How does it feel to live with Ménière's syndrome?

Earlier I wrote about the intricate link between the visual and the vestibular system. They cannot be understood separately. During this research on the vestibular system I stumbled upon something called Ménière's syndrome.

What is Ménière's Syndrome?

(Taken from the book 'Vision Rehabilitation'.)

"The etiology of Ménière’s syndrome is not completely understood but is considered to be idiopathic (meaning the cause is unknown) endolymphatic hydrops. Symptoms occur when excessive amounts of endolymphatic fluid swell the endolymphatic space in the membranous labyrinth. Onset is typically spontaneous with symptoms of severe rotational vertigo, fluctuations in hearing, tinnitus, and aural fullness.

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.

It is uncommon 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
(1) two or more spontaneous episodes with rotational vertigo for 20 minutes or longer,
(2) audiological assessment showing hearing loss (unilateral or bilateral), on at least one occasion,
(3) tinnitus or aural fullness reported in the affected ear,
(4) other etiologies were excluded (i.e., vestibular schwannoma), and
(5) histopathological findings in the temporal bone.

Treatment begins with a trial of medical management with diuretic therapy and a restricted sodium diet (2000 mg/day). During severe episodes of vertigo, diazepam (antianxietal), or meclizine (antihistaminic vestibular suppressant) may help. Abstinence from alcohol, nicotine, and/or caffeine can be beneficial. 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. Vestibular rehabilitation can be beneficial for teaching the patient to use movement and balance strategies. 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."

What is it like to have Ménière's?

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.

Hillary is 56 years old and lives in Minnesota. Because she suffers from Ménière's, a vestibular disorder, her Vestibulo-Ocular Reflex 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.

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. It felt like I was trying to thread a needle on a moving train.

While watching your short videos demonstrating your eye movements, I think I noticed this in you too . 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. 

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 

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 the beginning of the video. It’s more static – you aren't including any micro movements from you jaw, neck or shoulder muscles.

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?

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.

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?

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 among Ménière's patients 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. 

credit to Shayne Town and his Meniere's in Art facebook page

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 Tinnitus (perception of sound when no external sound is present)?

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.

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!

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.

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."

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.

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.

Understanding the problem itself helps a lot though. So there's that. Gradually stabilizing my visual world is helping to take a lot of that uncertainty away. 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!

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!

Looking back at 2014 and looking forward to 2015

I 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.

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!

It might have to be the next Christmas, or the one after that,
but I will get what I'm after.

VIDEO: Current convergence status + The 'time-of-day-effect'

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. 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.

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.

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.

The first video was recorded around 6PM on December 11th, 2014. I was already quite tired when recording this video so the problem is very noticeable.

The second video was recorded around noon on December 13th, 2014. 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.

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.

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 'Convergence Insufficiency, how hard can it be?' but I admit it's a b*tch.

PS: It's my birthday! :)

Check-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.

This is my current Rx.
OD: +2.50
OS: +2.50 cyl -1.0 axis 35°

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 haploscope 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 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. 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).

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.

Revised 'timeline' - Last surgery was in August 2009

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.

In order to add more perspective, I'd like to translate and paraphrase some of the conversation I had with him in Dutch.

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?"

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."

MICHAEL: "I'll have to make it happen then."

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."

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."

Session 80: Large rope circles projected on the wall

After 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 polarized quoits vectograms 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!

This brings me back to the goals I stated in July 2014. 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.

I'm also working on procuring Rapid Alternating Occlusion Goggles 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!

Session 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 'Doing time' two years ago. Last week I asked my Vision Therapist whether I could try the AR again to verify.

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.

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.  

Good. This is where binocular vision problems come to die a slow and painful death. 

The story of Ilaria Invitto: 'Vision Wars in Medical School'

"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?" - Ilaria Invitto

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.

Ilaria and her mother

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!

Ilaria and her sister Serena

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?

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.

https://www.facebook.com/AskaDoctorofOptometry

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?

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.

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 anxiety, panic attacks and depression.

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...

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. Fortunately I discovered Fixing My Gaze on the internet. How did you break the dead lock?

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 Susan Barry's Fixing My Gaze. 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.

MICHAEL: What did you do with this new information?

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 Revital Vision. 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.

...

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 Rino Gattuso.

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!

MICHAEL: That's an insane amount of traveling. I hope it's worth it!

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.

MICHAEL: Wow, the floating circles are a very nice first step considering you only started VT in April. That's awesome.

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.

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.

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?

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!

Notice the lack of reflection
in the right eye

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.

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!

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 renounce or give up, just postpone for a little while to come back even stronger.

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.

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?

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.

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?

ILARIA: Hahaha. That might be true when being angry. Maybe the Corleone bodyguards have a point there.

However, to get back to your question. A specific activity that helps me cope with my vision problem is singing. I'm in a Vocal Ensemble 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!

una publicación de Ilaria Invitto.

MICHAEL: That's beautiful! I'm glad you are able to vent your frustrations and emotions in such a graceful way.

ILARIA: Yes, I need to upload some Italian or Latin songs now that I think of it.

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!