Session 72: In pursuit of more speed, accuracy and consistency

The foundation has been put in place. Finishing it up by perfecting the collaboration between vergence (eye movements) and accommodation (manipulation of the eye lens by your tiny muscles in the eye) and increasing capacity will be the closing deal. Major physical restrictions have been largely eliminated. More speed, more accuracy and more endurance. These will be the stakes as I move towards normal functionality. The time that I could not even participate in certain training activities has passed. Finally most activities are accessible and progress will, rather than being merely damage control and laying foundations, start to improve daily function and influence the way I can interact with my environment. Things are about to get extroverted instead of introverted.

“When vision is working well, it guides and leads; when it is not, it interferes.” - John Streff

The coming year we will go over that speed bump and make my vision guide and lead rather than interfere with my behavior. Right now my vision deficits still monopolize my life but I can feel and imagine how it will be as I gradually break through that 'visual firewall'.

Not only are all exercises accessible now but I'm making tangible, numerical progress at them and we can compare it to 'the standard values'. Before I also made numerical and tangible progress but it was still so subpar it sometimes seemed a Pyrrhic victory. At this time, I have entered the charts approaching normal function. This is totally new and makes it more fun. It's a game, not a tragedy. Three years and five months into the game I feel as optimistic as ever. Everything indicates a successful outcome and things keep moving into the right direction. When (eye) muscle tone, visual input and sense of balance will be synced up, I'm in for a major brain fart.

When testing my abilities on the biopter, both divergence and convergence, I could successfully execute up to slide 5 (out of 8), whereas last year I'd be stuck at slide 3. Well, pre-VT I'd be stuck at slide zero. :D

When playing with the vectograms today, which are supposed to bring out stereopsis if you already possess that skill, I was asked to 'grasp' the portrayed characters. If percieved correctly with the polarized glasses they would be floating midair. I don't see them floating at differing distances but when grasping for them my arm movement apparently more or less reflected the appropriate distance, or at least the right hierarchy.

*Spoiler alert* The king was closest, the monopoly guy furthest and the girl in between in terms of 3D distance, if I'm not mistaken. So there's that intuitive feeling telling me something based on my vergence movements I suspect. They are still too sloppy to be good, but we'll deal with that over the next year. Can't wait to put the cherry on that visual cake. I've been told Americans put cherries on everything. On top, on cakes, on your lips, in the fridge... Wherever you put it, I'll put it there.

Next time: "Standing on your head, yoked prisms and prism flippers".

Things that make you wonder...

This morning I went for an eye-hand basketball training session at the local public basketball court. Near point fixation for better reading skills is my priority but you can't focus on that all day because then it gets counter productive. On the court next to the one I was occupying there was a tall, black kid also throwing some baskets etc. We just did our thing, observing each other.  I'm pretty good at throwing baskets and dribbling, even if I say so myself. I don't look at the ball when I'm dribbling because I can just do it based on the sound, I think. That's nice. After a while he asked me whether I wanted to play a one-on-one match as our levels seemed compatible.

I explained to him that I was recovering from a brain injury and I just throw baskets as a way of 'entraînement visio-manuel'. My vision is not fast or consistent enough to react to too many unexpected changes so I have to play calmly. Sometimes my vision still goes double and I tire easily when losing control.

That's the big difference between him and me. Even without stereo vision I look as descent a player as him but my visual skills are not subconscious and automatic enough to deal with fast paced situations.

As a kid I've always been above average when it comes to football (soccer) and basketball. I was a natural at running and could easily do 5 km in under 20 minutes. Of course running is the only sport which doesn't require much spatial vision so that's why I was good at it.

Because that guy seemed to be taking his training regimen seriously I figured he played professionally. He did. He played in the junior team (younger than 21) of one of the major Belgian clubs. He asked me whether I played for a team, which I don't and never have. He just answered 'Really?'.

That stuff really makes one wonder... Take the strabismus out of the kid and he just might be a professional athlete in whatever discipline. But I'm not deterred. I'll just eliminate the strabismus, go back to being 18 and do this thing! :D Get those visual skills in order and you can do just about anything.

What many people don't realize is that vision is not only about eye sight, but just as much about action, integration, perception, reaction, ... A continuous and crucial loop of information.

"The visual system is a covert system, where the process and outcome are evidenced not as “visual”, but as motor or verbal outputs."

You need good visual input for good motor output, but you need good (ocular) motor abilities for proper visual input. If something goes wrong in that loop the whole system is sub-optimal and can even destroy itself trying to compensate for a weak link in the chain leading up to a burn-out. True story!

I wonder what stereo vision would do to my game. Probably I'd have to get used to it first but would then result in major improvements. We shall see.

What about strabismus and anxiety?

A few months ago I started working on a blog entry called 'Vision and the limbic system'. I was going to blast you guys away with brain regions, circuits and neurotransmitters so we'd all go tell our friends how cool this is and how  it explains everything in the known universe. So that entry was just sitting there in the draft section waiting for its Nobel Prize when our strabismic buddy Connor (21) popped this simple question:

Question! Do any members of the group with strabismus experience anxiety? Do you think the anxiety is a symptom of the strabismus?

Upon this question I decided to keep it real and say something meaningful about this subject instead of dissecting it like a dead frog.

To formulate an answer I will be drawing on my own experience, neuroscience/neurology courses I've taken and visual rehab books I've read/listened to.

It must be said, the visual system and limbic system: big marriage, grand ceremony, long-lasting relationship, potential for beautiful off spring and all that kind of stuff. It's the holiest of unions. Hallelujah! But how exactly do our feelings and vision relate?

Some people think of strabismus as a cosmetic problem which does cause its share of social anxiety. It's annoying and awkward sometimes. Certainly. Although the problem goes much deeper than that. I do feel anxious sometimes but I don't look very strabismic anymore. The anxiety comes from being acutely aware of the fact that I do not yet possess the visual skills to handle many situations effectively. This simply creates anxiety. That generated a follow up:

I've just noticed that sometimes I feel anxious for no reason, and when this happens my strabismus is worse. So I was wondering. Is the anxiety a symptom of strabismus, or is my strabismus a symptom of anxiety?

Since strabismus or vision disorders are head-to-toe problems, I'd say these are communicating sources. When one feels threatened or anxious, your brain makes short cuts and ponders less on the visual input it is receiving to make a potential reaction more timely. Your autonomic nervous system goes into sympathetic mode (fight or flight) and a whole bunch of attention resources are being relocated for other purposes than enjoying the view. On the other hand, when you are calm and are enjoying a parasympathetic state (rest and digest), you are getting more nutrients out of your food and the energy is distributed in such a manner visual input is processed more elaborately. In other words, your brain and body can invest in the future and build new capabilities rather than just having to survive.

Here's the catch 22. A defective visual system and impaired reading skills are a source of stress by itself. You are going to have to work harder to get things done. You are being excluded from many opportunities. Energy-wise you are not getting much bang out of your nutrient buck and so this vicious cycle grabs hold. With a vision dysfunction you can work yourself to death and still get nowhere even though you have above average intelligence (whatever that means). You try, you succeed, you try, you succeed, you try, you sacrifice everything, you succeed barely, the effort is increasingly disproportionate to the result, you keep working, surgery gone bad, keep working, another surgery to make up for the other one, you burn out, you partly recover, you keep working, you burn out again, there's no help to be found, you end up in prison or an insane asylum and lose everything. The end. Anxious yet? Treat the vision dysfunction appropriately when it presents itself and you can avoid this whole mess. Prevention, prevention, prevention.

One of the big challenges for me is to stay calm in a de facto underdog position but I'm getting it down. :) Contain the environment and get your juice back. Being anxious is a big waste of energy and slows down vision rehab, nevertheless it has to run its course and potential threats have to be handled with your primary goal in mind. Once you've depressed to a low key mood and are still not in prison, things do get better. Peace of mind is a great asset as the limbic system is the gate keeper of brain power but it's hard to acquire!

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How to make your own bar reader sheet

By Mike Robinson

Self-made bar reader sheets

"These are my homemade red/blue reading bars for getting both eyes working together. Wear red/blue glasses and hold it over your book or tablet. I got the clip on red/blue glasses and assortment of colored acetate sheets on Amazon. I cut the sheets into strips and, for the smaller one, I glued them onto a clear cd case cover, just using glue at the top and bottom. For the larger one I cut a hole in the middle of a file folder, put glue all over the inside of the folder, placed the strips so they're glued top and bottom and then closed the folder to stick it all together and make it more rigid."

Illustration of the principle that underlies
the practice of bar reading. One is forced to use
both eyes while reading otherwise
parts of the text are invisible.

You want more evidence? I'll give you some evidence right here.

“Every man can, if he so desires, become the sculp­tor of his own brain” - Santiago Ramon y Cajal (1852–1934)

Ever since I was four years old I've been cross-eyed (accommodative esotropia). My brain learned to suppress the image of one eye by turning the eye inwards. Over the years my visual situation changed and expensive mistakes were made. If you want to read the entire story click here. After the last surgery I had very little control over my eyes and they tended towards exotropia although that highly depended on the viewing direction. Bottom line: constant double vision, restrictions in gaze and considerable convergence insufficiency. An esotropic brain in an exotropic-ish body isn't easy. Not workable, not livable, not good, ...

Here's a video I made on December 5th, 2011 showing how hard it was to converge my eyes. Not being able to merely converge while putting your full attention to the task is clearly going to ruin your every day vision, reading ability, energy levels and performance. How the hell did I graduate like this? At this point I was already in VT for a year and had already somewhat improved compared to my initial post-surgical starting position.

The second video was recorded on the 3rd of May, 2014. It's still pretty hard to converge but there has been huge improvement as you can see. In another year'll converge like it's nothing. The year after that even better!

This is three years and four months into VT. It is still all hands on deck to finish the job but progress is obvious. My brain is changing and my eye muscles are recovering and stretching. The better I see, the safer I feel. The safer I feel, the better I see.

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Head rotations, bar reading and bring on the prism flippers

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

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

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

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

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

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

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

All I ever wanted was to read well and comfortably

And I'll get it.

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

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

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

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