks ago when I saw a fly with different levels of depth, it was very clear but I didn't know what the big deal was! These things creep up on you</b>,</i> I think I had been doing a lot of stereogram tests and failed to appreciate the progress I was making! For me, the results are not dramatic and immediate but do build up over time. I'm amazed at how little understood and acknowledged VT is in the medical community given that they estimate that 10% of the adult population has stereo-blindness due to vision alignment problems. Every time I have had an eye test they tell me that my vision is perfect, 20/20 and that I have nothing to worry about and nothing can be done except for surgery!<br />
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<b>MICHAEL: How does Vision Therapy fit into your aviation activities and plans?</b><br />
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MARK: I am currently doing some more flying courses (flying on instruments, night flying) to keep the flying going while I go through Vision Therapy. Flying will always be fun even if I don't ever work in aviation. Nevertheless, I do plan to go back to Gatwick sometime and get my class 1 certificate and who knows where I'll go from there. I do intend to keep working my full time job for the time being but the eventual aim is to get a full commercial licence and train to be an instructor. I think I'll retire as a flight instructor in the Scottish highlands, taking people on pleasure flights. In comparison to my current job, flying is so much simpler but much more exciting and with a better view!<br />
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<b>MICHAEL: That sounds like a great plan. It's good to have plans and goals to aspire to. It will certainly keep you motivated. Thanks for taking the time and good luck with everything you do, Mark! Onwards and upwards!</b><br />
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<b><br /></b>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com1tag:blogger.com,1999:blog-2865728535786772093.post-67406590113343246582015-01-26T07:46:00.001-08:002015-01-26T09:08:04.281-08:00When you hit a wall and can't push through it, erode it<i>When you hit a wall and can't push through it, erode it.</i><br />
<i><br /></i>
<i>"It's always impossible until it becomes inevitable." - Jeffrey Sachs </i><br />
<i><br /></i>
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLWl7iaXubh9_wyT_82j2EdFUhwjbz4DjSGcC277g44A4BHYWpNMkzre2Zv47wnBUAzD52L2NPuvhMGe4pq1sOpxry_u7Z_bwVa2IACUXp9jp8td3FVebXpZK2CT8XtE4EY_Yqg-3k3dfV/s1600/wall.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLWl7iaXubh9_wyT_82j2EdFUhwjbz4DjSGcC277g44A4BHYWpNMkzre2Zv47wnBUAzD52L2NPuvhMGe4pq1sOpxry_u7Z_bwVa2IACUXp9jp8td3FVebXpZK2CT8XtE4EY_Yqg-3k3dfV/s1600/wall.jpeg" height="240" width="320" /></a>So far I've already reached some major visual goals I set out to achieve. Good! I know more or less how this process works and how real unexpected change can and does happen over time. Good! The downside is that the time table always turns out to be much longer than I'd hoped for. Nevertheless, results do materialize. I watched some of my previous eye videos, some of which were more than two years apart, and re-examined the progress made. It dawned on me that, for my vision to be completely automated, I'd might need another some such amount of progress as was achieved in between those two videos.<br />
<br />
Thus when being completely honest with myself I realize that it might take another two years. I'm hoping one year but I should mentally prepare for the worst. It's clearly possible to streamline my visual system and remove the remaining blockages providing me with a proper functional level but it will take some more time and concentrated effort. Not to get lost or discouraged I work in blocks of six months. When looking at it this way there are only four of those blocks left! That doesn't sound too bad!<br />
<br />
I'm already much less in a warlike state of mind than four years ago. It's interesting how my temper has cooled as my vision has further improved. However, there is still a vital need for improvement. Drawing on the last twenty years of experience I learned that you can't just go running around like some idiot hoping things will resolve themselves. Therefore I organised myself and got the political support I need to pursue my goal. No man can do it alone. Certainly not if there is no official support system whatsoever (clueless ophthalmologists/strabologists screwing over their patients, no social security when binocular vision problems impair productivity, you name it, ...). <b>The current main stream treatment of strabismus by the medical establishment, only offering surgery, is nothing less than continued and organised <a href="http://en.wikipedia.org/wiki/Character_assassination" target="_blank">character assassination</a> of people with binocular vision problems.</b> To survive this you need to approach Vision Rehab as a regular enterprise: deal with the disability and damage inflicted by surgery, find funding and support for your recovery, do the research and ultimately do the work in order to get to the end of the tunnel they have carved out for you. No potential has ever been harnessed without some type of investment. Reliable and workable vision and basic reading ability is one of the fundamental elements of independent life and therefore a must. I'm not planning on depending on others forever. I rather die. It's that simple.<br />
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I should never forget to be pragmatic though. In that respect, I'm unrolling some new projects this year. First of which were the Rapid Alternation Goggles as mentioned in my last blog entry. It's going to be a good year! :)Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-85116490295769379082015-01-24T06:09:00.000-08:002015-01-24T06:35:21.018-08:00"Electronic Rapid Alternate Occlusion Goggles" as Anti-Suppression treatmentFollowing an interesting thread on Facebook and some e-mailing back and forth with Patricia Simone Fink OD and Eric Hussey OD who were generous enough to share their time, research and experience with me, I decided to make another investment in my vision in the form of Electronic Rapid Alternation Occlusion Goggles. New year, new projects and new ways of approaching existing problems!<br />
<b><br /></b>
<b>What are Electronic Rapid Alternate Occlusion Goggles?</b><br />
<b><br /></b>
"Electronic rapid alternate occlusion (ERAO) using liquid crystal lenses is used to treat suppression of binocular vision, a defect affecting the sensory combination of two eyes’ images into actual binocularity; that is, simultaneous two-eyed, bi-foveal vision. Suppression remains a primary focus of the investigation of visual sensation in strabismus and amblyopia. However, abnormal binocular sensation in the form of suppression also occurs in the absence of strabismus and amblyopia as <i><u>intermittent central suppression (ICS)</u></i>. As the name implies, intermittent central suppression is a repetitive on-and-off form of loss of central visual sensation. <i><u><b>Active therapies for suppression, and ICS in particular, almost always involve two components: a bilateral (bi-optic) visual environment (e.g., a stereoscope) and visual motion.</b>"</u></i><br />
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<b>Demonstration videos</b><br />
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By Eric Hussey OD<br />
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<b>Idea and research</b><br />
<b><br /></b>
Without stealing too much of Eric Hussey's spotlight I want to explain some of the ideas behind the treatment.<br />
<br />
In his study <i>'<a href="http://www.oepf.org/presentation/remote-treatment-intermittent-central-suppression-improves-quality-life-measures" target="_blank">Remote treatment of intermittent central suppressionimproves quality-of-life measures</a>'</i> Dr Hussey extensively tests this type of goggles on young adult students at Job Corps with significant reading difficulties due to diagnosed intermittent central suppression. These are students without strabismus or severe amblyopia but have lapses of interrupted binocular vision disrupting their reading abilities.<br />
<br />
Why does this type of intermittant suppression happen? Traditionally suppression was thought of as a cortical inhibitory process all the way back at the visual cortex. Hussey, however, proposes that suppression is not solely contributable to inhibition at the cortical level. He suggests that suppression is the result of lack of development or disruption of the motion (magnocellular) neural pathway. This lack of development in the early stages of the visual process results in a lack of binocular integration further down the line, notably at the visual and extrastriate areas of the cortex.<br />
<br />
<i>"As an alternative to the cortical inhibitory
explanation, Iʼve suggested that motion is the
“on-switch for seeing” and that ICS (Intermittant Central Suppression) is a
deficiency in the motion pathwayʼs ability to keep
the image alive. Lack of motion signal lets the
visual sensation drop out through the same
mechanism as Troxlerʼs Perceptual Fading. <b>That
would explain why anti-suppression therapies
revolve around visual motion in a bilateral field.</b>
Since Troxlerʼs probably happens at or near the
Lateral Geniculate Nucleus, viewing that visual drop-out in the context
of developing visual neurology in an infant might
well explain some of the cortical changes in
strabismus and amblyopia. <b>Defect at a
neurologically lower area will affect development
of neurology in higher areas.</b> This differs from
the more top-down conventional wisdom
summed up in the word Bielschowsky used to
explain strabismic suppression: Diplopiaphobia. ... Merrill Allen theorized that a 9 Hz alternation rate made use of the Bartley Phenomenon brightness enhancement, in this view representing an improved visual signal at the cortex." - From the User Document accompanying the goggles</i><br />
<br />
This principle is further elaborated in Eric Hussey's paper <b>'Is Anti-Suppression the quest for visibility'</b> which will be published in the <a href="http://www.ovpjournal.org/" target="_blank">journal of Optometry & Visual Performance</a> in the near future.<br />
<br />
So if in cases of Intermittant Central Suppression inhibition at the visual cortex is not the main problem but rather an underdeveloped primary visual motion pathway, treatment should be targeted accordingly. Motion should be used stimulating this pathway and consequently encouraging more solid binocular vision.<br />
<br />
<i>"This does mean Iʼm suggesting suppression is a primary visual problem that is a result of lack of development of
the motion (magnocellular) neural pathway. Developmental, yes, although Iʼve documented whiplash-produced
ICS in an adult who did not show a suppression prior to the trauma. I suspect suppression and ICS in particular is
not a simple function of stress. Development and/or trauma are involved. <b>Thatʼs why we treat it with therapy and
why lenses do not eliminate suppression. Lenses may reduce fatigue, fatigue may make ICS more evident, and
therefore lenses may increase reading time before sensory meltdown, but lens application doesnʼt eliminate
suppression.</b>" -</i><i> From the User Document accompanying the goggles</i><br />
<br />
In short when using Rapid Alternate Occlusion while doing a binocular activity these goggles provide a constant motion stimulus, even if put on a frequency at which motion is no longer consciously perceived. Frequent use wakes up this underdeveloped motion pathway, increases binocular viewing time and gradually 'glues' the eyes together. To learn about the consequent improvements in reading ability in students undergoing the treatment, which are above those of control groups and not attributable to any other factors, you should take the time to read the <i>'<a href="http://www.oepf.org/presentation/remote-treatment-intermittent-central-suppression-improves-quality-life-measures" target="_blank">Remote treatment of intermittent central suppression improves quality-of-life measures</a>' </i>study.<br />
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<br />
<br />
<br />
<b>Other ways this device may influence binocular vision (according to me)!</b><br />
<br />
Vision is as much about retinal information (the visual stream) as it is about extra-retinal information (proprioception and efference copy). If you don't understand some of those words, that's alright.<br />
<br />
As mentioned above, the goggles stimulate the visual motion perception pathway by the constant motion of the rapid on off alternation and thus a constant change in <b>retinal input</b>. That is the grunt work of anti-suppression, as Eric calls it, and should ultimately 'glue' the eyes together.<br />
<br />
Rapid Alternate Occlusion might also influence the <b>interplay of retinal and extra-retinal information</b>. During the brief period of occlusion your brain doesn't have a visual reference of where your eyes are pointing, forcing your visual system to rely on other mechanisms like proprioception to keep its gaze steady and avoid uncontroled retinal slippage. If during occlusion the visual system relies too much on (absent) retinal information to stabilize gaze, and too little on extra-retinal information, one or both of the eyes will start drifting. Uncontroled retinal slippage is what sometimes happens to me while using the goggles because the proprioception and control of the muscles surrounding my eyes (extra-ocular muscles) has been significantly impaired through strabismus surgery.<br />
<br />
Therefore, another effect of these goggles then is that they constantly force the visual system to re-evaluate itself and stay busy relying on different neural information to accomplish gaze stability. This too will improve visual stamina! As it forces the visual motion pathway to stay active and develop itself more fully, it also forces these two types of neural input to integrate more fully to deal with the visual challenge imposed by the goggles.<br />
<br />
<b>How I currently use it </b><br />
<br />
I have a visual history of alternating strabismus with pretty good eye sight in both eyes. I have experienced constant double vision for a couple of years. Nowadays my eye alignment has improved to the point that I have aligned eyes most of the time. Traditionally I used to be a esotrope but after surgery my strabismus became non-committant with a tendency towards exotropia. Right now I still have Convergence Insufficiency and intermittant suppression in certain fields of vision resulting in a lack of real binocular fusion.<br />
<br />
I'm pretty confident as far as further ocular motility improvements go. I can eliminate the Convergence Insufficiency by continuing my visually conscious lifestyle. It's also important to realize that these are not separate issues. If Convergence Insufficiency disrupts eye alignment for near tasks, there is no fusion. If there is no binocular fusion, eyes have a tendency to wander.<br />
<br />
With these goggles I hope to continue and accelerate the 'grunt work' of anti-suppression. It will do so by means of a combination of the retinal and extra-retinal information mechanisms described above.<br />
<br />
I use it every day while doing not so spectacular tasks like watching TV, daily domestic activities (if it doesn't get in the way) or maybe some brief reading. I have yet to use it with a Cheiroscope as demonstrated in the video next time I go for VT. It does feel intense and the increased visual load tires you. Unsurprisingly it also tires people without a history of binocular problems. Go figure.<br />
<br />
I have been instructed to use it 40 to 50 minutes a day, 5 to 7 days a week. If that is too taxing, I should work up to it. That is what I am doing. I think I'm more or less at 20 minutes a day. I use it in periods of 5 to 10 minutes a time at a setting of 5Hz with equal 'open time' for both eyes as I am not severely amblyopic. As Eric puts it: "<i>The hope would be that we literally improve/wake up the central visual sensation or central visual signal which means your brain should have the information necessary to glue your eyes together.</i> <i>With diligent use, I’d like to think that the end of the year might bring some improvement. Neurology is tough stuff, though."</i><br />
<br />
Nevertheless, the theory makes sense and it feels visually intensive in various ways so I'm very curious about what the results of my experiment will be!<br />
<br />
<b>More information about another provider of Rapid Alternate Occlusion treatment and trails</b><br />
<br />
<a href="http://www.eyetronix.com/">http://www.eyetronix.com/</a>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-6220934188187717542015-01-05T12:27:00.000-08:002015-01-05T12:27:30.204-08:00How does it feel to live with Ménière's syndrome?Earlier I wrote about the intricate link between the <a href="http://livingwithdiplopia.blogspot.be/2014/10/the-vestibular-system-and-vision.html" target="_blank">visual and the vestibular system. They cannot be understood separately</a>. During this research on the vestibular system I stumbled upon something called Ménière's syndrome.<br />
<u><b><br /></b></u>
<u><b>What is Ménière's Syndrome?</b></u><br />
<br />
(Taken from the book '<a href="http://visionhelp.wordpress.com/2011/02/06/new-textbook-on-vision-rehabilitation-following-brain-injury/" target="_blank">Vision Rehabilitation</a>'.)<br />
<br />
"The etiology of Ménière’s syndrome is not completely understood but is considered
to be <a href="http://vestibular.org/secondary-endolymphatic-hydrops-seh" target="_blank">idiopathic (meaning the cause is unknown) endolymphatic hydrops</a>. Symptoms occur when excessive amounts
of endolymphatic fluid swell the endolymphatic space in the membranous labyrinth.
<b>Onset is typically spontaneous with symptoms of severe rotational vertigo, fluctuations
in hearing, tinnitus, and aural fullness.</b><br />
<br />
Intervals between episodes are symptom-
free and may be days, weeks, months, or years. Triggers may be stress, fatigue,
changes in barometric pressure, some foods, excessive dietary salt, or by other illnesses.
When the initial episode of Ménière’s occurs following TBI, it is identified
as posttraumatic Ménière’s syndrome.<br />
<br />
<b>It is uncommon</b> and symptoms may not be
manifested for weeks or months or years after the injury.
Hamid reported that a diagnosis of Ménière’s syndrome is “certain” in the presence
of<br />
<b>(1)<i> two or more spontaneous episodes with rotational vertigo for 20 minutes
or longer</i></b>,<br />
<b>(2)<i> audiological assessment showing hearing loss (unilateral or bilateral),
on at least one occasion,</i></b><br />
<b>(3)<i> tinnitus or aural fullness reported in the affected ear,</i></b><br />
<b>(4)<i> other etiologies were excluded (i.e., vestibular schwannoma),</i></b> and<br />
<b>(5)<i> histopathological
findings in the temporal bone.</i></b><br />
<br />
Treatment begins with a trial of medical management with <b><a href="http://en.wikipedia.org/wiki/Diuretic" target="_blank">diuretic</a> therapy</b> and a
<b>restricted sodium diet</b> (2000 mg/day). During severe episodes of vertigo, diazepam (antianxietal),
or meclizine (antihistaminic vestibular suppressant) may help. <b>Abstinence
from alcohol, nicotine, and/or caffeine can be beneficial.</b> Studies involving intratympanic
injections of gentamicin (an ototoxic antibiotic) are exploring other methods to
relieve severe vertigo. However, vertigo may be relieved but some hearing loss could
occur. <b>Vestibular rehabilitation can be beneficial for teaching the patient to use movement and balance strategies.</b> Prognosis may be good with early identification and
treatment. If aggressive medical management fails, a final resort involves surgery to
destroy vestibular nerve tissue or to prevent vestibular signals from going to the brain."<br />
<br />
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<br />
<br />
<b><u>What is it like to have Ménière's?</u></b><br />
<br />
It just so happens that a little while after reading about Ménière's that I met someone suffering from this syndrome over the internet. She likes her privacy so she won't be mentioned by her real name. Let's call her Hillary for sake of simplicity.<br />
<br />
Hillary is 56 years old and lives in Minnesota. Because she suffers from Ménière's, a vestibular disorder, her <i>Vestibulo-Ocular Reflex</i> is impaired. She has nystagmus, balance, posture and gait problems. She has tried to do gaze stabilization through vestibular therapy but it hasn't worked as well as she wished. That is the reason why she is exploring the workings of human vision and visual rehabilitation. Here's an excerpt of a conversation I had with Hillary.<br />
<br />
<b>HILLARY: When I was in Vestibular Therapy, I noticed during the gaze stability exercises how much my jaw, neck and shoulder muscles worked harder to keep my head steady. It was contributing to my vertigo. <u>It felt like I was trying to thread a needle on a moving train.</u></b><br />
<br />
<b>While watching your <a href="http://livingwithdiplopia.blogspot.be/2014/12/video-current-convergence-status-time.html" target="_blank">short videos</a> </b><b>demonstrating your eye movements, I think I noticed this in you too . <u>The forehead muscles or the jaw muscles moved first, then the eye followed – the other body muscles try to help get the eye on task. </u></b><br />
<b><br /></b>
<b>I think part of the problem is that you are holding the fixation target (the pen) yourself. An OT suggested that I find an old-fashioned desk pen holder so I don't use my other postural muscles to complete an ocular fixation task. The idea is to keep the jaw, neck and shoulder muscles out of the equation </b><br />
<b><br /></b>
<b>I try to develop static postural control and keep my head in the same plane in space while moving my eyes independently.
Maybe that is similar to focusing on your eyeglass supports as you do in t<a href="https://www.youtube.com/watch?v=Tm4BRSIozI8" target="_blank">he beginning of the video</a>. It’s more static – you aren't including any micro movements from you jaw, neck or shoulder muscles.</b><br />
<b><br /></b>
MICHAEL: You are quite the observer! Amazing! The 'thread a needle on a moving train' metaphor is very spot-on too! One of the biggest problems I experience because of the remaining Convergence Insufficiency is the cramping up of my left jaw while reading or trying to read. After a relatively short amount of time I usually have to stop because of jaw pain. Then I have to 'unwind'. The pen holder might be a good idea. How did Vestibular Therapy turn out for you?<br />
<br />
<b>HILLARY: Vestibular therapy helped somewhat. I have fluctuating symptoms (Ménière's) so everyday is unpredictable. I'm working on gaze steadiness now. Six years ago, if I were to direct my eyes upward, I would fall down.</b><br />
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<b></b></div>
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<br />
MICHAEL: Ha, I read about Ménière's syndrome recently. I'm sorry to hear you had such a hard time. Do you have any idea about what caused Ménière's in your case?<br />
<br />
<b>HILARY: Ménière's is idiopathic - which means they don't know the specific cause. I'm sure mine was caused by a series of genetic and environmental triggers. One ear has a slow-draining tube then add to that several ear infections as a child, allergies, a poor functioning immune system, etc. I had several Meniere's episodes - maybe one a year - from age 20 to age 35. Episodes became more frequent after that. I think I was diagnosed around the age of 40. The average age of diagnosis </b><b>among Ménière's patients </b><b>seems to be in the 4th decade. There were only a few doctors in my area that had the equipment and experience to diagnose this condition. </b><br />
<b><br /></b>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1Li2lIqYbwd_iVE_eb421ekIs6ryBGYlvS_aWvfmK5gt2e_oVpSlOIXzDG-dwY0lE35Gt4xEVsRDEO8MerqbuJ_djp-Ek8kXtlup9iBtpL8FtlvZCDgrZZ9VWC_Sg_BaNm4pCySoD_QTk/s1600/meniere.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1Li2lIqYbwd_iVE_eb421ekIs6ryBGYlvS_aWvfmK5gt2e_oVpSlOIXzDG-dwY0lE35Gt4xEVsRDEO8MerqbuJ_djp-Ek8kXtlup9iBtpL8FtlvZCDgrZZ9VWC_Sg_BaNm4pCySoD_QTk/s1600/meniere.jpg" height="320" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="background-color: #f6f7f8; color: #373e4d; font-family: Helvetica, Arial, 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 12px; line-height: 15.3599996566772px; text-align: left; white-space: pre-wrap;">credit to Shayne Town and his Meniere's in Art facebook page</span></td></tr>
</tbody></table>
<b><br /></b>
<br />
MICHAEL: Wow, I see. That puts a perspective on things... Clearly our situations are different but I identify with the unpredictability even though I don't suffer from Ménière's exactly. Taking naps does somewhat help for me. Do you experience <a href="http://en.wikipedia.org/wiki/Tinnitus" target="_blank">Tinnitus (perception of sound when no external sound is present)</a>?<br />
<br />
<b>HILLARY: Tinnitus! Yes, it would drive me batty. I did TMJ exercises and can now modulate it down from a roar to a hum. I think part of controlling the Tinnitus has to do with controlling blood flow pressure.</b><br />
<br />
MICHAEL: Honestly, I don't know what TMJ means but congrats for making such great progress! Gosh, you have been fighting your way through A LOT of sensory attacks!<br />
<br />
<b>HILLARY: TMJ stands for temporomandibular joints. Clenching the jaw can reduce blood flow to ear. Hearing damage and some medications can cause it too. I wear my earplugs often in loud places as a prevention measure too.</b><br />
<br />
<b><u>Before I understood how much eyes and vestibular are connected, I would think of the British women who learned to still hang out the wash in between the World War 2 bombs because "Monday is washing day."</u></b><br />
<br />
<b>A lot of reducing the anxiety of unpredictability is establishing whatever predictability you can muster. That's one reason I try to "anchor" the object I am trying to see.</b><br />
<b><br /></b>
MICHAEL: I like the World War 2 anecdote. I often felt like that. Whatever came down, you have to try to keep calm and carry on.<br />
<br />
Understanding the problem itself helps a lot though. So there's that. <a href="http://livingwithdiplopia.blogspot.be/2014/05/what-about-strabismus-and-anxiety.html" target="_blank">Gradually stabilizing my visual world is helping to take a lot of that uncertainty away.</a> External problems are relatively easy to overcome when you have mastered the internal neurological problems. I'm very glad I posted the videos and got your insights, Hillary. Thanks a lot!<br />
<br />
<b>HILLARY: After fifteen years of vestibular and physical therapy, I learned a few things! I enjoy your writing very much and thanks for sharing the video! Now I'm typed out because it takes a lot of effort for me. While some activities are invigorating mentally, they can be very taxing neurologically later on. I'm sure you understand. Talk to you later!</b>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-54754148527684364712014-12-25T09:04:00.000-08:002014-12-25T09:12:51.607-08:00Looking back at 2014 and looking forward to 2015I just reread my post from December 25th, 2013. It's always interesting to compare thoughts over time. Often we get lost in the day to day to remember the overall progress we have made. I remember being able to do some bar reading for the first time ever in January 2014. I also remember being able to do head turns without the view going double and shaky in May. This still isn't always the case, depending on fatigue, but that's when it happened for the first time. Stabilizing the Vestibulo-Ocular Reflex will be of utmost importance to complete this visual rehab process. Two major milestones right there.<br />
<div>
<br /></div>
<div>
These firsts produced themselves under controled circumstances and while maintaining a regimen including lots of rest. They need to be solidified but they are obviously good signs. I still face trouble reading and using electronics due to convergence problems BUT there is improvement. Improvement is what we are going for. You can't expect to directly go from being partially paralized to running marathons. It feels like I'm litterally completing a picture and filling in the holes, motorically and perceptually. Each year, since I discovered Vision Therapy, I have added or improved underdeveloped or damaged visual skills and it's compiling into something substantial. I hope all these elements will come together, integrate and anchor themselves through sensory fusion and hopefully stereovision the upcoming year. In the end it will have been worth every second. As the years go by I feel less shell-shocked and post-traumatic stressy and more grounded and armed with more adequate visual artillery to face the world and its challenges. If I can pile another year of improvement on top of that, who knows where that will lead me. I'm eager to find out and pursue that road. Usually the results always produce themselves but the timeline is always more extended than I'd hoped for. God, give me patience! :) Happy New Year!</div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdRj6bDFaGqbCLCUa_zzI6iU1MRg8aoEUOEcSE6uq1wgBQGuXDpwE8EKnQIpwYCDFHojGE9Je1dMWgv2C_ErGuVKW8FS6r6XUNutkuBfNhcDYQau5QvczYmLG_ApGhy2l72FDYNOGk6Adq/s1600/all+i+want+for+christmas.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdRj6bDFaGqbCLCUa_zzI6iU1MRg8aoEUOEcSE6uq1wgBQGuXDpwE8EKnQIpwYCDFHojGE9Je1dMWgv2C_ErGuVKW8FS6r6XUNutkuBfNhcDYQau5QvczYmLG_ApGhy2l72FDYNOGk6Adq/s1600/all+i+want+for+christmas.jpg" height="640" width="425" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">It might have to be the next Christmas, or the one after that,<br />
but I will get what I'm after.</td></tr>
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Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-48291209416708990402014-12-17T11:33:00.000-08:002014-12-17T11:33:40.855-08:00VIDEO: Current convergence status + The 'time-of-day-effect'<a href="http://livingwithdiplopia.blogspot.be/2014/05/you-want-more-evidence-ill-give-you.html" target="_blank">For a previous post I uploaded a video recorded in December, 2011 and went on to compare it to a video captured in May, 2014</a>. The images were self-explanatory and it was pretty spectacular! I recommend for anyone with strabismus to make videos of their eyes. It's great to monitor VT progress and, in doing so, keep motivation levels high. Adhering to that idea I made some more flattering videos.<br />
<br />
In those earlier videos I converged on a pen. In 2011 I failed radically. In May 2014 it finally started to look like something you'd call convergence. Converging on a pen was just a way of demonstrating the problem because, in reality, just being able to maintain that static pose won't get you far in terms of every day visual activities. In other words, there's still a lot of work improving more dynamic convergence activities such as the tiny saccades needed for reading. While reading I have to do a lot of correcting my eye movements. These corrections drain your energy, up the frustration and visual confusion levels, diminish reading comprehension. Generally it just brings you down! However, that's very hard to get on camera... Those mistakes and their consequent corrections are now likely to be something akin to nano-millimeters, at least initially. From the inside these issues are very noticeable but not so much from the outside.<br />
<br />
Because of this, I thought of a different way to register my remaining convergence issues by shifting the convergence frontier to the extreme. Instead of converging on a pen, this time I converged on the little nose supports of my glasses. Not a very natural movement but useful to elicit and demonstrate remaining convergence problems. You'll see that my left eye can't sustain this posture and drifts out towards the middle.<br />
<br />
The first video was recorded around <b>6PM on December 11th, 2014</b>. I was already quite tired when recording this video so the problem is very noticeable.<br />
<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/ztZHnge3hTg?feature=player_embedded' frameborder='0'></iframe></div>
<br />
The second video was recorded around <b>noon on December 13th, 2014</b>. It was a Saturday so I was able to sleep longer. Sleep is an important factor. No perfect convergence either but a very remarkable difference compared to the first video.<br />
<br />
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<br />
Not only are these videos interesting as a record of my current convergence status but also a reminder that the time of day and fatigue levels can influence the results of a vision exam! Sometimes you do better or worse at the optometrists's office than is generally the case! Keep that in mind.<br />
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In an unspecified period of time I will post a similar video in which I will be able to sustain this kind of convergence without trouble. Haaaa, one of the final frontiers in order to improve reading stamina and overall visual stamina. This is a big deal, people. A BIG DEAL! Back when I was a full-blown and manifest strabismic, I thought <i>'Convergence Insufficiency, how hard can it be?</i>' but I admit it's a b*tch.<br /><br />PS: It's my birthday! :)Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-92217402143289782922014-12-03T07:46:00.000-08:002014-12-03T07:55:14.344-08:00Check-up 9: Our four year anniversary On December first I had my half yearly optometric evaluation. Sight in both eyes is good but the axis of astigmatism in my left eye has shifted marginally.<br />
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This is my current Rx.<br />
OD: +2.50<br />
OS: +2.50 cyl -1.0 axis 35°<br />
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When testing my binocular vision my ocular motor abilities are approximating what it should be. When testing sensory fusion things are less clear. Looking through an <a href="http://en.wikipedia.org/wiki/Haploscope" target="_blank">haploscope</a> using some basic targets I do perceive the suppression controls and have what looks like a consistent and fused image. Based on this my optometrist tells me I have 'central and peripheral fusion'. I'm not so sure though. Using anaglyph (stereo)targets <a href="http://squintyjosh.blogspot.be/2011/03/what-is-fusion.html" target="_blank">I do not perceive 'luster' fusion, rather I perceive constant switching between red and green. It seems hard to agree on a definition of fusion.</a> But it is true that even though I might still have some form of intermittent and partial suppression at times, it is very easy to consciously break that suppression. Nonetheless it might still be too conscious a decision, especially while in motion. (More about the issue of unconscious intermittent and partial suppression and a potential solution in later blog posts).<br />
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In stereo targets, as seen through the haploscope, I can discern the correct relative distance between various elements of the picture by the way my eyes converge or diverge while viewing each of them in turn. When using polarized stereomaterials I do not directly perceive any 3D. To sum up, during none of the tests did I perceive any salient 3D but there are promising signs. "Certainly no bad news today.", the optometrist said.<br />
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<tr><td class="tr-caption" style="text-align: center;">Revised 'timeline' - Last surgery was in August 2009</td></tr>
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The challenge as a chronically untreated young adult with strabismus would have been to overcome the neurological atrophy and the decay of my vision, both motorically as perceptually, as it unfolded ever since my visual development went array. Compared to the current undertaking, that would have been relatively easy. Not easy, but relatively easy. However, I (and my optometrist with me) would say that eighty percent of my recovery is about overcoming the abysmal results of the surgeries I have undergone as a young adult (ages 16, 18, 19) completely obliterating my academic and professional prospects. That is why I am about to enter my fifth year of Vision Therapy.<br />
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In order to add more perspective, I'd like to translate and paraphrase some of the conversation I had with him in Dutch.<br />
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<b>MICHAEL: "Let's forget I've been doing this for four years and I were to walk into your office for the very first time in my current condition. What would you tell me?"</b><br />
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G. NAEGELS: "I would tell you you have a slight exophoria and all physiological preconditions for stereopsis recovery are present. In view of the fact that you only developed strabismus at the age of three (accommodative strabismus) your recovery prospects back then would have been excellent. At that age it is very likely you have already SEEN in stereo up until the binocular disruption. I'd recommend for you to try and re-acquire stereo vision because it will greatly improve the quality and stability of your vision and life in general. I think it's within reach now. But it has to happen of course."<br />
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<b>MICHAEL: "I'll have to make it happen then."</b><br />
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G. NAEGELS: "That being said, I still think that deontologically speaking I made the right call four years ago by telling you there was not much hope for recovery. Not every patient is as motivated and persistent as you are. I could not have foreseen that and I would not want to arouse expectations that can not be met by the optometrist alone. I've never seen someone so engaged in his recovery. I'm very happy to may have witnessed this in person. It's a pleasant surprise for me and it reaffirms what we are doing here."<br />
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<b>MICHAEL: "Thanks. I have no other option so I act pragmatically. It's swim or drown. It's that simple. This HAS to work out."</b>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-82210701143646103722014-11-25T12:29:00.000-08:002014-11-30T12:53:03.949-08:00Session 80: Large rope circles projected on the wallAfter almost four years of me doing Vision Therapy, our VT office finally got around to repairing an old projector they had in storage. It's pretty cool. Now we can finally do <a href="http://littlefoureyes.com/2010/11/01/vision-therapy-progress-maybe-little-efforts-are-a-big-deal-after-all/" target="_blank">polarized quoits vectograms</a> on a bigger scale by projecting them on some kind of grey screen on the wall. My Vision Therapist named Sofie was doing the exercise simultaneously with me. Funnily enough her ocular movement ranges at that distance (2 to 3 meters) were similar to mine. Keeping my circles singled out is going pretty well then but I didn't see any depth or changes in circle size (SILO - Small In Large Out). Damn it!<br />
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This brings me back to <a href="http://livingwithdiplopia.blogspot.be/2014/07/setting-goals-for-july-2015.html" target="_blank">the goals I stated in July 2014</a>. Easy convergence, more agile accommodation, sensory fusion and possibly stereo vision. That's what I hope to achieve by July 2015. That's all still on the table. Let time to its job. On a positive note, I have already reached the 75 kilograms weight target. One goal down, four to go.<br />
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I'm also working on procuring <a href="https://www.youtube.com/watch?feature=player_embedded&v=nH9cWBC0vx0" target="_blank">Rapid Alternating Occlusion Goggles</a> which are supposed to help with decreasing remaining fields of suppression and stimulate sensory fusion. Movement seems to be the key to 'blowing open' the magnocellular pathways, even when that movement is so rapid one does not consciously perceive it anymore. Read some papers about it, talked to the optometrist who invented it, ... I am very excited about the research papers but I'd like to SEE it for myself. More about this later!Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-65620395081547299512014-11-20T12:46:00.001-08:002014-11-20T12:56:02.399-08:00Session 79: A short Aperture Rule update.Recently a VT friend of mine named Pasquale asked me how I had progressed in executing the Aperture Rule ever since I wrote <a href="http://livingwithdiplopia.blogspot.be/search?q=doing+time" target="_blank">'Doing time'</a> two years ago. Last week I asked my Vision Therapist whether I could try the AR again to verify.<br />
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Two years ago I only recently started having single vision some of the time. Back then I was able to execute the AR up to level 4 (of a total of 12) both with the exo and eso settings.<br />
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Right now I am able to execute the AR successfully up to level 7 using either the exo or eso aperture. Not too shabby! Certainly when considering my Vision Therapist said that even people with 'normal vision' often have trouble going beyond level 9 or 10. </div>
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Good. This is where binocular vision problems come to die a slow and painful death. </div>
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Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-56792734184042445802014-11-06T06:20:00.000-08:002014-11-06T15:06:19.138-08:00The story of Ilaria Invitto: 'Vision Wars in Medical School'<i>"Am I wrong when refusing to surrender to my visual limitations? Am I condemned to live a life suspended in uncertainty while continueously fighting these limitations?"</i> - Ilaria Invitto<br />
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My name is Ilaria Invitto. I'm 23 years old and I live in Battipaglia, Italy. I was only three months old when my strabismus presented itself. It suddenly appeared after a night during which I suffered from strong respiratory problems due to bronchitis. I've undergone strabismus surgery when I was six but that hasn't really resolved my vision problems on a functional level.<br />
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<tr><td class="tr-caption" style="text-align: center;">Ilaria and her mother</td></tr>
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During high school I experienced the need to cover one eye with my hand while reading. I also lived through periods when I was unable to read, suffered from headaches and had to rest excessively. I knew it had to do with my strabismus but wasn't sure how exactly. I didn't know that I was lacking stereopsis. I didn't even know what stereopsis was!<br />
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<tr><td class="tr-caption" style="text-align: center;">Ilaria and her sister Serena</td></tr>
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<b>MICHAEL: That sounds all too familiar. I only discovered how much I'd been missing as a young adult too. Do you feel as if your strabismus has put the brakes on your performance and stopped you from living up to your true potential?</b><br />
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ILARIA: It's as if you've taken the words right out of my mouth! I feel there's been a considerable lack of productivity compared to my potential. I know I have a good memory and I am quick to learn. Still, there's always been something wrong ever since I was a child. It is as if there's a 'fire wall' between me and the world. Something preventing me from interacting and learning freely.<br />
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<tr><td class="tr-caption" style="text-align: center;">https://www.facebook.com/AskaDoctorofOptometry</td></tr>
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<b>MICHAEL: I completely identify. The mounting academic load led my partially developed vision to gradually disintegrate and break down, particularly during my University years. What has been your experience as you got older?</b><br />
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ILARIA: Currently I am pursuing a degree in 'Medicina e Chirurgia'. That is the Italian equivalent of Med school. To enter this branch of study one has to pass a demanding entry exam. Receiving the news that I had passed the test was the happiest moment of my life! It was also around that time I met my boyfriend. Things were good. I had a fairly normal life. My vision still didn't give me as much trouble as it does now. Everything seemed to be okay until I started to become unable to read and study. That was after my first year of Med school. That's when the real 'war' started.<br />
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Under these circumstances the problem with Med School is the amount of reading. I suddenly couldn't study or read a book anymore at all, the headaches got worse and my eyes always felt strained and painful. I didn't understand why I couldn't study anymore. I didn't understand why I felt so numb, slow and ... old! From that period on I started to suffer from <a href="http://livingwithdiplopia.blogspot.be/2014/05/what-about-strabismus-and-anxiety.html" target="_blank">anxiety, panic attacks and depression</a>.<br />
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This will be my fourth year of medical school attendance. Sadly however, in terms of exams, I am still working towards finishing up the second year. Studying Medicine normally takes six years in Italy so I'm still far from obtaining my degree. I'm very worried about my future...<br />
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<b>MICHAEL: 'Numb, slow and old.' It's almost uncanny how I've used the exact same words in attempts to convey my situation to other people. Although it's hard for others to understand a twenty something with a burn out due to badly treated binocular vision problems/strabismus. </b><b>Fortunately I discovered <a href="http://livingwithdiplopia.blogspot.be/2013/09/book-review-fixing-my-gaze-by-susan.html" target="_blank">Fixing My Gaze</a> on the internet. How did you break the dead lock?</b><br />
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ILARIA: After a class on the anatomy of the eye, I talked to my teacher Mrs Stefania Lucia Nori (University of Salerno) about my troubles. She's an ophthalmologist. She recommended for me to read <a href="http://livingwithdiplopia.blogspot.be/2013/09/book-review-fixing-my-gaze-by-susan.html" target="_blank">Susan Barry's Fixing My Gaze</a>. I discovered a whole new world. I can tell you that Fixing my Gaze, in a sense, saved my life! Even if the book wasn't able to provide an instant resolution of the problem, at least now I understood what was going on.<br />
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<b>MICHAEL: What did you do with this new information?</b><br />
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ILARIA: Because of the perpetual and accute eye strain and headaches I started looking for ways to improve my vision. An ophtalmologist told me to look into a program called <a href="http://www.revitalvision.com/" target="_blank">Revital Vision</a>. It's a computer program containing eye exercises. A supervising orthoptist is to guide the patient through the program and track progress. The advantage would be that I didn't have to travel long distances to complete this treatment. One of the problems with Revital Vision however was that it was supposed to be a treatment for amblyopia. I'm strabismic but don't really have severe amblyopia. I've done these computer exercises at home for two or three months. I was very desperate, confused and was under a lot of pressure from my parents. I did those exercises in front of the computer with my good, fixating eye covered in order to enhance function of the deviating eye. Because of this fairly random treatment, I started to alternate between eyes frequently and experienced occasional double vision. I still remember when I used to see my teacher with two heads in the classroom at university! They said it was a good sign because my right eye was "waking up". Nevertheless, my headaches and the eye pain were getting worse whatever they might have said. In my opinion they didn't know what they were doing. That's when I decided that it might be worthwhile to travel long distances in order to get some proper advice. I even think that the changes induced by this treatment slowed down the actual Vision Therapy I participated in later on.<br />
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...<br />
<i><br /></i>I started Vision Therapy in April, 2014. My Vision Therapist's name is Angelo Caniglia. He works in "Ottica Pisani", an optical shop/optometric center owned by an optometrist named Sabino Pisani. It is located in Castellanza, near Milan. Some famous athletes have been treated there for vision problems, such as for instance the football player <a href="http://en.wikipedia.org/wiki/Gennaro_Gattuso#Milan" target="_blank">Rino Gattuso</a>.<br />
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A major issue for me is the traveling distance. I live in the south of Italy, near Naples. My optometrist is located in the north of Italy, near Milan. That's 900 kms from where I live. I have to travel 1800 kms using high speed trains to see my Vision Therapist. Originally I had to do it all in one day which was beyond exhausting. Luckily, recently my boyfriend moved to Milan for his job. That allows me to spread the commute which makes it more bearable. That was a happy coincidence!<br />
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<b>MICHAEL: That's an insane amount of traveling. I hope it's worth it!</b><br />
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ILARIA: Ever since I've seen sort of a hologram in the quoits vectogram, I totally trust my Vision Therapist. It was such an exciting and touching spectacle to see the stick in my hand passing through the circle. My Vision Therapist always explains why we are doing something and answers all my questions in a comprehensive fashion. I very much appreciate that.<br />
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<b>MICHAEL: Wow, the floating circles are a very nice first step considering you only started VT in April. That's awesome.</b><br />
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ILARIA: Yes, it's not all good though. A few weeks back my therapist told me he thinks it would probably be better for me to give up the idea of central stereopsis. He'd suggest to reactivate the suppression in the right eye and develop only peripheral stereopsis. He says that there is no coherence between the surgically altered posture of my eyes and the perception of my right eye. For instance, the position of my eyes looks like exophoria but the underlying neurology reacts like an esotrope's. He's worried about the possibility of developing constant double vision. He also doesn't want to give me false hope as he doesn't know for certain whether he might be able to resolve my problems completely. I think it might be an attempt to manage my expectations because either way it's not going to be easy.<br />
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<b>MICHAEL: Yeah, the physical re-positioning of the eyes through surgery can result in a mismatch with how your vision developed neurologically. That creates an entirely new host of problems. I understand that your Vision Therapist wants to be cautious... Although I'm not sure how one is to develop peripheral stereopsis without it leading to central stereopsis anyway? It sounds like a good idea to make sure your eyes move well enough before throwing suppression out completely, develop peripheral stereopsis and then zone in on central stereopsis. To me that sounds like a better game plan than stopping with a job half done.</b><br />
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ILARIA: I used to believe in the impossible. I'd do whatever it takes to achieve the goals I set for myself. Maybe I was wrong... He says that peripheral binocularity should help a lot with reading... but I'm scared! I thought that one day I would be able to see in three dimensions, but now what?<br />
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These days I'm suffering from severe headaches because I'm studying more in order to pass my upcoming exams. I don't know what to think. I only know that I want my life back! I've heard acquiring stereopsis is possible for people with surgically altered eyes. I can't accept that it might be impossible for me!<br />
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<tr><td class="tr-caption" style="text-align: center;">Notice the lack of reflection<br />
in the right eye</td></tr>
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<b>MICHAEL: I think your Vision Therapist underestimates how much you want this. Good luck with your exams by the way! I know how it is to sacrifice your health for a passing grade. Don't hurt yourself too much though because in the long run it's not worth it. Focus on your vision and the rest will straighten itself out all by itself.</b><br />
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ILARIA: You say "don't hurt yourself" but I have to! I want to fight against my terrible headaches and the other symptoms, because I totally reject the possibility of renouncing my greatest passion. I'm too much in love with medicine!<br />
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<b>MICHAEL: I've fought that fight against my own body too. It's a fight you can't win without losing. I'm not suggesting you should</b><b> renounce or give up, just postpone for a little while to come back even stronger.</b><br />
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ILARIA: I've seen my first vision improvements but the road is long. Literally and figuratively, considering the long train rides. Lately I'm feeling the exhaustion of the travel which slows down my progress and sometimes even makes me regress. I guess progress doesn't happen in a straight line.<br />
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<b>MICHAEL: Yes, I'm afraid so. I just try to do what I have to do to solve the vision issue while avoiding and dismantling any potential secondary social or monetary problems. How are you coping with that?</b><br />
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ILARIA: It's hard to stay in that kind of 'reasonable problem solving mode'. One of the things that makes it particularly hard is the fact that my parents don't understand my vision problems and think I'm just being lazy. Often times I feel very anxious about this... or angry.<br />
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<b>MICHAEL: It's very hard to be patient with people when they accuse you of being lazy while you are in fact maxed out by trying too hard. That always makes me furious. Fortunately I've always been able to control myself quite well. That reminds me. I've watched the Godfather recently. One of the Sicilian bodyguards warned Michael Corleone for women from the south of Italy. Allegedly they can be more dangerous than shotguns. Fact or fiction?</b><br />
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ILARIA: Hahaha. That might be true when being angry. Maybe the Corleone bodyguards have a point there.<br />
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However, to get back to your question. A specific activity that helps me cope with my vision problem is singing. I'm in a <a href="https://www.facebook.com/VoxAureaVocalEnsemble?fref=ts" target="_blank">Vocal Ensemble</a> and choral music is vital to me. I'm very passionate and I was soothed by singing in the choir during many bad times. It's the only thing on which I can focus without using these damn eyes!<br />
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<a href="https://www.facebook.com/video.php?v=10202550990077502">una publicación</a> de <a href="https://www.facebook.com/ilariainvitto">Ilaria Invitto</a>.</div>
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<b>MICHAEL: That's beautiful! I'm glad you are able to vent your frustrations and emotions in such a graceful way.</b><br />
<b><br /></b>ILARIA: Yes, I need to upload some Italian or Latin songs now that I think of it.<br />
<b><br /></b><b>MICHAEL: Italian does lend itself very well to singing indeed. I look forward to those videos and I wish you the best of luck with everything you're doing and with Vision Therapy in particular! Let me know how it goes. Arrivederci, Ilaria! </b>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-40206601500411819372014-10-30T13:16:00.000-07:002014-10-30T13:45:41.736-07:00The vestibular system and visionI've been reading up on the link between vision and the vestibular system. It's been quite instructive to say the least. Of course it's annoying not to be able to align the eyes and have double vision while reading etc... However, there's more. It's very interesting how compromised eye movements, in large part due to eye muscle surgery, and consequently a compromised <u>Vestibulo-Ocular Reflex</u> are likely to be the <u>biggest source of disability and fatigue for me personally</u>. When going beyond my relatively low visual endurance limit, the sensory conflict between the visual and the vestibular gets exacerbated. It sometimes feels like being drunk and can even give me something resembling to a hangover later on. Not merely alignment of the eyes but also the integration of these ocular motor skills with the vestibular system will be crucial in terms of lasting vision therapy results and daily functionality.<br />
<br />
<b>What is the vestibular system?</b><br />
<b><br /></b><u>
- Peripheral</u><br />
The term 'vestibular' comes from the Latin 'vestibule' which means room. This 'room' is located in the inner ear and contains a minute amount of chemical fluid. Its workings involve the detection of fluid movement by receptor hair cells in various differently oriented semicircular canals. Vestibular injury may or may not be accompanied by hearing loss.<br />
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<br />
<u>- Central</u><br />
The vestibular sense is often misunderstood or overlooked. That's because, for instance, there is no such thing as a primary vestibular cortex.<br />
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<i>'There is, rather, a complex of cortical targets many of which remain difficult to understand. From the brainstem, vestibular signals reach a subcortical structure called the diencephalon. Tucked in between the cerebral hemispheres the diencephalon houses such important structures as the pineal gland, hypothalamus, and thalamus. Compared to the cerebral cortex the diencephalon is small in size but is very rich in nuclei for sensory, motor and limbic pathways. The thalamus is a central relay station for all incoming sensory signals excepting olfactory information.' - <a href="http://visionhelp.wordpress.com/2011/02/06/new-textbook-on-vision-rehabilitation-following-brain-injury/" target="_blank">Vision Rehabilitation</a></i><br />
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Without going into detail, we can conclude this sense is for a large part located in the primitive, reptilian part of our brain which houses many basic but vital functions. In fact, this sense is so essential to our functioning and well-being, that the vestibular nerve is the first fiber tract in the brain to begin <a href="http://en.wikipedia.org/wiki/Myelin" target="_blank">myelination</a> during pregnancy. This process starts by the last week of the first trimester. By the end of the fifth month of pregnancy, the vestibular organ has reached full size with ongoing myelination of pathways to the eyes and the spinal cord.<br />
<br />
<u>- Function</u><br />
Whereas the anatomy and chemistry of the vestibular system itself are fascinating, its interaction with the visual system and other somato-sensory systems are even more interesting.<br />
<br />
<blockquote class="tr_bq">
<i>The vestibular system is responsible for</i><br />
<i>(1) detecting linear and angular head movement and head position in space;</i><br />
<i>(2) assisting gaze stabilization of the visual field;</i><br />
<i>(3) maintaining balance and postural control; </i><br />
<i>(4) providing spatial orientation or perception of body movement.</i></blockquote>
<br />
<u>The primary role of the vestibular system is to provide the brain with information to regulate posture and to coordinate eye and head movements.</u> Proper vestibular functioning and integration with the other senses is of major importance to good overall health, optimal functionality and vision.<br />
<br />
<b>Link with vision?</b><br />
<br />
<i>'The vestibular system plays an important role in the generation of eye movements
that compensate for head movements. Through vestibular nuclei in the brainstem, each
SCC (semi-circular canal) is able to communicate with motor neurons of extra-ocular muscles to cause eye
deviation in each canal’s own plane. This interaction is the basis of the <u>vestibuloocular
reflex (VOR)</u>, which stabilizes gaze upon an image or the visual world during
head movement. If the VOR is impaired, loss of gaze stabilization is the result. <u><b>For
example, as the patient turns the head while walking an object in the visual field or
the whole visual environment appears unsteady or “bouncing.”</b></u></i><br />
<br />
<i><u>Demer described the VOR as a <b>“synergistic” interaction</b> between the vestibular
and ocular systems. Normal VOR stabilization is needed for <b>“functional vision, and
vision optimizes the performance of the VOR”</b></u>. Dynamic visual acuity
(DVA) plays a role in maintaining a sharper image on the retina, while the VOR
steadies gaze during head movement. This interaction is called the visual vestibuloocular
reflex (VVOR).' - Vision Rehabilitation</i><br />
<i><br /></i>
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And in turn...<br />
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<i><u>'<b>Sensory receptors in the eyes provide important feedback regarding orientation of the body in space.</b></u> In other words, where is the head in relation to the horizon? As discussed in Chapters 5 through 7, dysfunction in the <u>visual perception of
“straight ahead</u>,” common following brain injury, can cause dizziness, disorientation,
and imbalance. In the process of orientation, visual input also provides information
regarding possible environmental hazards, barriers or avenues of escape. In
the presence of impaired inputs from either the somatosensory (sensory projections from all over the body) or vestibular or both
systems there is <u>a strong dependence upon visual input</u>. Defective input from one
of the three systems </i>(visual, proprioception/somatosensory, vestibular)<i> may be compensated for by the remaining intact systems such
that the patient is able to function, albeit with some discomfort and loss of efficiency. <u><b>However, dysfunction in two of the three systems will result in significant
disability.</b>'</u></i> - <i>Vision Rehabilitation</i><br />
<br />
<b>Problems?</b><br />
<b><br /></b>
Even though the vestibular sense might often be overlooked by physicians, one will be made aware of its existence in case of dysfunction.<br />
<b><br /></b><u>- Inappropriate nystagmus</u><br />
'<i>Spontaneous nystagmus, occurring when the head is static (still), is an indicator
of acute peripheral vestibular loss. Nystagmus is often along the horizontal plane.
Vertical or torsional spontaneous nystagmus usually indicates a direct injury to
the brainstem. The cause of this inappropriate nystagmus is a direction-specific
imbalance in the VOR as brainstem neuronal circuitry is activated. Inappropriate
nystagmus may also be related to medication toxicity, such as some antiseizure
medications.' - Vision Rehabilitation</i><br />
<br />
Inappropriate nystagmus may also be provoked by head shaking and indicates an imbalance of dynamic vestibular function.<br />
<br />
An indicator of inappropriate nystagmus of central origin, caused by brain dysfunction rather than dysfunction of the peripheral organ, is often the inability to inhibit nystagmus with visual fixation.<br />
<br />
<br />
<u>- Dizziness</u><br />
Feeling disoriented, especially in dark areas, or feeling spacey, floating, rocking, or lightheaded. Dizziness is not always related to vestibular dysfunction but may indicate non-vestibular causes, one of which being visual disorders. However, when dizziness is mentioned, involvement of a vestibular dysfunction must be considered.<br />
<br />
<u>- Vertigo</u><br />
Even though dizziness and vertigo are often used interchangeably, technically there is a difference. Vertigo refers to the illusion of movement, typically rotational, when no actual movement is observed. True vertigo refers to vestibular system involvement.<br />
<br />
<u>- Motion sickness</u><br />
What causes motion sickness?<br />
<br />
<i>'There is a hierarchical preference to rely on visual input more than any one of the other two systems (vestibular, proprioception) involved in balance. Vision, as proposed by Bronstein, had a dominant role or “hierarchical preference” over proprioceptive input in the process of maintaining upright posture and balance. However, <u>M<b>allinson et al. suggested that a “visual preference strategy” would not apply to some individuals who have an intolerance for any disagreement between visual and vestibular signals.</b> </u>Paige had previously called this disagreement between the two systems as a <u>“visual vestibular mismatch”</u> (VVM) and others referred to it as a <u><b>“sensory conflict.”</b></u> By 1996, the “sensory conflict” theory for the development of motion sickness had been accepted within the scientific field studying this subject.' - Vision Rehabilitation</i><br />
<br />
<u>- And more...</u><br />
Balance problems, <a href="https://www.youtube.com/watch?gl=BE&v=FpiEprzObIU" target="_blank">gait ataxia</a>, ...<br />
<br />
Of the top of my head I can think of two interesting cases I read about involving vestibular dysfunction.<br />
<br />
In the book <a href="http://livingwithdiplopia.blogspot.be/2013/02/youtube-book-review-brain-that-changes.html" target="_blank">'The brain that changes itself'</a>, Norman Doidge described a woman who felt like she was perpetually falling due to vestibular injury. Her vestibular organ was damaged but her central vestibular processing capabilities were intact. We can't even start to imagine how she felt. It completely ruined her life. Until a certain Doctor thought of the idea to supply her brain with 'vestibular input' in a different way. He connected an accelerometer to a tongue outlet which gave her a certain signal depending on the direction towards she was falling. Through the mechanisms of brain plasticity she learned to ignore her vestibular organ and to stabilize herself using this new input stream. Somehow over time, as her brain re-calibrated, she became less dependent on the device and needed it less and less.<br />
<br />
Another vestibular story was featured in Oliver Sacks' 'The man who mistook his wife for a hat'. A Parkinsonian, 93 year old, retired carpenter whose vestibular sense had become more and more unreliable started walking tilted over to one side without knowing it. His senses deceived him until he saw himself on camera. He was speechless. After this discovery he wondered whether he could apply the mechanism of a spirit level to his problem. He designed a pair of glasses including some sort of spirit level which he could then use to teach himself to walk upright again. Essentially he retrained his impaired vestibular system using visual feedback. At first it took a lot of conscious effort but later on it got easier and easier. Just like learning how to drive a car.<br />
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<b>Psychological impact of vestibular dysfunction</b><br />
<br />
<i>'There are a variety of reasons why patients suffering from episodes of vertigo
develop anxiety, depression, poor self-esteem, and a growing sense of disability.
The fear of falling or the fear of heights is common. Concern for a sudden onset of
vertigo and the loss of control in public venues often leads to <u>avoidance behaviors
or “safety-seeking behaviors,</u>” as coined by Gurr and Moffat. The appearance of
staggering, falling, and confusion may lead observers to believe that the person is
intoxicated. <u>The patient soon finds him/herself avoiding social events and staying
home to avoid embarrassment. Physical activity is avoided for fear of provoking an
episode.</u>' - Vision Rehabilitation</i><br />
<b><br /></b>
<b><br /></b>
<b>Testing</b><br />
<br />
- Static and dynamic balance testing. Dynamic balance tests require input from the Vestibulo-Ocular Reflex to stabilize the visual field and make rapid adjustments in posture. Dynamic gait, sit-to-stand, ...<br />
<b>- </b>Dix Hallpike maneuver<br />
- Bithermal Caloric irrigation test (COWS): spraying water in the ear. <a href="https://www.youtube.com/watch?v=IiE0_AKGlWA" target="_blank">Check it out on Youtube. It's pretty cool</a>.<br />
- Comprehensive Vision Testing: gaze, tracking, binocular vision, perceptual, functional, nystagmography, ...<br />
<br />
<i>Please read Chapter 9 of '<a href="http://visionhelp.wordpress.com/2011/02/06/new-textbook-on-vision-rehabilitation-following-brain-injury/" target="_blank">Vision Rehabilitation</a>' for more detailed information. </i><br />
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<b>Rehabilitiation of the vestibular system</b><br />
<b><br /></b>
Vestibular injury or dysfunction can impose dramatic alterations in a patient’s once active lifestyle. There will be occasions when medication can be helpful in the short term. Surgery is the rare choice. Therapists take caution when a patient has other disabilities (brain trauma, stroke, peripheral neuropathy, spinal conditions, and/or vision disorders), which may limit choices of exercises.<br />
<br />
<i>'A key factor in achieving the best outcome will be patient compliance. <u>Education is the greatest tool used by a good therapist to engage a patient’s willing participation in what is usually a difficult treatment program.</u> Between, both, the vestibular therapist and the psychotherapist the patient is assisted in understanding the basics of the dysfunction: Why symptoms occur; the emotional response; and how treatment should help. <u>Initial treatment typically provokes unpleasant symptoms but feeling worse comes before feeling better.</u> <u>Another factor in achieving the best outcome involves adequate intensity and duration of the treatment program.</u></i><br />
<br />
<i>Progression of function is the best gauge for the effectiveness of treatment. <b>The process of treatment involves strategies for adaptation and substitution
by using other strategies, habituation (desensitization), and retraining of balance.
As the patient is able, exercises are expanded to include cardiorespiratory conditioning.</b>
Goals of vestibular rehabilitation are to (1) optimize compensation in the
balance system; (2) habituate abnormal vestibular responses to rapid movements;
(3) reduce fall risks by improving balance and postural control; and (4) educate
the patient.' - Vision Rehabilitation</i><br />
<i><br /></i>
<b>Is it a vision problem or vestibular problem?</b><br />
<b><br /></b>
It's important to figure out whether you are suffering from a vestibular problem with a visual component or a vision problem with a vestibular component. For strabismics who identify with some of these issues, the answer is probably 'a vision problem with a vestibular component'.<br />
<br />
That is why in the more advanced stages of Vision Therapy you are not only training eye movement. You are to stimulate your way towards overall sensory and thus vestibulo-visual integration. There's a million ways to skin that cat. Some of the things I do as <a href="http://livingwithdiplopia.blogspot.be/2014/08/some-of-my-current-home-based-vt.html" target="_blank">vision therapy loading</a>: walking, head turns while attempting to keep my gaze stable, walking a beam with yoked prisms, balance board, jumping on a trampoline, standing on my head, running, ...<br />
<br />
When my vision tends to go blurry or double and I feel dizzy, it's time to take a break. I flirt with my limit, take sufficient rest and remind myself that sometimes you do have to feel worse before feeling better. Improving these elementary vestibulo-ocular skills does influence and improve more sophisticated and more cognitively taxing ocular motor activities such as reading. The ground is being prepared!<br />
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Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com2tag:blogger.com,1999:blog-2865728535786772093.post-35339027708809563842014-10-09T06:52:00.000-07:002014-10-09T10:52:02.217-07:00'The ticking time bomb that split my world in two'About a week ago me and a man named Ryan Brooks had a thought-provoking conversation on my Facebook wall. I had just shared my latest blog entry '<a href="http://livingwithdiplopia.blogspot.be/2014/09/the-margin-of-error.html">The margin of error</a>'. He commented <i><b>"I always find your posts extremely interesting. I had a bleed in the brain stem which has left me with double vision. This is how I see now."</b></i><br />
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That is not your every day Facebook comment but I knew the visual phenomenon he was talking about of course. As I'm always open to learning about how other people deal with visual brain problems, I asked him whether he wanted to share more about what happened to him. He was prepared to do so and I am happy for it. Even though our histories are different (developmental vs cerebral incident), we are talking about closely related visual issues and symptoms. Thank you for sharing your incredible story, Ryan!<br />
<br />
I present to you, Mr. Ryan Brooks.<br />
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<u>Part 1</u><br />
RYAN: "I am 40 years old. I live in Newcastle NSW, Australia. I was an occupational health and safety manager in the mining industry and traveled the world to places like New Caledonia and New Guinea to name a few. I had only been home for eight weeks when the incident happened. Over a period of three months prior to the bleed I had experienced three separate dizzy spells and racing heart episodes but only lasted for about ten minutes. I attributed it to maybe anxiety due to my stressful job.<br />
<br />
The brain bleed happened on the 25th of June, 2012 at 11.15AM, I woke up feeling great and drove down to a cafe on the beach for a coffee. As I walked down the beach to the cafe my vision started to blur and I felt a strange buzzing feeling at the back of my head near the base of the skull. I put it down to still being half asleep. I ordered a coffee and sat at a table outside watching the surf. The buzzing started to get worse. I started to feel like I had butterflies in my stomach and felt increasingly faint. I got up to go to the bathroom to wash my face. As I got to the door... Boom. Suddenly I felt as if pins and needles were penetrating my face. Down my left arm and leg I felt numbness as well as pins and needles. All this combined with a feeling of complete disorientation. I managed to stumble back to the front counter and said "Call an ambulance, I'm having a stroke." Then I passed out over a table. A short while after, I came back to and noticed no one was helping me. I was in a bad way. I remembered there was no phone signal inside so I got on my hands and knees and crawled out the front door. I laid on the path, rang my sister and told her what had happened and for her to call an ambulance. The people at the bar told my sister that they thought I was a drug addict having an overdose. My sister went absolutely ballistic. The ambulance arrived 20 minutes later and off to hospital we went. After some brain scans the doctors realized that I had a bleed in the upper mid brain, which is part of the brain stem. More conspicuously, by merely looking at me, they could see my left eye was turned in so hard towards my nose you could barely see it. "<br />
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<tr><td class="tr-caption" style="text-align: center;">Ryan and his daughter</td></tr>
</tbody></table>
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<br />
<u>Part 2</u><br />
"The official diagnosis was a cavernous malformation. In plain English this means that a blood vessel wasn't formed properly at birth and it took 38 years to wear out and rupture. In other words, a ticking time bomb."<br />
<br />
<b>MICHAEL: After the incident and the diagnosis, did they do something about that blood vessel?</b><br />
<br />
RYAN: "They did an angiogram and injected ink into my brain which basically gave them a map of all the blood vessels in my brain and of the problematic area of vessels in particular. They didn't do anything because the brain area where it happened is very complex. The vessels in that area of the brain stem are the size of a strand of hair. Fortunately they were not arteries. Doing something to 'fix' it would entail too much risk. An intervention might kill me or give me a major stroke. Instead we opted for yearly brain scans. There's no guarantee it won't happen again."<br />
<br />
<b>MICHAEL: How did things proceed from there on out?</b><br />
<br />
RYAN: "After four initial weeks of rehab for partial paralysis down my left side everything started to get back to normal. Sort of... Concerns regarding double vision as a result of the bleed and nerve damage remained.<br />
<i><br /></i><b>MICHAEL: Can you describe your current visual situation?</b><br />
<br />
RYAN: "The official definition of the visual dysfunctions caused by the brain bleed goes as follows. Bilateral asymmetrical superior oblique paresis, cranial nerve paresis with convergence retraction nystagmus and some myopia in the left eye. But I would like to try and explain what that really means from my point of view.<br />
<br />
From the outside my eye alignment looks normal other than a slight turn of the left eye. Yet from the inside that's a different story. When I look straight ahead the image of my right eye looks pretty level but the image of my left eye is on a 45 degree vertical angle.The left eye also has very bad torsion.<br />
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<i><br /></i>
When I tilt my head up and down the torsion becomes worse. I have vertical up gaze palsy and so when I try to look up my eyes wiggle. Notwithstanding, when I tilt my head slightly to the right it pulls the torsion nearly square. In that moment my brain relaxes because it almost feels like I have normal and steady binocular vision again. Sadly I can't sustain the binocular posture. It's like a stare and after five seconds my left eye starts to drift.<br />
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<br />
When I turn my head left and right the images split up and down so I have to patch my left eye. It is very hard after 40 years of normal sight to now have two separate images that 'do what they do'.<br />
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<br />
When I walk without the left eye covered, the image coming from that eye bounces.
So when using my right eye, with my left bad eye covered, the eye's movement compensates for any head movement. The image stays stable and straight (<i>proper Vestibulo-Ocular Reflex</i>). On the other hand, when I close my good right eye and only have to draw on my left eye, the image inadvertently moves up and down following head movement (<i>compromised Vestibulo-Ocular Reflex</i>). Not only does the image move up and down, but it also tilts because of the torsion. It's quite nauseating and throws my balance out. If I walk with only my bad left eye open, it feels like I'm walking across a very steep hill. The image just bounces around inconsistently.<br />
<br />
I have also noticed that the color isn't as good in my good right eye. At night my right good eye doesn't see as well as my left bad eye. Everything is a sort of tinted darker when looking through my right eye.<br />
<br />
When I close one eye, my vision feels quite normal. although I had to get used to the difference in depth perception. At night, when there is little light, it feels like my vision is back to normal which stops the headaches. That's the only time my brain isn't fighting to get properly aligned binocular input. Then I can relax.<br />
<br />
Considering all the above, using my vision is a very fine balancing act."<br />
<br />
<b>MICHAEL: How do you make these example images? Do you use an app?</b><br />
<br />
RYAN: "You are actually the one who inspired me to investigate the internet and thus coming across the apps to help explain what I see to other people. These are the two apps. My Doctor was very impressed with the idea of taking photos of what I see and simulate what I see as I move my head into different directions. The images shift when doing so. This way he can see exactly what I see<i>.</i>"<br />
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<b>MICHAEL: What kind of treatment have you been getting or participating in?</b><br />
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RYAN: "I have been seeing a strabismus specialist in Melbourne at the Private Eye Clinic by the name of Dr Lional Kowal. I had VT for 12 months. While doing VT I was also going to Melbourne every three months for examinations. The VT pulled my eye nearly back to its normal position but the double vision remained.<br />
<br />
After that initial year of VT, I have had five correctional surgeries but none have been successful due to damage to the 3rd, 4th, 6th, 9th and 10th cranial nerve. Every time a surgery was done it had a negative effect on either the vertical or horizontal relative positioning of the images. Unfortunately after five surgeries, two of which were to undo previously performed surgeries which had made my double vision worse, I am back to square one."<br />
<b><br /></b>
<b>MICHAEL: I'm just thinking out loud... You had the incident in June 2012. Then you had one year of Vision Therapy aka Visual Neurorehabilitation. That brings us up to August 2013. So you must have had five surgeries in one year? How did that go? You seemed to be making VT progress, albeit slow. Who proposed the surgery? What did the Doctor tell you about its effectiveness, risks and possible outcomes?</b><br />
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RYAN: "As the double vision wasn't disappearing mainly due to the torsion aspect of my case, the Doctor or Neuro-Ophthalmologist suggested surgery. They explained the risks. He was confident he could give me an improvement.<br />
<br />
The first operation was performed on both eyes and made the double vision worse. Five days later that surgery had to be undone.<br />
<br />
Another three months later I had more eye muscle surgery on both eyes while being awake using only the use of anesthetic drops. They placed a black letter T on the ceiling and also on the wall in front of me. He started with the left eye. Cutting and manoeuvring the muscle a millimeter at a time. Then he'd wash out the eye, take the eye clamps out and tell me to look at the T and ask if there was any difference. Then he'd sit me up and tell me to look at the T on the wall in front of me and ask whether there was any difference. My response was 'it has adjusted slightly'. So back down for more adjusting. This process went on thee times until he said he couldn't do any more. He stated that if he overstretched the muscle it was irreversible. Next we repeated the same process for the right eye.<br />
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It was an extremely stressful experience. I could hear my heart racing. I was boiling hot due to the lights and surgical blankets. To be honest, after you have had your eye ball cut open, the eye muscles cut and then flushed out with water, the mix of blood and water makes your vision quite blurry. So any indication of what I was seeing was compromised and not really accurate. My eyes kept drifting as my muscles were cut, my vision was blurred and the environment was extremely stressful.<br />
<br />
A week later after letting my eyes recover a bit the double vision was worse. Another week later I went in for surgery again in an attempt to undo things. Under total anesthesia this time.<br />
<br />
Four months later, one more surgery was done to do some slight tweaking. I was completely under for this one. Whatever the result was, I was going to have to live with it."<br />
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<b>MICHAEL: You said 'I am back to square one'. Do you feel the surgeries were just a useless exercise or would you say it deteriorated the situation? I'm asking out of genuine curiosity, not because I myself had a very bad experience with strabismus surgery.</b><br />
<b><br /></b>
RYAN: "Now it is more or less back to where it was after the brain bleed, although a little different. Looking back I'm glad we gave it a try because now I know that at least we tried. I put my trust in my Doctor and we came out the other side not having gained but not having lost much either. He was a wonderful Doctor and only charged me for the first surgery. All the other surgeries he put through my medical fund at a significant price reduction. That was an incredibly kind gesture and showed that he was more interested in my case than in my money. On top of that I was extremely fortunate to have wonderful friends and family who organized a charity events such as a dinner party, an auction and a golf day. They ended up raising enough money to cover my surgeries, anesthetist, flights, accommodation, check ups, glasses, lenses, ... That all amounted to 30.000 dollars. If they read this, I want to thank Brett & Gail Purcell, Nathan Palmer, Tim & Macushla Spencer, Chad Edwards, Leeanne & Jeremy Symes and many other friends and family members who were involved. I had been 14 months off work so without this bunch of phenomenal friends my treatment would definitely have been cut short. I'm immensely grateful to them all."<br />
<b><br /></b>
<br />
<u>Part 3</u><br />
"Nowadays I'm using a tailor made contact lens that looks normal but really isn't. The outer edges are clear so you can still see the colour of my eye but the area covering my pupil is completely blacked out. I had to have my pupil measured so it looks cohesive with my other eye. This means that I am basically blind in my left eye when I have the lens in. Well, not completely blind... I still get peripheral vision from my left eye as the dot on the lens is a little smaller than my pupil and pupil size is variable depending on light conditions. Therefore, I still wear my glasses. When I'm not wearing my glasses, I have learnt to ghost the images of my left eye but after a while this gives me head aches. So back on go the glasses! Looking at me you couldn't tell anything is wrong. However, without my blacked out lens and my glasses the double vision still gives me constant headaches. .<br />
<br />
In general, my life has changed considerably following my accident. I no longer work in the mining industry. I now work as a disability case manager and spend much more time at home with my beautiful daughter."Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-42701846618587440042014-09-24T07:00:00.000-07:002014-09-29T09:26:58.785-07:00The margin of errorInterestingly, my strabismus was developmental since the age of three but in a relatively short amount of time I lost many of my adaptations (suppression, strabismic ways of eye teaming) to cope with misalignment of the eyes. First my suppression gradually declined because of life style, i.e. overly zealous studying, and then the way my eyes moved and alternated was abruptly changed through eye muscle surgery. This left me without any reliable adaptation to deal with my abnormally developed visual system.<br />
<br />
So the only option then, is pick up the pieces and start all over again. My visual system seems to act as a binocular system that was disrupted rather than a visual system which developed strabismically. It has no real inclination, or possibility for that matter, to go back to monocular viewing, alternation or any of its other former ways. There's a strong incentive to use both eyes, and it's constantly trying to do so, with varying rates of success. It's a binocular system whose inability to move its eyes accurately is cramping its style. Because of its poor handling, my case more resembles strabismus which was acquired later in life through brain injury than that of a developmental strabismic equipped with coping tools safeguarding functionality.<br />
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<a href="http://rlv.zcache.com/there_is_no_time_for_having_a_margin_of_error_postcard-r165dfe3940e44afba9b34dec1c05ebad_vgbaq_8byvr_512.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://rlv.zcache.com/there_is_no_time_for_having_a_margin_of_error_postcard-r165dfe3940e44afba9b34dec1c05ebad_vgbaq_8byvr_512.jpg" height="320" width="320" /></a></div>
<div>
The level of spasticity or lack of control when it comes to eye movement is fortunately declining. It has been declining for some years and every improvement is a win. <a href="http://livingwithdiplopia.blogspot.be/2014/09/some-vision-testing-in-front-of-webcam.html">As can be seen in previous video posts, it's getting harder to spot there is any problem at all!</a> However, automation is the goal, not merely the ability to execute the movements using disproportionate amounts of attention and energy resources.<br />
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<div>
Despite already increased accuracy and speed, there is still a considerable margin of error when it comes to my eye movements. I can not entirely rely on solid binocularity yet. It's either right or not right, and if it's not right you need to waste extra energy on correction which could have been used for observation and interpretation of visual input. Another issue associated with the continual trial and error, and the exertion it requires, is the build up of tension. Because of the lack of eye muscle control, surrounding areas of my body (face, jaw and gradually the entire body) start to tense up. The efforts to keep my left eye in check and attempts to keep up binocular performance will often result in jaw cramps on the left side and headaches. In order to avoid such an escalation it's recommended to allow for a margin of error and try to cut the visual system some slack.</div>
<div>
<br />
<b>What activities allow for a margin of error?</b></div>
<div>
<br />
<i><b>Reading vs General Navigation</b></i><br />
<i><br /></i></div>
<div>
Given this larger than normal margin of error, I prefer to avoid situations which require specific eye behavior.and do not leave much room for error. An obvious example of such an activity that requires precise and infallible eye movements is reading. There's a number of different ways to read but they all require impeccable eye movement control. That's why reading with audio back-up is much more agreeable with me. There's more room for eye movement error that way.</div>
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<div>
In contrast, the general observation of a road, square or real life situation can be done using an endless variety of eye behaviors. Some are definitely more effective than others but you can still get around. For someone whose eye behaviors start looking deceptively normal such activities requiring an accuracy level of 'approximate' are starting to be fine. It's starting to get less overwhelming, less out of control. More ocular control will be very welcome over the upcoming year(s) but it's already quite manageable.<br />
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Driving is actually easier than walking or running because my body and head stay more or less in position, especially on a highway. Because the road and the mirrors are much larger than the words on a page while reading, and driving is less cognitively taxing, my current level of eye control is okay for driving. In fact, driving is pretty calming as it allows for staring and the use of peripheral vision.</div>
<div>
<br />
<i><b>Individuals vs Groups</b></i><br />
<i><br /></i></div>
<div>
The difference between reading, general viewing of scenes and driving is pretty straight forward. Here's something which might be more unexpected, or maybe not. Perhaps people without eye muscle palsy experience this difference too. Meeting with one person is a lot more taxing to my visual system than meeting with a bunch of people. I don't look strabismic anymore so it's not about appearance. Meeting with one person just doesn't allow for much of an error margin when it comes to eye behavior. When talking to someone you have to look at that person. That's specific. It's likely you will have to hold your gaze steady but every once in a while you have to look away. The social situation dictates your eye behavior and your eye muscle control system better be up to the task. Most people I know and enter in contact with are aware of my vision issues and if I do act a little more peculiar than normal and start staring in the distance, I just explain. No biggy. Nonetheless, I try to keep up the eye contact dance. After all, it's good practice! It's also an important means of communication but you need the physical eye fitness to do it. </div>
<div>
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<div>
When meeting up with larger groups, there is more room for errors in eye movement. You can just listen to the conversation and stare randomly every so often. Attention is divided and you don't always have to look at the person who's doing the talking. It clearly also depends on how familiar you are with the group. An entirely new group in an new environment is a probable overload. I will have trouble moving my eyes to explore and keep up with the new situation, people and environment, especially over extended periods of time. Not much room for eye movement errors in that case because you'll preferably need your brain to deal with the situation rather than an eye movement deficiency. You're losing attention to something that should be working automatically.<br />
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<b>Factors that decrease the margin of error</b><br />
<b><br /></b>
<i><b>Short term</b></i><br />
<i><br /></i>
When I'm going to do something relatively visually taxing, which includes many daily activities in varying degrees, you want to have me well fed and well rested.<br />
<br />
I burn calories like you wouldn't believe and when I get hungry my accuracy diminishes and errors occur more frequently. So I'm eating a lot of the time these days as my appetite returned after a couple of very stressful years. This has a double benefit. It more or less keeps up my visual performance in the short run and makes me look less emaciated in the long run.<br />
<br />
Naps seriously improve my vision. Even an half an hour nap will seriously improve my visual performance for the night. Don't be a hero, take naps.<br />
<br />
Basically I'm just a baby learning how to see. Now we know why they too eat and sleep all the time.<br />
<br />
<i><b>Long term</b></i><br />
<i><br /></i></div>
<div>
Current practice consists of finding ways to allow a margin of error while slowly crushing that same margin as time goes by. Sometimes it is not possible to avoid situations that are too visually stressful. Then I do have to hurt myself by pushing it too far, resulting in tension and headaches. But by minimizing the time I exceed my limit and by granting the visual system relative rest, the comfort zone slowly expands.<br />
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Eye control and eye alignment should be invariable but is, in my case, all to often variable. Invariable and reliable eye movement control is a great advantage when executing bottom-up visual processing (taking in new visual scenes and observing them) and top-down visual processing (combining stored memories with what is seen). Virtually any human activity employs these kinds of visual processing. Therefore, I'm very curious about the dormant potential that might be uncovered as the rate of movement errors further declines. Stereo vision, for one. If I ever want to live a 'normal', independent life, there's no other way but to keep working on accuracy, speed and stability of eye movement.<br />
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<br />
<b>Eye movement control and the use of glasses for hyperopes</b><br />
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It's still frail and not ready to be stress tested, but it's happening. As my gaze gets steadier and the margin of movement errors declines, there is less need for my glasses. As vergence gets easier, I can focus more on the accommodation aspects of visual training. <a href="http://livingwithdiplopia.blogspot.be/2014/02/improvement-of-accommodation-and.html">Seamless interaction and collaboration of vergence and accommodation is crucial to obtain a lasting end result in VT. </a>As I'm farsighted (+2.5 in each eye) this evolution could have been expected. The glasses are more a way of avoiding fatigue and thus gaze instability than a way of providing better visual acuity. In fact, I often have to look over them to read things far away. As gaze stability is maturing I actually see better in daily life without the glasses. Ultimately they will just be reading glasses for near point work. Sometimes it even has a calming effect to take them off, even refreshing in a way. I'm still wearing them daily but every so often I let my visual system have a go on its own. Even though my glasses are rimless, it feels different not to wear them. I can believe people have an easier time seeing 3D without glasses or with contact lenses. Glasses have a way of distorting light and possibly binocular vision. However, I'm not going in heals over head... They are a useful anti-fatigue tool while I acquire more eye movement control. </div>
Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-46514383933319627932014-09-12T13:36:00.000-07:002014-09-14T06:38:06.194-07:00Some vision testing in front of the webcamInspired by <a href="http://learningmanagement.ca/cover-test/" target="_blank">Dr. Charles Boulet's article on the Cover Test</a>, I myself felt like doing some testing in front of the webcam.<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/P1eplSB2Kwg?feature=player_embedded' frameborder='0'></iframe></div>
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First you can see me doing some saccades, or jumping movements, going from one corner of my laptop screen to the other. I started off quite well but then my left eye started lagging and had trouble keeping up. This resulted in some double vision when looking at the right. I slowed down and paid more attention to remedy the problem. In order to reduce 'slippage' my left eye needs to improve its quickness of reaction and accuracy. This will be a key factor in acquiring stereo vision and reliable reading skills.<br />
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During the cover test my gaze seems pretty solid. In hindsight, I realize that I should have covered each eye for a longer period of time to see whether it would stay in place. Still, not a bad result in view of where I came from.<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/pYYoBiTTpbM?feature=player_embedded' frameborder='0'></iframe></div>
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In this video I am testing my ocular movement ranges. This slow tracking of the object seems mighty fine. I still feel some strain on particular eye muscles and have to stretch them to the limit but the video looks nearly perfect. There are no obvious restrictions in movement anymore.<br />
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I must say it makes me very happy to watch myself performing so well on these basic tests. From the outside I almost look 'normal'. There's no way in hell the untrained eye could tell I've had manifest strabismus for the larger part of my life.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX_XoPNWn1tj9d_kalv7Ydamt51aYekyru4jf4CqIyGOf17LKNGL3qXGMDlZwl9bjdJh1csHwgjjJIPnV8qOmiiobxLu7T-njfjW-zN87GOjIjm8x52teytP8r_gB0rtxxSJOA_6Vm6UiE/s1600/pyramid+of+binocular+vision.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX_XoPNWn1tj9d_kalv7Ydamt51aYekyru4jf4CqIyGOf17LKNGL3qXGMDlZwl9bjdJh1csHwgjjJIPnV8qOmiiobxLu7T-njfjW-zN87GOjIjm8x52teytP8r_gB0rtxxSJOA_6Vm6UiE/s1600/pyramid+of+binocular+vision.jpg" height="188" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Not a hierarchy of visual skills but a proposed aid for vision testing sequence</td></tr>
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<b>Hence I have definitely graduated to the '<a href="http://livingwithdiplopia.blogspot.be/2014/02/matan-on-living-with-and-overcoming.html">Convergence Insufficiency class</a>'. I still have trouble reading, problems with fatigue and trouble keeping up consistent performance (especially while moving) which are common symptoms in 'milder' forms of binocular vision issues. 'Milder' binocular vision issues are still a pain in the ass...</b> Nonetheless, when talking about convergence insufficiency I often heard professionals say it can be treated successfully in less than a year. God, I so hope that's true!<br />
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As we get closer to a resolution, it is only natural my strabismus became less visible from the outside and more visual change will happen on the inside. <b>That idea is so exciting. The idea of effortlessly pointing your eyes and just being able to focus on what is seen.</b> Can't wait!<br />
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Related articles:<br />
- <a href="http://livingwithdiplopia.blogspot.be/2014/05/you-want-more-evidence-ill-give-you.html">You want more evidence? I'll give you some evidence right here.</a>Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-24129918745974944592014-09-02T14:07:00.001-07:002014-09-02T14:50:06.699-07:00A wedding without double vision<a href="http://s3-eu-west-1.amazonaws.com/rpicms/4fcf81fd34763b4b70000008/3312_1~1.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://s3-eu-west-1.amazonaws.com/rpicms/4fcf81fd34763b4b70000008/3312_1~1.JPG" height="200" width="320" /></a>This weekend I attended a friend's wedding. I enjoyed it immensely. It was a reminder of the fact that not everything in life has to be a struggle. Not everything needs to be difficult. It's nice to see so many happy faces celebrating a joyous occasion.<br />
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During the last three years I have gone out of social circulation a bit. This is because I was suffering from all the symptoms you might associate with a severe concussion due to chronically untreated and mistreated strabismus. Social circumstances don't always bend to health and resting needs. It's weird to suddenly need to close your eyes to rest them or have to lie down so I prefer to avoid such situations. It has been hard enough to manage and explain my condition to my in house family. It has often proven challenging not to lose my nerve and get angry at their incomprehension of what is obvious, at least, to me. Certainly when thinking they could have avoided the whole thing by using their own brains. Sometimes Sartre is right. <i>L'enfer, c'est les autres.</i><br />
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I also didn't socialize too often because it doesn't change anything about my peculiar problem, drains my energy and adds to the frustration. I simply have to 'do the time' while not bashing into the walls too much. I have been fairly successful at doing my recovery time without repaying, often unintentional, hurt with hurt. That's the best and most sensible way of doing it. I'm good at restraining myself from doing stupid things.<br />
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Still, life goes on. Everyone else goes on to live their life and you have to start from scratch. While they get to have opportunities, jobs, weddings and babies, I have to teach myself how to read. The wedge has always been there, and I have done a remarkable job of covering it up, but in the end the truth remains. I don't possess the visual motor skills to do even basic reading. High intelligence and impeccable work ethic will only get you so far without those.<br />
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Meritocracy is dead. I felt as if whatever I do makes no difference and gets me nowhere in life. No wonder I didn't feel like socializing. I mostly felt furious and alienated. This is why, despite being a sociable person and having lovely friends, I was not always capable of being good company. The last thing I wanted to do is lash out at them for something that isn't their fault. They can't help the fact that they have what I want without even giving it a second thought. They can't help a whole series of ignorant, negligent and blameful people made me squander my youth and are still making me pay for their mistakes. However, irritation is natural when being locked in in your own body. Usually thinking about all this lost time and effort makes me want to throw up. Fortunately I have a good understanding of the situation now and know the only solution for me is to take my losses and build a better visual system.<br />
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This weekend I felt differently. It might be because I was able to get through the entire day without running into double vision or insurmountable exhaustion. This made me enjoy the day, the lovely people and the beautiful party. However, I think there's more to it. Even though I'm not exactly aiming for a 'normal' life, it must be nice to be able to function normally. In other words, take your life into your own hands. I think I can eventually attain that freedom. I'll have to work with the delayed time frame but I feel as if there's still hope for me after all. In a recent e-mail conversation with Sue Barry, she told me:<i> "It's amazing how much we were missing visually, but this also gives us the opportunity to keep improving. Although my biggest visual changes occurred when I was in formal therapy in 2002 and 2003, I still strategize with my optometrist a few times a year about new exercises I can practice at home, and my vision continues to improve. I'm 60 years old, and while all my friends are complaining about how they are aging, I'm seeing better. So, there are compensations and -you're right - the best is yet to come."</i><br />
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Being there I could just savor the moment without feeling betrayed by anyone having had 'an easier time' than me. I could be happy for them without thinking about our contrasting lives. I won't have to be a dysfunctional illiterate person without opportunities forever. I too will be okay one day and get out of this mess. Among all those happy people I thought about how far I have already come in recovering the unrecoverable, enjoyed my single vision and smiled. Indeed, the best is yet to come.Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-63857238865153873182014-08-13T12:11:00.000-07:002014-08-13T12:11:53.659-07:00Session 76: Bring in the peripherySkills acquired so far<br />
- Smooth eye movements, improved <a href="http://livingwithdiplopia.blogspot.be/2014/02/improvement-of-accommodation-and.html">vergence amplitudes</a> and eye alignment<br />
- Improved <a href="http://livingwithdiplopia.blogspot.be/2014/02/improvement-of-accommodation-and.html">accommodation amplitudes</a> and continuing improvement with flippers<br />
- <a href="http://livingwithdiplopia.blogspot.be/2014/04/head-rotations-bar-reading-and-bring-on.html">Stabilizing Vestibulo-Ocular Reflex</a><br />
- Being able to <a href="http://livingwithdiplopia.blogspot.be/2014/07/session-75-trusting-yourself.html">judge depth using physiological diplopia and reference cue</a><br />
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Left to do:<br />
- Automation and stamina<br />
- Integration, integration, integration.<br />
- My VT seems to be expecting I'll see some float in the Vectograms rather soon. To accomplish this I have to widen the span of my visual field. That's hard for me. Most of my life I've been busy suppressing my peripheral vision as an adaptation to strabismus. When I try to include more objects into my field of attention my gaze tends to get unsteady. This happens because my limited attention resource partly shifts from eye alignment to the widening of visual intake. That will be the next hurdle to take. "<b><i>Bring in the periphery!</i></b>" as my Italian friend Llaria likes to say.<br />
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Nice list of acquired skills though. What a journey it has already been over the last three and a half years... Every summer things look different. I'll keep inching forward and by next summer we'll have some good and honest '<a href="http://pexlab.wp.st-andrews.ac.uk/2014/07/25/fusion-float/" target="_blank">float</a>'. Ha!Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-50811388479515976542014-08-07T13:33:00.002-07:002014-08-07T13:33:52.494-07:00Some of my current home based VT activities<i>Everything we do or don't do has neurological consequences. That's why everything we do or don't do matters.</i><br />
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It's important to note that these activities are not suitable for every VT patient. Nor are they suitable at any stage in the rehabilitation process. They are suitable for me because my ability to control my eyes has reached a level allowing me to handle these activities without imploding, albeit with appropriate rest. Getting to this stage has taken a long time. I've had to do a lot of boring ground work first. Expanding the range of ocular movements, improving saccades, tracking and so on. VT is an active form of patience.<br />
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Another important reason of why these activities are appropriate for me as a VT patient is that my central suppression, especially while moving, is very poor. This means there is a very strong incentive for me to use both eyes and align them, rather than trying to suppress one eye. That's a very important point. Taking that into consideration, this means that I'm ALWAYS doing VT. I'm always trying to align my eyes and see binocularly because there's no alternative as there would be in a strabismic with good suppression. That's exhausting, particularly when trying to get out of an initial post-surgery double vision situation. Yet this might have some advantages at a later VT stage.</div>
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<b>So what do I do outside the VT office?</b><br />
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1. <a href="http://livingwithdiplopia.blogspot.be/2014/05/how-to-make-your-own-bar-reader-sheet.html"><b>Bar reading</b></a> or, when more tired, <a href="http://livingwithdiplopia.blogspot.be/2013/09/why-and-how-can-text-to-speech-programs.html">listening to a text with TextAloud while tracking the words with my eyes</a>. Even without suppression controls, I know when I'm doing it right when the text doesn't go double. The audio support while reading brings some relieve to my vision while still being able to practice saccades and integrate vision, audio and reading comprehension. Over time I feel like the saccades become easier and the audio support is less necessary. I'm gradually inserting prism and spherical flippers into the process to keep it challenging. So far however, (bar) reading hasn't been particularly easy yet.</div>
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2. Wearing a <b>translucent filter</b> on my glasses in order to stimulate my left eye and the neurology behind it. I do it in the morning when I'm relatively crisp. Initially doing this was a serious source of energy drainage. The filter in front of the 'good eye' makes the 'lazy' eye work harder in terms of acuity. It also forces me to acquire more dexterity relying on the more impaired eye. Lastly, there's a higher tendency for my eyes to go EXO with the filter requiring more of an alignment effort. <i>To sum up</i>: it works on acuity, eye motility and general integration of the eye into the nervous system.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-p57eLKcTOvg82J0NANc5qSmkwdxjRuMxdqXg8hDiXh4PStECApsn_BTzG0Dv-uIFyTjv4O-03gQXe44a7_Ki7NrnGo-ywA9H8RPCX1aPp34fgfE1cOigGUPFWHDhwNoSCXAMg1XJfMad/s1600/20140805_160846.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-p57eLKcTOvg82J0NANc5qSmkwdxjRuMxdqXg8hDiXh4PStECApsn_BTzG0Dv-uIFyTjv4O-03gQXe44a7_Ki7NrnGo-ywA9H8RPCX1aPp34fgfE1cOigGUPFWHDhwNoSCXAMg1XJfMad/s1600/20140805_160846.jpg" height="225" width="400" /></a></div>
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3. When having to rest, meaning I just want to stare, I sometimes watch some kind of series or movie. When I'm up for it <b>I use the flippers while watching</b>. It's less tiresome than using them while reading because the eyes are more stationary. In fact, the spherical flippers help to relax my eyes when they are all tensed up. It's like stretching soar muscles.<br />
When watching I also like to put a finger (or a remote) in front of my face. If I see two of them I am sure I'm not suppressing part of the view. (<a href="http://squintyjosh.blogspot.be/2011/02/physiological-diplopia-and-fun-exercise.html" target="_blank">physiological diplopia</a>)<br />
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4. <b>Head turns.</b> My Vestibulo-Ocular Reflex hasn't been working properly for a long time. This means that when my head moved, my eyes didn't make the appropriate compensatory movements to maintain a stable world view. This year (my 4th VT year) this has finally been leveling out and my eyes do make the appropriate movements for the world to stay fixed and stable. This new and highly anticipated skill isn't entirely reliable as it often gives way when I get tired. That's why I often check up on it and train it for short intervals by making head turns. My VOR needs further refinement, integration and staying power.<br />
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5. <b>Anaglyphs:</b> I play with these cards or other anaglyph visuals when I feel like it.<a href="http://livingwithdiplopia.blogspot.be/2014/07/session-75-trusting-yourself.html"> Lately it's more fun because I can figure out the DEPTH in them by using my hand and physiological diplopia as a reference.</a> It helps the learning process of corelating eye posture, image disparity and distance. The needed information is being picked up by my brain but I need to further automate these inferences. In the VT office we also use vectograms.<br />
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6. <b>Lately I'm playing a lot of<a href="http://livingwithdiplopia.blogspot.be/2014/06/football-without-stereoscopic-depth.html"> football (soccer)</a></b>, sometimes with the translucent filter in front of my left eye. Movement is good. Interaction with the environment is good. Messing around with a football is good visio-motor exercise. When my eyes stop aligning because of fatigue I notice two footballs and know it's time to call it a day. It's important not only to get both eyes working together but also to integrate them into a moving body. I put special emphasis on using both feet and both sides of my body, mixing it up and trying to stay aware of the entire visual field and physiological diplopia. Football may not be for everyone but I have some very fond memories of playing football as a child so I try to tap into that. Positive emotions and enthusiasm are very important in terms of motivation and creating new pathways in the brain. </div>
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7. Recently I had ten days of access to a <b>trampoline</b>. You'd think it doesn't really make that much of a difference but it does. When getting off the trampoline the world feels like it's moving beneath your feet. It's similar to disembarking a boat. Trampolines are great to further load and consolidate visio-motor and vestibulo-ocular skills. If that gets easy, you can further load the exercise with cognitive processing. Have a look at this cool exercise: <a href="http://www.oepf.org/sites/default/files/journals/jbo-volume-21-issue-3/21-3%20Slotnick.pdf" target="_blank">http://www.oepf.org/sites/default/files/journals/jbo-volume-21-issue-3/21-3%20Slotnick.pdf</a> </div>
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8. <b>Yoked prisms</b>. These powerful prisms, used with bases to one side, shift your entire visual field to the direction of your choice. The lenses are adjustable. I use them bases up, down, left and right. By doing so I train internal adjustment to new visual circumstances. More specifically they stress test the brain's ability to ajust its egocentric localization, eye and body posture as well as sense of balance and spatial vision. I have found them very useful in terms of aligning my subjectively perceived and objective midline which is often an issue in strabismus patients. Be careful with these toys though. Don't use them for more than 10 minutes at a time or you might suddenly get licked. They are effective but exhausting. I don't use them every day either. That said, I've had my most 'unusual' visual experiences after using yoked prisms.<br />
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9. <b>Deck of cards exercise.</b> <a href="http://livingwithdiplopia.blogspot.be/2014/06/the-accommodative-rock.html">It's similar to the 'classic' accommodative rock exercise.</a> Get yourself two decks of cards. Tape one on the window, hold one in your hand and start scanning the window looking for corresponding cards. Emphasize accuracy, binocularity and physiological diplopia. Do it well rather than fast.<br />
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10. <b>Taking walks.</b> As for integration of the eyes into the body walking is perfect. <i>Fast is easy, slow is hard.</i> Running is not bad either but you might be paying less attention to the visuals and wasting a lot of energy that could be used for visual consolidation. Vision first, running later. That's how I see it. While walking, take care of your visual experience: eye alignment, physiological diplopia and just being aware of your body and the view. Don't just go walking around dull-minded with ear-buds. </div>
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11. <b>Being aware of my left side and using my left hand sometimes</b>. As my left eye is my amblyopic eye, my right brain hemisphere needs fitness. This is almost surely a gross oversimplification but nonetheless trying to become more bilateral is part of becoming more binocular. Eg. if there's no time pressure I try to use my left hand. My mother told me that before I developed strabismus and amblyopia due to undetected farsightedness at age three, it was very hard for my kindergarden teachers or herself to tell whether I was left or right handed. I was just using either one. Then when I became strabismic the right side heavily dominated things visually and motorically. The chauvinist left hemisphere started hindering the development of my right hemisphere, visually and otherwise. Apparently, as I'm recovering, this is somewhat being reversed. Sometimes when I'm bored I doodle. Yesterday I was doodling with my left hand and noticed I could draw reasonably well with my left hand too. This is new!<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_pDbwl0Cr4qc4FhV4tUXwTfHrelRqebrAQ21Q3R7BgGhcQFkgp4yyieT57v1bI_B9pAUSDH38999tIFHQcv_RlpaiNjUVG8eqAXcT2f79r4r8EAx2AUo7CGx7_rSAn5qSXaLcr31Pnc4r/s1600/10557350_935993346427826_5485140062823467138_n.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_pDbwl0Cr4qc4FhV4tUXwTfHrelRqebrAQ21Q3R7BgGhcQFkgp4yyieT57v1bI_B9pAUSDH38999tIFHQcv_RlpaiNjUVG8eqAXcT2f79r4r8EAx2AUo7CGx7_rSAn5qSXaLcr31Pnc4r/s1600/10557350_935993346427826_5485140062823467138_n.jpg" height="400" width="225" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Left hand drawing</td></tr>
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12. <b>Thump-Pinky Vergence Rock</b>. An exercise similar to the Brock String. The best thing about this exercise is that it works on the integration of visual and proprioceptive input. This is often a decisive factor in getting ahead. </div>
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13.<b> Doing somersaults with my eyes open until I get dizzy. </b>Usually three. That's another Vestibulo-Ocular Reflex integration exercise.<br />
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Obviously these activities are not exhaustive. There are many ways to combine and load activities according to your current level. I also don't do all of them every day. Rather, I try to make whatever I'm doing into a visual exercise. If you have some idea how a healthy visual system is supposed to work, you can aspire to that goal. <i>Just as important as what you do, is how you do it.</i> In the end, life is just one big visual exercise!<br />
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Aside from exercising, I'm also eating a lot. <a href="http://livingwithdiplopia.blogspot.be/2014/07/setting-goals-for-july-2015.html">It appears that I have already reached one of the goals I set for next year. In two to three months I've gained 6 kilograms bringing me up to 75kgs.</a> This takes my BMI (height=1,85m) from 19.9 to 21.9. I'd been trying to gain weight for a long time but I guess I'm finally <a href="http://livingwithdiplopia.blogspot.be/2014/05/what-about-strabismus-and-anxiety.html">calm enough</a> for it to stick.<br />
I'm mentally preparing myself for the fact that eliminating the residual Convergence Insufficiency and other visual instabilities up to a workable level will likely take another year to year and a half. With some luck and steady work I'll be an 80kg binocular machine by next year. That reminds me... I need to go eat something!</div>
Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0tag:blogger.com,1999:blog-2865728535786772093.post-57032778413165916512014-07-27T05:46:00.000-07:002014-08-04T13:42:33.117-07:00Strabismus, visual field loss and visual-spatial neglect<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><br />
<a href="http://38.media.tumblr.com/c280206848b79ff27ed638ecc67aa0cd/tumblr_n8wum3q4GJ1qggwnvo1_1280.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="http://38.media.tumblr.com/c280206848b79ff27ed638ecc67aa0cd/tumblr_n8wum3q4GJ1qggwnvo1_1280.jpg" height="266" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">"Right after I lost vision in my eye, I was so bad at walking that I ran into a girl eating ice cream, and knocked her cone out of her hand. She screamed: ‘Are you blind!?!?’ I turned to her and said: ‘I am blind actually, I’m so sorry, I’ll buy you a new cone.’ And she said: ‘Oh my God! I’m so sorry! Don’t worry! It’s no problem at all! I’ll buy another one.’ So we walked into the ice cream store together, and the clerk said: ‘I heard the whole thing. Ice cream is free.’"</td></tr>
</tbody></table>
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This little charming story by 'Humans of New York' reminded me of the many times I have bumped into people and objects on my left side. For instance, as a kid I was frequently punished for accidently breaking things or 'not behaving'. As a teenager I remember one incident that occurred while I was trying to navigate a busy street. By mistake I bumped into a young woman with my shoulder without bad intentions, immediately apologizing. I quickly left the scene before her Alfa-male boyfriend was ready to punch me. Ha!<br />
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On another occasion I quite simply hit the metal detector at the airport with my left side while trying to walk through it. Apparently regulations state that anyone walking onto the detector has to be frisked in any case. Another pleasant left side neglect experience!<br />
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Even now, having much less suppression of my left eye, having a wider visual field and being relatively more binocular and bilateral, I frequently bump into objects on my left side. Just yesterday I hit a door post with my shoulder while running into a room. Ouchie.<br />
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Fortunately, as it happens, I just read the '<b><i>Evaluation and Treatment of Visual Field Loss and Visual-Spatial Neglect</i></b>' chapter of the book <a href="http://visionhelp.wordpress.com/2011/02/06/new-textbook-on-vision-rehabilitation-following-brain-injury/" target="_blank">'Vision Rehabilitation'</a>! Just when I thought I had read all about my life in the Spatial Vision (!) chapter, or at least about what has been missing from it, those vision nerd authors pulled me back in! -------- (Expect a book review, people. Expect it!)<br />
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<b><u>Visual field loss</u></b><br />
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The most known causes for visual field loss are eye disease (see picture) or damage of some sort to one or both of the eyes. This is the case for the gentleman featured above.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRLgfIJWRV8Xh96ocNDSNryQz63FxB2F7mFLC0yy8FsmLywIX2IOksOR-K8mPBL8oOkHdnhitajJH0HKc_N7EETMPmO6ylE27CWFZ3hp94QzxxkLSMOuVMSzJ0iP6Jo0mnSxVxpCosEdLl/s1600/visual+field+loss.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRLgfIJWRV8Xh96ocNDSNryQz63FxB2F7mFLC0yy8FsmLywIX2IOksOR-K8mPBL8oOkHdnhitajJH0HKc_N7EETMPmO6ylE27CWFZ3hp94QzxxkLSMOuVMSzJ0iP6Jo0mnSxVxpCosEdLl/s1600/visual+field+loss.jpg" height="320" width="320" /></a></div>
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Often, however, visual field loss can present more subtly on a cortical level. Cortical vision loss can occur developmentally or due to various kinds of brain injury. Whatever the cause of the visual field loss, the symptoms and the suffering associated are similar. Because of the complexity of the brain, cortical vision loss is very personal and presents itself differently in each patient.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtwcHDO0WH8lUHWJN2VMSPOXplLftM9kaP-8t7qfx1iB09D-CORWNvDZDgB8TtVJoMv82MXYA_brVSU0wL2tSQNpPmFiM2N-Ya3HUMHrEU9T7wXeNGlXX_-X9VQBlhG2rXFEZ2KUHG0RTK/s1600/visual+field+loss+2.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtwcHDO0WH8lUHWJN2VMSPOXplLftM9kaP-8t7qfx1iB09D-CORWNvDZDgB8TtVJoMv82MXYA_brVSU0wL2tSQNpPmFiM2N-Ya3HUMHrEU9T7wXeNGlXX_-X9VQBlhG2rXFEZ2KUHG0RTK/s1600/visual+field+loss+2.gif" height="303" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">This image gives you an idea of how various cortical disturbances can lead to<br />
different types of visual field loss </td></tr>
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Measurements of visual field loss are performed following the quadrant schematic. I’m not going to get into all the possible types of vision loss but it is important to know that various types of visual training, sometimes including the use of prisms, are available to improve visual brain function. Even when it is impossible to recover vision in a certain field, training can systematically improve adaptation by optimizing residual abilities. Relearned environment scanning can avoid future accidents, elevate quality of life and increase independence. <br />
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One very interesting aspect about visual field loss is that some patients lose conscious awareness of what is seen in a field due to damage to the primary visual pathway or the visual cortex but can still intercept valuable visual information through unconscious visual processing. This is called <b>blindsight</b>. In case of blind sight a partially blind patient might be able to perform saccading or pointing to an object in the blind field, be able to use information from the blind field to better execute perceptual tasks in the intact field or even be able to ‘guess’ features of an object in the blind field at much higher rates than chance. There is indeed a neurological basis for these peculiar skills. Even more interesting for the cause of vision rehabilitation is that these latent abilities can be trained to eg. improve maneuvering. --- <a href="https://www.youtube.com/watch?v=wZMAzwtX5Tg" target="_blank">Also check out this video on blindsight</a><br />
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<b><u>Visual-spatial neglect</u></b><br />
<b><br /></b>Many patients with visual field loss are aware of the fact that they have lost vision in a certain field yet some aren’t. That’s where things get even more tricky. Some patients with visual-spatial neglect are in some sort of ‘denial’ about their missing visual field. It simply doesn’t exist in their mind. People with visual-spatial neglect think they have an accurate representation of their environment and don’t really feel the need to compensate for their visual deficit. This too can present in a number of degrees. There’s <b>personal, peripersonal or extrapersonal neglect</b>. People with personal neglect do not only ignore half of their visual space but also ignore half of their own body image to a greater or lesser extent. Peripersonal neglect indicates the neglect of space within arm’s reach and extrapersonal neglect adds the neglect of space beyond arm’s reach.<br />
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<blockquote class="tr_bq">
<i>The presence of moderate to severe visual-spatial neglect can disrupt a variety of daily activities such as dressing, eating, reading, writing, walking, returning to work, and driving. Patients with left visual-spatial neglect will typically veer to the left when walking or bump their left shoulder on the doorframe.</i> (BINGO) -- Vision Rehabilitation</blockquote>
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Since most eye doctors aren’t even capable of detecting or treating any brain based vision dysfunctions which are often literally staring them in the face, it is no surprise visual-spatial neglect often goes undetected. In my case bumping my shoulder and what seem minor mishaps were less worrisome to me than, say, double vision. Nonetheless, many with more severe visual-spatial neglect, but without associated motor deficits, go undiagnosed and untreated following stroke or TBI.<br />
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<i>They may be misdiagnosed as having dementia, as family and caretakers are unable to understand why a person might end up with their pants on backward (when they put them on, they only acknowledged one leg, so there was no frontward or backward choice), or why they forget to finish a task or put away tools. It is not always as easy as noticing that they do not finish food on one side of their plate. Patients with visual-spatial neglect are frequently misdiagnosed as having visual field deficits by vision care practitioners who are unaware of the possible diagnosis or visual-spatial neglect. </i>-- Vision Rehabilitation</blockquote>
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Indeed, it is not always easy to determine whether a patient has visual field loss, visual-spatial neglect or both! That’s why appropriate testing has to be done in order to get answers to those questions and get appropriate treatment.
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<b><u>Visual field loss and visual-spatial neglect in strabismic and amblyopic patients</u></b><br />
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As for the connection between strabismus, visual field loss and visual-spatial neglect, it is clear there must be a considerable incidence of neglect among strabismics. <b>Suppression of part of the visual field to deal with misaligned eyes can be seen as self-induced visual field loss.</b> This suppression of one of the eyes, be it permanently or alternately, leads to a reduced field of vision. In my case it is no surprise I bump into doors with my left shoulder as my left eye was traditionally the ‘lazy’ one. Even now with a field of vision that is as binocular as ever, I still tend to suppress peripheral vision coming from my left eye in more stressful situations requiring focus. Clearly this also affects my body image as I seem to be less likely to take into account the existence of my left side while moving.<br />
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<i>The most common location for the lesion causing left spatial inattention is thought to be the right parietal lobe. In most patients, corresponding lesion to the left parietal lobe causes mild or transient visual-spatial neglect of the right space. It has been hypothesized that the right hemisphere modulates attention to both hemi-fields, where the left hemisphere modulates attention mainly to the right hemi-field only. Thus, damage to the left parietal lobe may cause an imbalance in allocation of attention from the pre-injury state, but damage to the right parietal lobe, common in middle cerebral artery infarct or aneurysm, causes marked visual-spatial neglect, as this is the major cortical substrate for orienting and allocating selective attention to the left hemifield. (!) In very young children, this hemispheric dominance for spatial attention is not yet fully developed (!) as evidenced by line-bisection tasks at age 4-5 years (!). Children show adult-like bisection with a slight leftward bias in bisection by 7-8 years of age. </i>-- Vision Rehabilitation</blockquote>
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That solves the mystery then. At the age of three my bispherical development went array and I developed amblyopia, strabismus and visual-spatial neglect. <b>In addition to the distorted body map and frequently missing visual fields, unreliable alignment of the visual axes produces conflicting input to answer the basic ‘where am I?’ and ‘where is it?’ questions. Answering those two questions are the two primary objectives of the visual system preceding the ‘What is it?’ and the ‘What to do about it?’ questions</b>. In developmental strabismus, neglect might in fact be a way of dealing with these conflicting inputs. To resolve the conflict one side has to foot the bill. That’s why, at this point in my rehabilitation, I am putting a lot of emphasis on not only aligning the eyes but also paying attention to my entire visual field and doing activities that promote bilateralism. Again it seems to come down to the magic three: the integration of visual input, vestibular input (balance) and proprioceptive input (self awareness and body image).<br />
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I'll try to be more practical about what I actually DO to integrate those types of sensory input next time. :)<br />
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Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com1tag:blogger.com,1999:blog-2865728535786772093.post-84865902825471325152014-07-11T09:09:00.000-07:002014-07-11T12:42:22.019-07:00Session 75: Trusting yourselfI had another training session on Tuesday. I did more 'feeling depth' in anaglyph pictures by reaching out for them with my fingers. It's very exciting how that keeps working. This practice also enhances physiological diplopia. That makes sense given that this ability is based on positioning your eyes correctly, seeing the object of interest single and everything after it double. When my hand is singled out and the object of interest is singled out, that's where it should theoretically be in space. It isn't really, because it's just an anaglyph stereogram of course. That sounds pretty obvious but it wasn't when I first started doing this exercise. It takes accuracy.<br />
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I'm so astonished by the fact that this is starting to work out for me. My training optometrist/vision therapist Sofie (as opposed to the supervising optometrist who does the check-ups) said: "Yeah, just trust yourself. That's how it should be." After all these years of double vision, it's hard to trust my vision. The illusion of seeing is believing is gone. It feels like it was all just one crazy conspiracy designed to screw with me. So I guess trusting myself would be a good start. In this spirit, my brain is finally starting to interpret the normal alignment of the visual axes. Sweet.<br />
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Of the supervising optometrist I already knew from the very first meeting he thought my case was hopeless and I should not even start training, but Sofie had never said this with so many words. She'd always been patient. For the first time she now admitted: "I never thought you would ever get to this stage of correctly interpreting stereograms by reaching out for them." There's always been progress but this new feat is very outspoken. It's added functionality and that is what we have been laying the groundwork for all along. I like it. It's like the first time you used WiFi. It's awesome and incredible, yet it's 'normal'.<br />
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Earlier, when listening to the book 'Phantoms in the Brain', I was struck by an anecdote very similar or related to using fingers to sense depth and develop binocular depth perception.<br />
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<i>"... Many stroke patients, like Bill, with dyscalculia also have an associated brain
disorder called finger agnosia: They can no longer name which finger the
neurologist is pointing to or touching. Is it a complete coincidence that
both arithmetic operations and finger naming occupy adjacent brain
regions, or does it have something to do with the fact that we all learn
to count by using our fingers in early childhood? The observation that
in some of these patients one function can be retained (naming fingers )
while the other ( adding and subtracting) is gone doesn't negate the argument
that these two might be closely linked and occupy the same
anatomical niche in the brain. It's possible , for instance, that the two
functions are laid down in close proximity and were dependent on each
other during the learning phase, but in the adult each function can survive
without the other. In other words, a child may need to wiggle his
or her fingers subconsciously while counting, whereas you and I may not
need to do so. ..."</i></blockquote>
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V. S. Ramachandran, Sandra Blakeslee - Phantoms in the Brain: Probing the Mysteries of the Human Mind page 19</blockquote>
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This excerpt demonstrates the intimate interaction of seemingly unrelated neurological functions during developmental processes. Body image, (ocular) movement, counting, seeing, whatever... They all cross contaminate each other and create synergies. Right now I have to use my fingers to judge depth in a similar fashion as a kid learning how to count with his fingers. As I'll develop further and my vision matures, dependence on finger reference will decline. For now however, it's all still highly connected. That's why it's obvious that if I want to see better, the movement of my eyes and their integration in a moving body will have to be perfected further. Nonetheless, it's not only about getting both eyes to work together. It's about getting the two sides of the body, notably the two brain hemispheres, to work together. That's a tough job and that's why I'm tired a lot of the time. Unlike a normal job, this job goes on every waking hour. Even though it's exhausting, I'm very excited about it. The elimination of Convergence Insufficiency and the integration of balance, proprioception and other senses are now entering a critical phase.<br />
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In order to integrate my visual streams, vestibular system and proprioception, I'm trying to move a moderate amount every day. Biking, walking, two-footed football juggling, ... Not brute force movement, but activities that emphasize (eye) movement, balance and taking in the environment. It makes me kind of dull and tired afterwards as my visual accuracy diminishes but it's beneficial in the long haul. That's training. Stress yourself, get a little worse and tired and then get better. In contrast to the twenty years that have come before, this time there is a clear plan and a road to follow. My eyes have never been on the verge of permanently aligning themselves, making it possible to integrate all these factors for the first time since I was three years old. If all these sensory input streams start completing each other instead of competing with each other, I will be set up for life.<br />
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More about sensory integration over the next few weeks and months!
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Michael Lievenshttp://www.blogger.com/profile/04322577959888347184noreply@blogger.com0