Tunneling—A Pervasive Vision Disorder

Tunneling—A Pervasive Vision Disorder

Tunneling—A Pervasive Vision Disorder
Jeffrey H. Getzell, OD, Evanston, Illinois

ABSTRACT

Tunneling, a form of exclusive concentration, is a common spatial adaptation. The patient seems to be solely aware of that on which they are centering and block or ignore all other sensory input. It is both a sensory and motor phenomenon that is pervasive in our culture and presents concurrently with all refractive, binocular, and monocular conditions. Tunneling is a common symptom of visual perceiving, processing, and performance issues. Tunneling affects all sensory systems and is caused by physical, physiological, or intellectual/psychological stress. The symptoms affect how we think, speak, listen, and move. If tunneling is not addressed, it can effect an individual’s ability to see the bigger picture quickly and easily.

Keywords: attention, exclusive concentration, spatial projection, tunneling

Introduction

Tunneling is defined as a form of exclusive concentration. We are centering on a target and restricting or ignoring awareness of all other sensory input. Tunneling reduces peripheral awareness, and to the extreme, reduces focal awareness. Essentially, in moderate to high degrees of tunneling, people lock into the task, visually paying attention to the central visual field or a portion of the central field, and ignore all other sensory information. Whether they are diving and locked in on the wonders of the undersea world or are only attentive to the computer screen, there is a reduced spatial volume. It is pervasive in our culture and a common symptom of visual perceiving, processing, and performance issues.

In my over 40 years of optometric practice, I have become more cognizant of the high number of patients who tunnel. The following characteristics of tunneling stand out:

  1. Tunneling is a subconscious spatial adaptation to reduce the information the individual handles. The individual is either overwhelmed with information or has trouble sorting out the significant area for attention.
  2. It is a sensory and motor phenomenon impacting perception, processing, and performance. It is a sensory phenomenon in that we ignore or block out information. It is a processing phenomenon as we subconsciously preclude our attention, and it is a motor phenomenon in that it can affect us posturally. For example, when we reduce our peripheral awareness we tend to lean forward as we walk (toe walker) or we can be unstable.
  3. It is pervasive in all refractive, binocular, or monocular conditions.
  4. It causes a wide range of symptoms affecting how we think, speak, listen, and move.

The signs and symptoms of tunneling will be discussed later; the following discussion demonstrates how tunneling permeates life. A current patient of mine, a 38-year-old high school science teacher, was referred by an optometrist because of nearpoint stress. During the evaluation, it became evident that the patient was tunneling. As I explained my observations, the patient realized the true extent of her vision problem and how it permeated much of her life experience. She related the following very frightening incident that had occurred while scuba diving:

“It is difficult and even dangerous to dive if you have a tendency to tunnel and are not aware that it occurs. I started diving a few years ago. It is recommended that one always dive with a buddy. This is a good thing because it has helped keep me alive. I remember once being so excited after I had spotted a turtle at the surface that I tried to get to it quickly. I began ascending too fast which is not good because of dissolved nitrogen. Both my dive computer and my dive watch sounded the alarm, yet I never heard either of them. My buddy could hear them going off from a few feet away but I never did. I was concentrating too much on the turtle. Finally, I realized my dive computer’s reading, and it was the reading that saved me as I saw the words ‘slow down, slow down …'”

It is natural to center on a target so that the rest of the field becomes the background.

Table 1: Signs and Symptoms of Tunneling

  • We lock in on the road in front of us and miss our exit sign.
  • We call someone several times to get their attention when they are reading, working on a computer, or watching TV.
  • We go off on tangents in conversations, failing to keep in mind the bigger picture.
  • We answer a question, but we are not responding to the question being asked. That is, we have locked into part of the information in the question and are ignoring all the other content.
  • There is difficulty making transitions, e.g., the child or the adult who blocks out everything else while engaged in an activity and doesn’t like to be interrupted until it is completed despite time constraints or scheduling issues. It is as if time and space do not exist outside the activity for the person who tunnels.
  • There is reduced or lack of body awareness, e.g., unaware of shoulder, neck, or back tension from reading, writing, or computer activities until it becomes intense.
  • There is difficulty following multiple directions—this is the struggling of a very bright child or adult who locks into part of the information and ignores the rest and is misdiagnosed with central auditory processing problems.
  • The head moves up and down while speaking.

However, if we have sustained moderate to exclusive concentration or attention, it leads to maladaptations. For orientation, or being able to locate objects in space, we have to appreciate things in relationship to the environment in which they reside. When we cannot do that appropriately, we have difficulty staying in our lane when driving or staying on the line when writing, we miss the ball when we swing, and we lose our place when reading, for example. Table 1 shows the signs and symptoms of tunneling.

A tunneling adaptation occurs because of physical, physiological, or intellectual/psychological stress. The adaptation is mediated through the visual process. An example of physical stress is when a student is placed at a desk that is too big and his head is too close to the desk top, leading to a shortened reading and writing distance. When that student is required to read for extended periods of time and does not follow visual hygiene guidelines, physiological stress occurs. Intellectual stress is found in a pre-schooler who is cognitively ready to read but who does not have the physiological visual skills to support comfortable and efficient reading without making maladaptations. An example of psychological stress is the high school student who becomes anxious prior to or during timed tests (standardized achievement tests) or lengthy reading assignments because they know they are slow readers or need to re-read for comprehension. The anxiety makes him unaware of what is going on around him and aggravates preexisting problems. A tunneling pattern is likely to develop regardless of whether the stress is chronic or acute.

Once the tunneling adaptation is made in a particular situation, it tends to become a generalized response to being in the world. Studies have demonstrated that stress reduces the amount of information we perceive through our vision or auditory processes. Hence, a universal reaction to stress is to reduce or limit input so we can cope with the world. Hans Selye, an endocrinologist, wrote about how we respond to a stressor; we can fight (engage the task) or flee, and the sympathetic branch of the autonomic nervous system becomes aroused. The parasympathetic branch of the autonomic nervous system then allows us to return to rest. A sympathetic or parasympathetic response produces a cascade of neurological and physiological responses under control of the autonomic nervous system, from changes in pupillary dilation to breathing. It is a nonspecific or generalized response to the perceived stressor. This can be perceived as fun or positive (a puzzle or thought-provoking book) or negative (a lengthy reading assignment for the person suffering with a binocular dysfunction or a receded nearpoint of convergence). Tunneling is a “fight” response and is driven by sympathetic arousal. Acute or chronic stress leads to the organism making an adaptation and being locked into that pattern as a generalized response to being in the world.

Below I have detailed how cognition, speech-auditory, and body awareness are affected by tunneling. One symptom of tunneling, moving the head up and down while speaking, is something you can demonstrate on yourself. While visualizing a person 10-15 feet away, count out loud backwards from 100 to 80 so they can hear you. As you count, move your head up and down. Then, repeat counting from 80 to 60, this time with your head being still. Typically, when the head is moving up and down, speech becomes softer, monotone-like, fragmented, or with pauses because of the effort to ignore the constantly changing peripheral input. This input can be disorienting, so we start to ignore the periphery. With the head still, the constant peripheral input is a stabilizing factor, and our speech becomes more fluent and often louder because of more accurate spatial projection, i.e., knowing where things are in space allows us to project our voice accurately. Competent spatial projection is derived from being able to center on an area of space and simultaneously sustain peripheral awareness.

In behavioral optometric terms, we are evaluating the organism’s competency at central-peripheral or figure-ground relationships and how it will impact cognition, as well as posture balance, movement, speech-auditory, and emotions and feelings. If the dynamic balance, or synchrony, in the central-peripheral relationship is not present, the central-peripheral relationship becomes compromised. Tunneling impacts thinking because we can become too central (focal vision) and focused on the details and then struggle to see things in perspective; or we can become too peripheral (ambient vision) and have difficulty perceiving the intra- relationships.

As previously stated, tunneling is a phenomenon regulated by the visual process, and it affects all sensory systems. We become so intent on that on which we are centering that our awareness of all other sensory input is diminished. This has massive implications due to the way we organize space; our vision serves as the foundation for how we think (abstract and conceptual learning), speak, listen, and move. Vision sets the stage for allowing an individual to select an area for attention and simultaneously see the space and objects around it. This allows humans to see the big picture. Thus, a competent visual system allows us to stay on the subject matter without going off on tangents. A visual system that has not developed properly with regard to being able to maintain figure-ground relationships will not be able to support abstract or conceptual thinking.

As a result, many of the patients that I see will go off on tangents or begin obsessing about things because they lose sight of the bigger picture. In addition, when given multiple directions, we can lock in on part of the information presented and ignore the rest. In my experience, I have seen it misdiagnosed as a central auditory processing problem. Also, we can trip, stumble, and bump or walk into someone or something because we have been inattentive to our surroundings. This tunneling behavior can be exhibited in thinking, speaking, listening, and moving through space.

Let’s relate tunneling to sports. In soccer, if the players are visually competent, they are able to center on the ball, see teammates and opponents, and predict where the ball is going simultaneously. When the player begins to tunnel, and thus compromises the central-peripheral relationship, they begin to see things in a fragmented or piecemeal manner and may eventually only lock onto a part of what is happening in the field of play. Consequently, the player is a step behind the action, or is out of position, and at worst becomes disoriented or overwhelmed.

As stated earlier, tunneling is present in all refractive states and binocular conditions. In my experience, with myopia and esophoria the field of view becomes constricted in all dimensions; the ground is reduced and details become squeezed together. I often observe myopic or esophoric individuals who see a world full of details and feel overwhelmed with all the information. Missing is the ability to see the details in perspective so they can be managed. To do this we need to be able to see the ground or the bigger picture. Myopia is a more natural form of tunneling, making it easier to reduce the information needing to be processed. In comparison, with hyperopia and exophoria, we see an expanded space world, but the world is flattened so the details or intra-relationships are difficult to select because they do not stand out. The hyperopic or exophoric individual will then tend to jump from one detail to another because of difficulty centering and seeing things in perspective. In either example, the organism is making an adaptation as a response to stress. This adaptation results in the patient living in a reduced-space world.

Operating in a reduced-space world will produce various motor and postural changes. For example, one might walk with smaller steps, round their shoulders, lock their knees when standing, and develop upper back, shoulder, or neck tension. Harmon’s work dealt with the postural changes evident with myopic and hyperopic refractive states. Harmon observed that a myopic adaptation would result in a forward shift of the pelvis, creating a backward tilt of the head, resulting in a chin up appearance and a feeling like the eyes are turned in. The hyperopic and exophoric adaptations tend to be more challenging to individuals. In my experience, patients with hyperopic and exophoric adaptations have a higher link to learning, reading, coordination, and organizational issues. Cognitively speaking, for these individuals to succeed, they subconsciously fragment space or tunnel, i.e., reduce the amount of information processed in order not to be overwhelmed in dealing with abstract or conceptual activities. In the physiological aspect, the complications of this adaptation for the hyperopic patient include moving the pelvis backward and the forehead forward, and the eyes feel like they are turned out. The exophoric patient adapts with the feet being turned outward, creating tension in the upper and lower back.

What is meaningful can be limited to what is directly in front of our faces; we ignore our surroundings. It is as if we are seeing the world through a telescope and do not see things in plain sight. For example, we cannot find our keys on the table amongst other objects or cannot find the ketchup bottle in the refrigerator if it is not directly in line with where we are looking. Another characteristic of those that suffer from tunneling is that they can be unaware of their bodies. They are unaware of visual adaptations made by the body unless pointed out to them, or their symptoms and/or resulting body or facial tension and adaptations have increased dramatically.

Body and facial tension is produced by concomitant body adaptations to the refractive state and binocular conditions. Anytime the head is moved from its neutral position for sustained periods, tension is produced. In addition, the change in the pelvic position creates tension in the back and legs. When we tunnel we typically do not feel the tension until it increases to a high amount or it is pointed out to us. For example, we have all seen patients who are sitting and turn their feet inward. As an experiment, sit with your feet turned maximally inward and then point your feet outward and feel where the tension is produced in your body. When we turn our feet inward there is tension from our feet all the way up through the body.

When we turn our feet outward, tension increases, but not to the level of turning our feet inward. Tension in the body is produced anytime we move away from the ideal dynamic or static posture. Myopia, hyperopia, exophoria, and esophoria are adaptations occurring for the most part due to a generalized response of being in the world affecting the operation of the mind-body.


Measurement and Testing of Tunneling

A wand is brought in slowly from the periphery in all the cardinal positions and halfway between the patient and the doctor, towards the patient’s midline position, so it would end up at halfway between the patient and doctor and in front of the patient’s nose if the silver wand came in all the way. Typically, if all the points where the patient can identify the silver wand are connected, a circle is formed. The size of that circle is then estimated, e.g., beach ball, basketball, volleyball, softball, baseball, or ping pong ball size. The diameter of the circular field can also just be estimated. The expected response is basketball to beach ball size. A smaller response zone indicates tunneling. The testing is then repeated with the other eye. Often one eye will have a smaller field than the other eye.

Using the same guidelines for doctor and patient positioning, with both eyes open for children under age 10, the child is instructed to look at the doctor’s eyes. The doctor brings in his or her index fingers slowly from the periphery and the patient is to say ‘now’ when he can see the fingers of each hand at the same time. Preschoolers typically don’t make a verbal response, but look off to one side when they see both the doctor’s fingers.

Another way of measuring tunneling is through the use of the Van Orden (VO) Star. Figure 1 is an example of a VO Star in a patient who is tunneling. The two vertical lines, which indicate the ortho position, are drawn in after the patient has completed the VO Star. The apices are connecting within the ortho position with an asymmetric pattern and greater tunneling on the right side. A patient who was unlikely to tunnel would have the apices meeting at the ortho position (Figure 2).

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Measurement and Treatment of Tunneling

Tunneling is measured in several ways. The easiest way to chart tunneling is through a syntonics field assessment or kinetic field testing. Another way is the confrontation test with Wolff wands. The patient and doctor are sitting 30” across from each other with their head at the same level. The patient has one eye covered. The wand with the gold ball is held at the doctor’s nose. The patient is instructed that the silver Wolff wand is going to be brought in slowly from the periphery while the patient centers on the gold wand at the doctor’s nose. The patient is asked to say ‘now’ when they can clearly identify the silver wand and not just when they are merely aware of it.

Consequently, in optometric vision therapy or training (VT), it is important to emphasize appropriate posture beginning with foot positioning. The feet are the foundation and support the legs. The legs support the torso and the torso holds up the head. The head is the center for the visual system. If the feet are not in the appropriate position, adequate posture becomes difficult to uphold, and body tension is created. Tension or tightening in general creates additional stress, resulting in more tunneling or lack of awareness. A detailed discussion of VT for tunneling warrants another article unto itself; consequently, the topic will not be addressed at this time, but in a future article.


Conclusion

In summary, tunneling is a widespread visual adaptation present in all refractive states and perceiving, processing, and performance issues. Tunneling affects how we think, speak, listen, move, speech-auditory, and emotions and feelings. If tunneling is not addressed in VT, we have patients who are more comfortable and efficient visually but who lack the wherewithal to see a bigger picture quickly and easily.


References

  1. Flach FF, Kaplan M. Visual-perceptual rehabilitation in psychiatric patients. Directions in Psychiatry 1983;3(10):1-7. http://bit.ly/FlachFF
  2. Hoopes A, Hoopes T. Vision and the Brain. Eye Power. New York: Alfred A. Knopf, 1979:42-75. http://bit.ly/EyePower
  3. Forrest EB. The Visual Stress Response. Stress and Vision. Santa Ana, CA: Optometric Extension Program Foundation, 1988:161-70. http://bit.ly/SressVision
  4. Kaplan M. Exophoria and Yoked Prisms. New Haven Seminar. New Haven, CT. 5 December 1992.
  5. Godnig EC. Tunnel vision its causes and treatment strategies. J Behav Optom 2003;14:95-9. http://bit.ly/Godnig
  6. Francke AW. Size Constancy–Part I. Introduction to Optometric Visual Training 1st ser. Optometric Extension Program Foundation, 1988;60:409-12. http://bit.ly/Fracke
  7. Francke AW. Size Constancy–Part II. Introduction to Optometric Visual Training 1st ser. Optometric Extension Program Foundation, 1988;60:445-6.
  8. Kraskin RA. Lens Power in Action. Santa Ana, CA: Optometric Extension Program, 2003. http://bit.ly/LensPower

Correspondence

Correspondence regarding this article should be emailed to Jeffrey H. Getzell, OD, at jeffgetzell@sbcglobal.net. All statements are the authors’ personal opinion and may not reflect the opinions of the representative organizations, ACBO or OEPF, Optometry & Visual Performance or any institution or organization with which the author may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2014 Optometric Extension Program Foundation. Online access is available at www.acbo.org.au, www.oepf.org, and www.ovpjournal.org.


Getzell J. Viewpoint: Tunneling—A pervasive vision disorder. Optom Vis Perf 2014;2(1):29-35.

A Process Approach to Treatment of Vision Dysfunctions

A Process Approach to Treatment of Vision Dysfunctions

A Process Approach to Treatment of Vision Dysfunctions
Jeff Getzell, OD • Evanston, Illinois

ABSTRACT
This paper will present a process approach to the treatment of vision dysfunctions with the use of lenses and vision therapy. The process approach views vision dysfunctions as syndromes, potentially impacting cognition, posture, balance, movement, speech-auditory,emotions, and feelings. Performance lenses can be prescribed for most daily activities. A set of office vision therapy activities is performed in free or real space, most often slowly, relying on feedback to create change. This process requires the trainer to plant questions for the patient to consider rather than informing them of what they should be seeing. Diaphragmatic breathing, “hanging onto space, and good posture are fundamental ot each activity. Balance and movement are emphasized throughout the program.

Keywords: diaphragmatic breathing, dissociating glasses, hanging onto space, multifaceted activity

Introduction

Vision is a complex activity that interacts with various other processes. The intra-acting processes include eye movements and location skills (saccades), orientation, centering, identification, peripheral-central integration, visual memory, and visualization. The interacting processes include vision and cognition, posture, balance, movement, speech-auditory, vestibular, emotions, and feelings. Each process modifies or shapes another. The human brain carries out wide-ranging parallel processing, which can be impacted by contrary emotions and motivational influences.

Impact of Visual Dysfunctions

Visual dysfunctions rarely affect just a few skills; they generally impact the entire body. Inadequate centering, identification, or poor eye movement and location skills often signify more complex problems. Vision dysfunctions can affect cognition and communication, and may lead to various physical imbalances like:

  • Head tilts or turns
  • Shoulder, neck, and back tension
  • Leg weight imbalances
  • Locking knees
  • Heavy-footedness, toe walking, or difficulty standing in place

These dysfunctions may also cause shallow breathing, fidgetiness, fragmented behavior, tunneling, procrastination, frustration, and anxiety.

Performance Lenses in Vision Evaluation

In my vision evaluations, when new patients don’t require or wear compensating lenses, I often notice compromised cognition, posture, balance, movement, and speech-auditory patterns. Performance lenses can quickly impact these patterns. Types of performance lenses include:

  • Low plus lenses
  • Reduced plus for moderate to high hyperopia
  • Reduced or eliminated cylindrical power
  • Small amounts of prism (0.254 to 0.504 range)
  • Binasal occluders, tints, and spot or sector patches

The profoundness of performance lens evaluations is evident in the visible changes in most patients. These changes include better balance, walking with increased speed, taking bigger steps, lighter footedness, more accurate voice projection, and reduced fidgetiness.

Interactive Visual Therapy Techniques

During the therapy, I typically guide patients through exercises where the doctor or therapist and the patient maintain a 1-inch space between their hands. The patient’s job is to keep this space consistent as the therapist moves their hands. Slow and controlled movements (6-10 inches in each direction) are made, and the patient is asked to focus on breathing and synchronization of hand movements. If a hand moves slower or there’s a delay, it’s a signal that more attention is needed.

The Process Approach to Vision Care

A process approach to vision care acknowledges that patients experience real and perceived physical, physiological, perceptual, intellectual, and psychological stresses. Vision can deteriorate in response to acute or chronic stress, and patients should be educated about maintaining healthy vision through:

  • Visual hygiene
  • Avoiding being overly focused on small details
  • Maintaining awareness of the bigger picture

Key Components of the Process Approach

The process approach involves several key principles:

  1. Posture, Balance, and Movement – Establishing these as the foundation for creating a new space world throughout the program.
  2. Incorporation of HOS – Using head orientation strategies (HOS) in all activities.
  3. Diaphragmatic Breathing – Ensuring patients use diaphragmatic breathing during all activities.
  4. Feedback and Feedforward – Employing activities that provide immediate feedback and opportunities for feedforward learning.
  5. Visualization – Engaging the mind’s eye to enhance performance.
  6. Working in Free Space – Performing exercises as much as possible in real or free space.
  7. Use of Lenses and Prisms in Vision Therapy – Maximizing the impact of lenses and prisms during therapy.
  8. Critical Questions – Asking the following questions during each activity:
    • What do you see?
    • Does what you are seeing change?
    • Can you change how you are seeing?
    • What helped you in this activity?

    If a patient has performed an activity over multiple sessions, they are asked how their approach has changed over time.

  9. Feedback After Activities – After each activity, the patient walks around and reports on differences in how they perceive space, how their body moves, and how they feel.
  10. Slow and Deliberate Practice – Activities are conducted slowly to maximize the effectiveness of feedback.

Conclusion

In vision care, even small changes can lead to significant improvements in patients’ lives. A process approach considers the whole person, integrating posture, balance, movement, and the use of lenses and prisms to address and improve visual dysfunctions. By focusing on feedback and visualization, patients can experience profound shifts in their physical and perceptual abilities.

References

  1. Karskni R. Lens Program Foundation, rwoePin n, Inc. Aoicnt. Sanat Aan Optometric 203. http://bit.ly/2U0ViD8
  2. Kaplan M. Seeing Through New Eyes. Jessica Kingsley Publishers, 2006. http://bit.ly/2BKBg8G
  3. Kaplan M, Flach FF. “Visual-perceptual rehabilitation in psychiatric patients. Directions In Psychiatry 1992;4(4):2-27.
  4. Getzell JH. The Power of Prescribing in Eighth Diopter Steps, Micro Prisms and Visualization. Great Lakes Optometric Congress, March 2012.
  5. Hoopes A, Hopse T. Eye Power: Improved Self-Awareness, Vitality, and Mental Efficiency Through Visual Training. Knopf, 1979. https://amzn.to/2U5vPIN
  6. Loher JE, Migdow JA. Take a Deep Breath. Villard Books, 1986. https://amzn.to/2BKDYuG
  7. Francke AW. Introduction to Optometric Visual Training, 5th ed. Optometric Extension Program Foundation, Inc., 1988. http://bit.ly/2U3Q2yE

 

Neurological Transitions

Neurological Transitions

Neurological Transitions
Jeffrey H. Getzell, OD, Evanston, Illinois

ABSTRACT

Neurological transitions occur when the patient’s style of vision does not match the changes they are making through vision therapy/training programs. As patients realign vision coordinates with postural coordinates in VT, the stage is set for a transition. In the realignment of vision with postural coordinates, unresolved emotional conflicts may come to consciousness.

This was first described in the literature by Larry MacDonald, OD. During transitions, patients undergo three passages, which often involve physical, physiological, and cognitive/emotional changes. The changes common to transitions include headaches, brain fog, fatigue, and body tension. Bruce Wolff, OD, a pioneer behavioral optometrist, created visual training procedures that intentionally provided the patient opportunities to develop a matching or re-alignment of the visual and kinesthetic through the use of dissociating or doubling glasses. The personal experience of children and adults going through a transition is described.

Keywords: brain fog, critical empathy, cybernetic principles, hanging onto space, performance lenses, transition.

The following viewpoint is on neurological transitions or simply “transitions.” This view- point is also based on my experience and conversations with Dr. Amiel Francke, as well as the late Dr. Antonia Orfield and her experiences in her unpublished book as a vision therapy patient of Dr. Francke’s. In an optometric literature search, I found only two articles on either transitions or neurological transitions. One was written by Dr. Larry MacDonald, providing a wealth of information.1

In my experience, patients who are using performance lenses, syntonics, and/or who are engaging in a visual training program develop new habitual behavior patterns. Performance, in many cases, significantly improves following the transition. It is my thinking that current neural pathways cannot incorporate all the changes, and new pathways or neural networks must be established.

Transitions have three passages, as have been described in psychological literature.2 The

first passage is a marked life change: e.g., divorce, loss of job, death of a loved one, or serious illness. However, from a vision perspective, it would be a significant improvement in performance that initiates the transition. The second passage is a period of chaos characterized by disintegration or breakdown, disorientation, or distress and psychologically referred to as an “identity crisis.”1 It is a disturbing experience for the patient and can be a challenge for a family to deal with. Adult patients can feel especially vulnerable. Finally, the third passage is a new orientation. The patient behaves and feels like he or she is better fit in the world, has an enhanced comprehension of the world, and has a more productive interaction with it; one could say the organism has created a more functional space world to meet the demands of life.3

In a conversation with Amiel Francke on June 13, 2014, the following was his description of a transition:

Optometry & Visual Performance 26

Volume 4 | Issue 1 | 2016, February

Dr. Getzell talks about his findings about transitions in Visual Therapy.

Transitions are the cumulative effects of training having produced a situation where the existing style of vision is no longer acceptable to the patient, and the patient has to change. In order to change, which the visual training has directed, they have to change not only their vision but also their support systems, primarily posture. As the patient changes and gets vision information in a totally new way, their thinking changes to match the new, more effective vision system. The change in the vision system allows the patient to process more information, be better organized, and work at a lower cost of energy. Therefore, thinking becomes broader in scale and better organized. This is stressful for the body, so the patient may go through a variety of physical changes, including but not limited to needing more sleep, increased appetite, and critical empathy (the point in which the patient changes; e.g., uncontrollable crying or laughing are the obvious signs, but can be rare). Critical empathy is the key component, and once they are through the experience of crying and laughing, they are a different person.

Larry MacDonald wrote a paper published in the Journal of the American Optometric Association.
The following are his salient comments:

  1. There is an optometric principle that a restriction of movement will be present with any vision dysfunction. The restriction or limitation can be anywhere in the organism.
  2. Primal therapy or bioenergetic medicine is founded on the belief that our muscles hold unresolved emotional conflicts. A realigning or matching of the visual and postural coordinates through visual therapy may bring these unresolved emotional conflicts to the forefront. MacDonald views the emotional breakthroughs, experienced as crying, laughter, nausea, or disorientation, as a marker of the progress in the successful completion of a vision therapy program.

MacDonald credits Dr. Bruce Wolff with recognizing early on the significance of the transition. Dr. Wolff labeled the nausea and disorientation responses as critical empathy, marking the point where the vision system is more appropriately reorganized and realigned with the postural coordinates; a new space world has been created. Dr. Wolff created visual training procedures that intentionally provided the patient opportunities to develop a matching or re-alignment of the visual and kinesthetic systems through the use of dissociating or doubling glasses. The activities were founded on cybernetic principles: i.e., “goal-seeking, self-directing and self-correcting.” The activities that Dr. Wolff created include Wolff Pursuits and Prism and Dowels. I believe that Dr. Wolff was saying that vision therapy allows the patient to develop awareness of space and self, providing the opportunity for the patient to direct self and to make more efficient responses.

In my experience, this means allowing the patient the freedom to see and to experience through exploration rather than planting answers in the patient’s head. This can be done by asking questions like:

  • “What do you see?”
  • “What changes did you notice?”
  • “What were you more aware of today?”
  • “What helped you make changes, or what did you do differently that led to an elevated level of performance?”
  • “How is this different than last time?”

The aforementioned allows the patient to take an active role in reorganizing their visual process and space world; therefore, it is referred to as goal-seeking, self-directing, and self-correcting.

There are at least nine different pathways or neural networks carrying information from the retina, which is all brain tissue, to other areas of the brain. These areas include the following:

  • Arousal
  • Visual orientation
  • Spatial attention
  • Visual-spatial ability
  • Higher-order control of body-centered action
  • Recognition
  • Language
  • Memory
  • Emotions and personality

One could conclude from the pervasiveness of vision in the brain that vision plays a significant role in when and where we do things: e.g., hitting or catching a ball, forming and spacing letters and words, stepping on the gas or brake pedal, reading fluency, and voice resonance. In addition, it seems that speech and language are one word at a time, while vision is global. From my perspective, through the function of vision, we see beyond the word or words at which we are looking to visualize or to comprehend. We learn to see the bigger picture; to organize a lot of information simultaneously; to anticipate; and to learn to speak, to write, and to read coherently and with fluency. When a patient is experiencing a transition, all of the above examples and much more can be affected because of the pervasive presence of vision throughout the brain.


The following lists of transition signs have been assembled from over 40 years of experience working with patients in vision therapy:

Signs of transition for an adult:

  • Flu-like symptoms: body achiness and fatigue
  • Brain fog: i.e., mentally not feeling on top of things, feeling like when you don’t sleep much and the day after you are in and out of a daze; you cannot think, someone asks you a question and it takes you forever to think about and answer the question; awareness in general is compromised
  • Unresolved emotional conflicts come to the forefront
  • Hunger
  • Headaches
  • Lethargy
  • Smaller functional visual field—more tunneled
  • Harder time starting activities and transitioning from one activity to another
  • Word retrieval issues
  • Loss of coordination—tripping, poor balance, bumping into things
  • Tendency to be startled (because of tunneling)
  • Visually: everything gets blurrier, peripheral vision is gone, so it feels as though one is looking through a tube, visual fields decrease greatly
  • Postural and body changes: less aware of body and posture, slouch—shoulders rounded, head is forward, sway back—belly forward
  • Emotionally: feel either completely numb or unresponsive, or could be very touchy-feely (uninhibited emotionally/demonstratively emotional) and everything makes you want to cry, very sensitive
  • Less of a sense of being calm and organized, more impulsive, not thinking ahead
  • Nausea

Signs of transition for a child:

  1. Timing off: e.g., stuttering, reading with lack of fluency and proper voice inflection
  2. Spaciness: e.g., forgetful of what one is doing
  3. Behavior returns to a less mature level
  4. Irritability
  5. Hunger
  6. Takes a long time to get going
  7. Thinking slows down
  8. Clumsiness
  9. Tantrums

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The following is one parent’s description of her 9-year-old son going through a transition; his symptoms were aggravated during the transition:

My son, Patrick, has been seeing Dr. Getzell for almost 6 months of in-office Dynamic Vision Training, as well as carrying out a home program, which includes various exercises along with wearing glasses as prescribed. Throughout the last six months, we have noticed an improvement in skills within various areas. Yet, there have been challenging times during these months where we have seen a regression in skills, which Dr. Getzell refers to as transitions, or periods of neurological growth.

In general, my husband and I find that transitions are marked by an intense magnification of the very behaviors and concerns that brought us to seek out vision therapy for Patrick: in particular, extreme anxiety, lack of focus, egocentric perspective of the world, hyperactivity, mindless chatter, and poor reading and comprehension.

Here are some of the red flags that indicate Patrick may be going through a transition:

  • Patrick will jump out of bed, not paying attention to anyone else in the house. He will stomp through his bedroom, slamming his closet doors and drawers as he gets dressed. He will throw his pillows and stuffed animals across the room as he makes his bed, all the while not realizing the rest of the house is still asleep or that he just woke everyone up.
  • Patrick will be shouting, singing, or talking very loudly to himself, not paying attention to anything else around him.
  • His morning routine becomes very disorganized and slow. He will need multiple reminders and prompts as to what he needs to do next. He will spend long periods of time staring off into his closet as he is supposed to be getting dressed. He will have a hard time finding his belongings and will ask where things are, even when they are right in front of him.
  • Patrick will skip, hum, sing, dance, or be silly, or he will be talking constantly or asking questions, often interrupting others, and looking for his needs to be met immediately.
  • Patrick will pose questions that he knows the answers to or that have obvious answers. We call it “lazy brain.” He asks a question, looking for someone else to answer or cue him through the activity/information rather than trying to process the information or problem-solve on his own. He is seeking immediate gratification and dependency.
  • His constant conversation is filled with anxiety and fear. He will be stuck on the “what ifs” of the world. His anxiety is so significant that everything is questioned or feared. Even things that have such a minute probability of occurring are brought up.
  • Patrick looks for reassurance from others to comfort his thoughts, feelings, and actions rather than independently evaluating them.
  • Along with his anxiety, he becomes incredibly emotional and sensitive. If others around him are not empathetic towards his concerns, he will get his feelings hurt, become frustrated, or start crying. He becomes hypersensitive to others’ body language, facial expressions, or tone of voice.
  • All of his academic, gross motor, fine motor, and social-emotional skills regress. His teachers have commented that he becomes more disruptive, lacks focus, appears confused, won’t follow the rules of the classroom, loses sight of daily routines, and will ask obvious questions.
  • At home, Patrick will behave in one of two extremes: “spaced out,” confused, flat, and fatigued; or hyper and in mindless motion.
  • Depending on the duration and intensity of the transition, Patrick’s feelings of anxiety move to depressive thoughts, feelings of inadequacy, insecurity, and lack of sense of belonging. His perception of himself is unrealistic and doesn’t match what others see in him. Again, he will seek reassurance and input from others to help him find his own self-worth. He will take on the words and feelings of others as his own.
  • Finally, his temper is short. He becomes angry, irritated, and frustrated much quicker, and in turn, will react in less than appropriate ways to seek resolution.

After Patrick moves through a transition, he shows maturity in many areas. He becomes more aware of others around him, more empathetic, and has less tendency towards wanting to be the center of attention. He interacts more reciprocally when socializing and may even ask how your day was, and then he listens and cares about the answer. He is more relaxed and seems more at peace within his body. He has an increased ability to assess his own performance and/or efforts within an activity. He relies less on outside sources to help guide him towards an answer, and he appears more confident with his own feelings and choices. Patrick requires less prompting while doing things. Additionally, he will do things when asked the first time, and he spends less time in what we call “Patrick World,” or in a state of mindlessness. Overall, with each transition, Patrick gains the ability to act and interact in a more thoughtful, efficient, and planned-out manner.

The following is a report from the parents of a 5-year-old and their experience with her transitions:

Rebecca is a 5-year-old girl who started vision therapy almost a year ago. Prior to receiving therapy, her parents noticed that she was afraid of her environment and was very socially reserved; she also had a speech delay. For instance, she would hold on to her parents when walking on the sidewalk, afraid of all the sights and sounds. In preschool, she would not participate in most of the activities and would mostly stare off into space. It was very hard to drop her off at school because she would cry continuously, afraid of being left alone.

When Rebecca is in transition (and there have been multiple transitions), it is extremely taxing for her. She begins to whine much more and has almost incessant bouts of crying. Her speech becomes much more stammered, and during her birthday a few months ago, she stuttered so much that her face grimaced and contorted just to get the words out properly. This stuttering was particularly unnerving because we were unsure how long it would last. It was very difficult for her to communicate, and the transition was very hard. This lasted for about two weeks. During her usual transitions, Rebecca has very little patience and is not placated by what she wants. For instance, if she wants to play with a toy and it is given to her, something is still wrong with it or how she is interacting with it, so she is still whining and usually crying about some aspect of it. During this time, it is best not to reason with her because she cannot process this, and the best thing to do is to embrace and love her and make her feel secure. Sometimes, she might cry and whine for the majority of the day. What helps in general is taking her outside and letting her enjoy the sunshine and freedom of movement; usually, she seems to calm down and is a bit more fluid when she is outdoors and not confined indoors. The hardest part of the day when she is in transition is the bedtime routine. Usually, her equilibrium is not wanting to go to bed, so when you superimpose a transition onto that fact, we usually get a very prolonged and protracted bedtime routine punctuated by resistance, whining, and crying.

After her transitions, Rebecca usually gains some aspect of her personality that was previously not seen before. For instance, after her incredibly difficult stuttering transition, where her face contorted, her sentence structure became more complex, and she had more fluid speech. After another transition, she became more empathetic and expressed more love toward her parents. We feel that with each transition, Rebecca is gaining some aspect of her personality, but they are incredibly difficult to deal with, and the randomness of them has not diminished.

The following recommendations are made when patients, both adults and children, are going through a transition:

  1. Get plenty of rest.
  2. Limit or avoid reading, writing, computer work, or near hobby/craft activities.
  3. Walk a lot and work on “hanging onto space” (simultaneously be aware of the space around you as you center on a distant target) to integrate the new changes.
  4. Suspend home training.
  5. Unresolved emotional issues often come to the forefront during transitions. Please arrange to talk with a friend or partner. The person you choose to speak with needs to be a good listener, or please request that they really listen to you. Through your own speaking, you will be able to see a bigger picture and work out the unresolved emotional issue.
  6. Please inform the doctor when you are experiencing a transition so he/she can guide you through it. A progress report may need to be scheduled following transitions because lens changes may be necessary to support all the visual changes being made.
  7. When overwhelmed, listen to whatever music you find soothing.

During office vision therapy, patients undergoing a transition may find that their performance can vary widely. Some patients can do quite well, while others will struggle. The following is the experience of an adult vision therapy patient following a transition:

After the big transitions, I’ve noticed a relief and an ease come back to me. But when some transitions are over, the only thing I realize is that the symptoms are gone—headaches disappear, I regain a bigger visual field, etc. During training, I notice things are easier. I remember one week one pair of dissociating or doubling glasses was so much easier than the other, and after or during the transition, the other pair was easier. Coordinating the many things together in training gets easier—breathing, being in control of my body, feeling the effects of wearing the glasses, etc. In general, I’m continuing to notice and be appreciative of 3-dimensional space—for example, snowstorms or walking down a street where the trees are budding in spring bring much more depth and beauty.

Another adult patient reported the following after a transition:

• Feel sharper mentally
• Energy levels go higher
• Feel more motivated
• Feel more grounded and balanced • Visual fields open up a lot more

Here are the above patient’s further comments:

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Transitions for me come in two forms: I can be emotionally numb, apathetic, non-responsive, and slow-processing, or I can become more emotionally sensitive than usual, meaning I feelemotionsintensely:compassion,empathy, hurt.Iwouldn’tsaythatparticularunresolved emotional conflicts come up; if anything, I am more sensitive to whatever is happening at the time of the transition.

In my experience in practicing behavioral optometry, transitions come about when patients use performance lenses, and/or are treated with syntonics or VT. Performance lenses in my practice are reduced powers with or without low-power prisms, tints, or binasal occluders for patients normally wearing compensating lenses. For patients not requiring compensating lenses, low-power lenses with or without low-power prisms, tints, or binasal occluders are prescribed. Initially, these latter patients wear their lenses full-time and then for classroom and at home for near-point activities, including computer tasks. The patients utilizing compensating lenses continue using them for driving if necessary, and the rest of the time they wear their performance lenses.

Performance lenses and syntonics, in my experience, can have an immediate, dramatic, positive impact on behavior, resulting in a transition. I find that performance lenses can immediately reorganize cognition, posture, balance, and movement, as well as timing in general. Syntonics in balancing the autonomic nervous system can quickly set the patient up for a transition. Vision therapy, on the other hand, produces changes more slowly, and it takes longer to integrate all the changes the patient is making. However, it is with vision therapy that I see the greatest number of patients reporting transitions.

Again in my experience, (Dr. Orfield referred to my vision therapy program as a “motor based program”) both children and adults

Optometry & Visual Performance

employ movement throughout the program. I work with patients primarily in real space with limited use of instruments (overhead projector) or two-dimensional spaces (chalkboard or dry-erase board). I think the combination of emphasizing movement throughout the program and working in real space with lenses and prisms creates transitions.

A former visual training patient of mine, Dr. Richard Harris, a Chicago psychiatrist, wrote the following about psychotherapy and visual training:

Freud was initially a neurologist. He noticed patients with unusual symptoms—blindness, paralysis—later called hysterical blindness or paralysis. The idea is that certain emotional intensities manifest in the body as apparent neurological symptoms. The process of psychoanalysis is a form of regression. In other words, the environment is set up to induce regressive functioning for the purpose of healthier reorganization. Just from the perspective of the patient lying on the couch without any eye contact with the doctor, the experience is a form of sensory deprivation, akin to a sensory deprivation tank. Such deprivation opens up other channels of experience. The idea of regression is also seen in the first homework assignment I had from you—creeping. So psychoanalysis and vision training could be seen as a form of planned disorganization for the ultimate goal of reorganization.5

In vision therapy, optometrists create a mismatch or disorganization with yoked prisms, and the patient’s mismatches (disorganization/misalignment) are revealed to them through dissociating glasses. Many years ago, I was working with a patient on the Prism & Stick activity. The patient is wearing vertical doubling glasses and looking back and forth from a near target to a distant target in a space 8-15 feet long and 5-10 feet wide. Ideally, the patient eventually appreciates the

32 Volume 4 | Issue 1 | 2016, February

whole space changing as a unit as he or she looks back and forth. When the patient I was working with all of a sudden became aware of the height changes, she started crying and lied down on the floor, assuming a fetal position. The patient reported that becoming aware of the space above her brought memories back of the difficult relationship with her father. This same patient had remarked to me at an earlier session during another activity, “Don’t the walls move when I move?” Obviously, this patient was tunneling and ignoring the periphery, leading to real confusion in her life. The crying and moving into a fetal position is a critical empathy response. The patient is acknowledging and feeling or commiserating with their own pain, which up to now had been stored or locked in their muscles.

Patients and families in my practice have reported that transitions can occur at any time during the treatment process and can last a few days to a week. Occasionally, transitions can go on for longer periods, and patients can have multiple transitions. I have found that older teenagers or adult patients who struggle with self-examination will often have longer and more numerous transitions. The same occurs with children with longstanding vision dysfunctions. Additionally, in my experience, patients with longstanding vision dysfunctions often develop secondary emotional adaptations, e.g., avoidance or procrastination with near point activities, difficulty with moving from one activity to another, avoiding group situations, etc. I find that following the completion of visual training, it can take up to a year for all the changes made to integrate into patient behavior. Transitions can occur during this period as well.

Because patients can experience challeng- ing transitions, it is obligatory to discuss transitions with adult patients and the parents of child patients at the start of therapy or even when performance lenses or syntonics are first begun. In my experience, it is only occasionally that patients need to be referred for psycho-

Optometry & Visual Performance

therapy. However, the example of the patient who had the critical empathy response was one I did refer. Over many years, I can only remember referring out two patients because the transitions the patients were experiencing required more help than I could offer.

I have found that if a progress evaluation is done while the patient is in the midst of a transition, the findings will be unstable. It is best to wait a week or two and then re-evaluate.

In summary, transitions are routinely seen in my practice and are indicative of developing a more effective functioning vision process. Transitions are typically brought on by a realignment of visual and postural coordinates. In vision therapy/training, yoked prisms and dissociating glasses are primary tools in bringing transitions about. A transition is often an emotionally trying experience for patients and families, but it is a stepping- stone to remarkable changes.

References

  1. MacDonald LW. Implications of Critical Empathy, Primal Optometric Visual Therapy. In: Schwartz I, Shapiro A, eds. The Collected Works of Lawrence W. McDonald, O.D., Vol. 2. Santa Ana, CA: Optometric Extension Program, 1993:148-57. http:// bit.ly/1QmOhCM
  2. Bridges W. The Need for Change. In: Bridges W. Transitions: Making Sense of Life’s Changes, 2nd ed. Cambridge: Da Capo, 2004:8,75-76,123. http://amzn.to/1SZEkjj
  3. Bridges W. Change and Transition. In: The Way of Transitions: Embracing Life’s Most Difficult Moments. New York, NY: Perseus, 2001:3-4. http://amzn.to/1W6IZiG
  4. Helvie R. Neural Substrates of Vision. In: Suter PS, Harvey LH, eds. Vision Rehabilitation, Multidisciplinary Care of the Patient Following Brain Injury. Boca Raton, FL: CRC, 2011:60. http://amzn.to/1ltitfV
  5. Freud S, Breuer J. Studies on Hysteria (Penguin Classics). New York, NY: Penguin Books, 2004. http://bit.ly/1WepOni

Correspondence regarding this article should be emailed to Jeffrey H. Getzell, OD, at jeffgetzell@sbcglobal.net. All statements are the authors’ personal opinions and may not reflect the opinions of the representative organizations, ACBO or OEPF, Optometry & Visual Performance, or any institution or organization with which the authors may be affiliated. Permission to use reprints of thi s article must be obtained from the editor. Copyright 2016 Optometric Extension Program Foundation. Online access is available at www.acbo.org.au, www.oepf.org, and www.ovpjournal.org.

Getzell J. Neurological transitions. Optom Vis Perf 2016;4(1):26-33

33 Volume 4 | Issue 1 | 2016, February

 

Vision Therapy Procedures for Tunneling

Vision Therapy Procedures for Tunneling

Vision Therapy Procedures for Tunneling
Jeffrey H. Getzell, OD, Evanston, Illinois

ABSTRACT
Tunneling is a form of an exclusive concentration and is a common spatial adaptation. Treatment strategies for tunneling and the overall visual process will be addressed. Strategies include diaphragmatic breathing, syntonics, and vision therapy activities that stress working in real space with lenses and prisms. Objectives, observations, expected responses, modifications, and questions for the patient are discussed for each vision therapy activity.

Keywords: aniso glasses, diaphragmatic breathing, dissociating glasses, hanging onto space, tunneling

Vision Therapy Procedures for Tunneling

Tunneling is defined as a form of an exclusive concentration and is a common spatial adaptation. The patient seems to be solely aware of that on which they are centering and blocks or ignores all other sensory input. It is both a sensory and motor phenomenon that is pervasive in our culture and presents concurrently with all refractive, binocular, and monocular conditions. Tunneling is a common symptom of visual perceiving, processing, and performance issues. Tunneling affects all sensory systems and is caused by physical, physiological, or intellectual/psychological stress. The symptoms affect how we think, speak, listen, and move. If tunneling is not addressed, it can affect an individual’s ability to see the bigger picture quickly and easily.1

Impact of Stress

Before the treatment of tunneling is described, there are other factors that need to be discussed. A highly significant factor is the impact of stress on the individual. The stress can be physical, physiological, or intellectual/psychological. Regardless of the source of the stress, in my experience, these individuals exhibit diminished breathing; more specifically, chest breathing, shallow breathing, or breath holding becomes apparent. In addition, individuals under stress begin to constrict their visual fields.2 It is a functional field constriction as opposed to pathological change. Consequently, the foundation for treatment of tunneling and associated vision problems includes diaphragmatic breathing and “hanging onto space.”

Diaphragmatic breathing is emphasized for all office and home vision therapy (VT) activities. It is recommended to inhale and to exhale through the nose. For children, we ask them to pretend that they are taking in air through their nose and blowing up their belly like a balloon. For some patients, diaphragmatic breathing is begun in a prone position with hands on stomach and fingertips touching. As we inhale, the fingertips should start to move apart, and then they should come together as we exhale. The chest should remain still. Inhaling should take at least four seconds and exhaling about six seconds. As patients become more skilled in breathing,inhaling and exhaling for 8-10 seconds or more is achieved. It is important not to hold our breath because this creates stress. We are striving to regulate our breathing. Diaphragmatic breathing not only allows us to be calmer and provides oxygen to the brain for conscious activity, but it also allows us to regulate movement.3 Diaphragmatic breathing can be easily incorporated in office and home activities.

The other fundamental is “hanging onto space.” When hanging onto space, we center on an object and should simultaneously be aware of our surroundings, i.e., the total spatial volume, including the space behind us. In my experience, space develops in the following sequence: first, forwards or away from us along the Z-axis; second, sideways along the X-axis; third, up and down along the Y-axis; and fourth, behind us. If the patient is not ready to be aware of the space behind them and places too much effort on being aware of that space, the awareness of the other areas of space becomes compromised.

Additionally, in VT it is beneficial to have patients remove their shoes upon entering the therapy area. We want patients to experience the proprioceptive feedback of their feet touching the floor. There are many receptors at the bottom of the feet having to do with balance and posture. For patients wearing orthotics, if they are more comfortable with their orthotics, it is recommended that they wear gym shoes with their orthotics during VT.

It is also best for patients to remove their habitual lenses. The quickest way to change performance is to take the patient out of their habitual world. When standing, it is important to keep the knees slightly bent and not locked. If we lock our knees, this creates undue body/mind stress or tension in general.

Another important factor to consider in the treatment of tunneling is working in real space vs. instrument space. Real space is more natural and expansive; good posture is emphasized in support of stable vision. When working in instrument space, we are working in a more limited environment, artificial or virtual in that it is a two-dimensional representation of a three- dimensional world. Posture is often seated or standing in place, so limited feedback is available.

Questions

Lastly, from a behavioral perspective and in my perspective, our obligation to the patient at the highest level is to plant questions in their heads without giving them the answers, i.e., telling them what they should be seeing. The questions for the patient for the following activities may appear repetitive or redundant; however, different patients often require different triggers to elicit awareness or a change in performance. Thus, the same question is asked in a different manner.

Pre-testing

Prior to doing syntonics or a VT activity, the following is suggested to demonstrate the effect of these treatment methods, to inspire patients, and to prepare patients for a very rewarding experience:

  1. Look out a window as far away as possible without any glasses or contact lenses and answer the following questions:a.) Does space appear flat or three-dimensional?b.) Am I seeing in small or big chunks?
  2. Walk forwards and backwards, monitoring how your body feels while looking straight ahead. Be aware of balance, posture, weight distribution, groundedness,and any tension in the shoulders, neck, and/or back.
  3. Read a short passage aloud occasionally.

Post-testing

The above pre-testing is repeated after any of the following activities.

Treatment

In my experience, syntonics is often the quickest way to open up the visual field and ideally is commenced along with performance lenses and VT at the start. I find that syntonics can either allow the patient to be ready for VT by opening up the visual field, or it creates many changes in performance from cognitive, motor, and/or emotional systems by bringing the sympathetic and parasympathetic nervous systems into balance.4

The College of Syntonics has an annual conference, and preceding the conference, registrants can learn how to bring syntonics into their practices. The Journal of Behavioral Optometry had an excellent article by Larry Wallace, OD on syntonics including treatment strategies.5

Vision Therapy Activities

There are hundreds of VT activities. I am going to present some activities that I have found extremely useful in opening up functional visual fields and establishing a competent vision system. These activities go beyond treating tunneling because they all emphasize vision as a process and have the potential to affect overall visual performance in a very positive manner. I believe that the following activities are highly effective

because they provide significant feedback to the patient. To maximize efficacy of the VT procedures, we want to emphasize diaphragmatic breathing, hanging onto space, and visualizing whenever possible during the performance of the activities. When visualizing, it is recommended to visualize in space rather than our heads. Our heads are too small. In my practice, visualizing in real space allows for an easier transition to actual performance because of more appropriate spatial configurations.

In addition, I find that inner chatter is counterproductive because it is as if the information is going through another filter before it is processed. Talking to ourselves appears to take us out of the immediate experience of heightened awareness. Patients are encouraged not to talk to themselves but instead to breathe diaphragmatically, to hang onto space, and to visualize when applicable. In this way, patients learn to trust what they see in short order, to move along more quickly, and they are calmer.

For all activities, patients are instructed that the highest level of performance is being aware of the following: the space around them, body posture, where they are centering, and what they are doing. Patients are praised for their efforts in awareness. When patients are successful in accomplishing an activity, they recognize it. However, I have observed that by emphasizing awareness over performance, the patient’s anxiety and frustration in dealing with a challenging activity are reduced greatly. The patient becomes more available to work with and quickly brings the changes that they have made in their vision and emotional well-being to their lives.

When dissociating (doubling) glasses are necessary, the following pairs are recommended:

1st Pair:
1. OD Pl=6∆ BU & OS Pl=6∆ BD 2. OD Pl=6∆ BD & OS Pl=6∆ BU

2nd Pair:
1. OD Pl=10∆ BU & OS Pl=10∆ BD 2. OD Pl=10∆ BD & OS Pl=10∆ BU

3rd Pair:
1. OD Pl=4∆ BU & OS Pl=4∆ BD 2. OD Pl=4∆ BD & OS Pl=4∆ BU

Observations & Questions: There is an observation section following some activities and a question section following all activities. A star (*) has been added to indicate when the question or observation is relevant to tunneling.

Hand Game (Three-dimensional Harmon Circles)

Objective: To comprehend what it means to hang onto space, to develop the ability to center, and simultaneously to be aware of the space around us as we direct and monitor movement.

Figure 1. The staff person’s hands are leading and moving very slowly opposite one another on the X, Y, and Z axes. It is important to stay within the patient’s vis- ible range, with the patient keeping their hands always 1” away from the staff’s hands.

Posture:

1. The therapist stands/sits 16-20” from the patient, who is standing, so heads are at eye level.

2. The therapist holds hands up with palms facing the patient. The patient holds hands up with palms facing the therapist. The therapist and the patient move hands towards one another until 1” apart and midway between them.

Procedure:

  1. The patient is instructed to center his or her eyes on the therapist’s eyes and simultaneously to be aware of the room.
  2. While maintaining eye contact, the patient is then asked to describe what is seen in the space around him or her while working to see the total spatial volume simultaneously.
  3. The patient is then instructed to move his or her hands with the therapist’s hands and keep them 1” away from the therapist’s hands at all times while centering on the therapist’s eyes. The therapist’s hands are moved very slowly in the same direction (Figure 1), the opposite direction, and in and out. Also, the therapist can keep one hand stationary while moving the other hand. It is important not to move too far out into the periphery where the hands can no longer be seen.
  4. For preschoolers, their hands can be touching the therapist’s hands, and then after the patient becomes comfortable with the activity, only the fingertips should be touching.

Observations:

Figure 2. Starting position with staff positioned below the patient so that the patient can see all around them, including the mirror in front of them.

Questions:

1. Ask the patient what they observed about their performance as they did the activity.*

2. If any of the above observations are made (or any others), ask the patient what they can do differently.

3. Ask the patient if they are breathing all the time when they are doing the activity. If not breathing, ask what they can do to change that.*

4. Ask the patient if they are aware of the therapist’s hands and the room at the same time or in a fragmented fashion? If fragmented, ask what they can do to change that.*

The Hand Game is an activity I created and initially used for all patients. As patients progress in office training, the Hand Game is used as needed, i.e., when good central-peripheral organization is lacking. The Hand Game is also recommended for all children for home training purposes.

Wolff Pursuits

Objective: To develop fluid and controlled eye movement, binocularity, centering, and identification and simultaneously to be able to center and to be aware of the total spatial volume.

This activity was originated by Bruce Wolff. OEP published a paper on this activity by John Streff during his time at the S.A. Noel Center in Lancaster, Ohio.6 This activity can be done with the patient either on their back, seated, or standing. Standing is the highest level because it requires the most postural control while vision is free to operate. The equipment required is a set of Wolff wands, a full-length mirror 3-4 feet wide, an eye patch, and a pair of opposite dissociating glasses (doubling glasses). The powers of the dissociating glasses are Pl=6∆

1. 2.

3.

Does the patient have delayed reactions?*
Does the patient follow more easily with one hand than the other?*
Does the patient twist, turn, or tighten their torso instead of just moving their arms?

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Figure 3. It is important for both the patient and staff to be comfortably positioned. The patient is standing with feet shoulder width apart and knees slightly bent.

BU OD/Pl=6∆ BD OS and Pl=6∆ BD OD/Pl=6∆ BU OS. If patients have difficulty seeing double with the glasses, increase the power to 10∆ and return to 6∆ when it is easily done. When patients can perform easily with the 6∆ glasses, do the activity with 4∆. Ideally for the activity, the patient is facing a wide (3-4 foot) floor-length mirror with the therapist sitting in between. The mirror allows the patient to have the potential to be more aware of the space in his or her surroundings, including him- or herself, added awareness of the wands moving in the mirror, and the space behind him or her. Of course, the patient also wants to be aware of the space outside the mirror. It helps to increase awareness early on by placing a foam rubber noodle lengthwise one foot from each side of the mirror.

For children having inadequate control of their bodies and/or eye movement, begin the activity in the supine position. All of the rest of the patients start the activity standing. The ideal standing posture is with feet parallel and aligned under the armpits, with knees slightly bent and never locked.7,8

First, the activity is done monocularly for two minutes with an eye patch. The patched eye is always kept open even though it is covered. This is done to reduce unintended body tension. The patient is asked to follow the wand moved by the therapist, which is moved slowly (Figure 2). Most doctors or therapists tend to move the wand too quickly in the beginning. Patients are encouraged to keep their eyes wide open. The wand is moved in large circles in all the cardinal meridians. By moving the wand in circles, the patient is continually asked to change centering (vergence) and identification (accommodation) in order to do the task well. The silver wand is used as the primary

target because it has a higher reflective surface than the gold wand. The patient is asked to describe what he or she sees. The objective is to make the wand and the surrounding space equally clear. For some patients, that may mean first making the wand and the surrounding space equally blurred and then working towards clarity. The patient is asked if he or she can feel the patched eye moving the same as the uncovered eye. If the patient reports that the eyes feel like they are moving unequally, move the silver wand around the open eye while touching the skin very slowly. This helps heighten proprioceptive awareness of each eye moving. At the end of each monocular period, location or saccadic skills are introduced. The patient is instructed to follow the silver wand as a gold wand is introduced. They are to change gaze to the gold wand when “gold” is called out and to return to the silver when “silver” is called out. Five or six movements are done. Usually, one wand is kept near the midline, while the other one is moved to randomly-selected positions. We want the head to remain stable and straight during the whole procedure, and the patient should maintain good posture. The same sequence is now repeated with the other eye for two minutes.

Next, the dissociating glasses are used for two minutes with each pair (Figure 3). The silver wand is again moved in the same manner as above. The objectives now include: a) making both wands real and solid. If one is more real and solid, instruct the patient to look at the less real one and to breathe and blink to make it clear, then look between the two wands and see if they can maintain the equality of the wands; b) make the wands and surrounding space equally clear (or blurred initially); c) make the wands align; d) make the wands the same distance from themselves (they may need to look closer or further away initially before moving to the plane of the wands). The last part is the location skill, which is the same as when the activity is done monocularly. The only difference when the patient is asked to change gaze is that the plural is used, i.e., “golds” or “silvers.” Repeat with opposite dissociating glasses.

*Emphasize to the patient that they should strive to see the entire tableau simultaneously rather than in a fragmented fashion during all parts of the activity. Always keep the eyes wide open and breathe diaphragmatically.

Questions:

1. Does the eye that is patched move the same as the eye that is open?*

2. Do your eyes move smoothly?*
3. Do you ever hold your breath?*
4. Are the eye movements the same, independent of which eye is patched?*
5. Are you aware of the space around the wand and of the space behind you?*

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Figure 4. Starting position of Streff Walk with patient centering on her eyes in the mirror and being aware of all the space around her.

  1. Are you aware of all space including the wands and the mirror simultaneously?*
  2. Does the wand stay the same size, or does it get bigger and smaller?*
  3. When wearing doubling glasses, do both of the wands appear solid and real? Are they the same distance from you? Are they aligned all the time, sometimes, in certain positions, or not in certain positions?
  4. Are you maintaining your posture?*
  5. Are the wand(s) clear?
  6. Is the room clear?
  7. Are the wand(s) and room equally clear or blurred?*
  8. Can you make everything clear or equally blurred?*
  9. Are there any differences with one eye patched compared to the other?
  10. Are there any differences between the two dissociating glasses?

Streff Walk

Objective: To develop visually-directed and visually- monitored movement, to recognize and to become sensitive to spatial changes, to be able to control static and dynamic body posture, to develop controlled and fluid eye movements, and to be able to organize a large volume of space in order to develop degrees of freedom between the vision and vestibular systems.

Materials:

  • Set of yoked prism glasses: Pl=15∆ BR OU, Pl=15∆ BL OU, Pl=15∆ BU OU, Pl=15∆ BD OU
  • Full-length mirror, 3-4 feet wideProcedure: Stand 10 feet in front of the mirror. Center on your eyes in the mirror, and very slowly bend forward at the waist (Figure 4). As you are bending forward, move your eyes slowly down the mirror to the floor below. When your back is parallel to the floor, move your head and eyes down towards your right foot. Look at the big toe of the right foot. Slowly pick up the left foot, raising the knee as high as possible while maintaining steady balance. Place the left foot down gently with the heel first, directly in front of the other foot, all the while keeping your eyes on the big toe of the right foot. If this is too difficult, place your foot off to the side. The goal is eventually to place one foot directly in front of the other. After the step is complete, slowly lift your head up while moving your eyes along the floor from your big toe to the mirror. Then, raise your body up from the waist as you move your eyes up the mirror, again centering on your eyes.Prior to taking a step, shift your weight to the hip above the foot that is going to stay still. This will be helpful in maintaining effortless balance.

Repeat the process for a total of three steps forward and three steps backward. Note: when going forward, look at the forward foot’s big toe and step with the rear foot forward, landing heel first. When taking steps backward, center on the rear foot’s big toe, and with the front foot step backward, landing toe then heel. Always be aware of the space all around you—in front, to the sides, and behind as you are centering on the big toe.

• While looking at the mirror, prior to any movement, take in a long, even, and relaxed breath.
• Bending forward, breathe out through the nose smoothly and evenly.
• Looking at the front/back foot’s big toe, take a breath. • While stepping forward/backward, breathe out.
• After the foot lands, breathe in.
• While raising your head and back, breathe out.

The patient is encouraged to consider the following questions throughout the activity:
• What do I see?*
• Can I look straight ahead and see the whole room as it appears, including the space behind me?*
• What do I feel?*
• Any spatial or size changes?*
• Do I experience my body differently?*

The patient should strive for the following:
1. Keep feet straight
2. Hang arms loose
3. Use hips for balance
4. Work slowly
5. Breathe slowly
6. Simultaneously be aware of all of the space around you
7. Feel your feet touching the ground
8. See how space and body have changed with each pair of glasses

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Questions:

1. What do you see?*
2. Are you aware of the space around you?*
3. Are you using the mirror to be aware of the space behind you?
4. Do the room, walls, and floor always appear the same?*
5. Are you seeing the changes in the entire room?*
6. Is the whole wall directly in front of you, appearing the same distance from you?*
7. How do you use your body to keep balance?
8. Are you breathing or holding your breath?*
9. Do you move your upper body to keep balance?
10. Are you shifting your hips to keep your balance?
11. Are you light-footed or heavy-footed with your steps?*

Observations with yoked prisms:

BU: Space appears to be displaced downward as if closer, objects at distance appear closer. Near (down) space is reduced and distance (up) is amplified, you feel taller (center of gravity shifted forward). If facing the center of a wall, the bottom portion of the wall pops out.

BD: Space appears to be displaced upward as if further away. Near (down) space is amplified and distance (up) is reduced, you feel shorter (center of gravity shifted back). If facing the center of a wall, the top portion of the wall pops out.

BR: Space appears to be displaced toward the left, the right side of space is expanded, and the left side of space is compressed. The right side of space is slanted downward; the center of gravity is shifted to the right. The left side of the body feels constricted, and the right side of the body feels expanded (right arm and leg feel longer and lighter), allowing increased mobility. If facing the center of a wall, the right side of space appears further away, and the left side appears closer.

BL: Space appears to be displaced toward the right, the left side of space is expanded, and the right side is compressed. The left side of space is slanted downward; the center of gravity is shifted to the left. The right side of the body feels constricted, and the left side of the body feels expanded (left arm and leg are longer and lighter), allowing for increased mobility. If facing the center of a wall, the left side of space appears further away, and the right side of space appears closer.

*If the patient reports the opposite or paradoxical spatial changes, they are typically tunneling. The space in which the activity is done may be too big for them readily to organize. Try repeating the activity in a more narrow space like a hallway. When the activity can be done easily in a narrow space, then return to the larger space. Play the hand game often and encourage the patient to “hang

Figure 5. Dowels elevated 45° from horizontal.

onto space.” Also, placing foam noodles a few feet on either side of the mirror and encouraging the patient to be aware of the noodles as they center on their eyes in the mirror may be helpful.

Prism and Dowels

Objective: To develop coordination of the two visual channels, to recognize and to become sensitive to likenesses and differences, to see space in an organized manner, to develop a solid space world, to organize a large amount of information quickly, and to communicate said information effectively.

This is another Bruce Wolff activity. Two approximately 3-foot dowels and dissociating glasses are used again. Rob Fox discussed this activity in his JBO article.9 A dowel is held in each hand at three primary levels: below the waist, at the waist, and at shoulder level. From these primary positions, the dowels are positioned 45 degrees downward, straight ahead, and 45 degrees upward (Figure 5). The patient is wearing a pair of dissociating glasses and is asked what he or she sees. This is a wonderful time for the patient to learn how to use vision to organize what he or she perceives and effectively to communicate this information. The patient is to describe what he or she sees as if the listener (therapist) is blind. The listener wants to be able to paint a picture of what the patient is seeing. If the patient is not describing what he or she is seeing, from the bigger picture to the smaller picture, or giving details in appropriate steps, the listener reports that they are confused or that they just do not get it. Emphasize to the patient that the proper foundation or big picture is necessary for the listener to make this picture. The listener then draws a picture of what he/she thinks is being described using small circles to indicate the dowels. Ideally, the patient sees 4 dowels (two coming from each hand or hands), and the dowels are lined up on each side and appear to be the same size. However, all kinds of responses are possible. Typically, in the beginning, the dowels are not the same size or are not aligned on each side. If the patient has a problem seeing

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Figure 6. This is an example of a patient employing extending arms all the way out and turning arms inward to accomplish matching and/or alignment.

4 dowels easily, use the 10∆ dissociating glasses; another alternative is to have the patient bend the elbows outward so that the dowels, instead of being perpendicular to the patient, are now angled inward towards the midline. For some patients, this makes it much easier to see the 4 dowels. As the activity becomes easier, return to the original way of following the procedure. If the patient reports that the dowels are of unequal length, the doctor or therapist can recommend looking further away in space and seeing if the patient can find the place where they can center to get the dowels to be the same length. If the dowels only grow so much, have the patient bend the arms at the elbows. The arms are now pointed inward to where the dowels are going to meet (Figure 6). The patient is centering at this point, hanging onto space, and breathing. The hands are turned inward as much as necessary until the dowels are equal in length. If the dowels are equal in length but not lined up on each side, the patient can tilt and/or turn their head until the dowels are lined up. Once that is achieved, the patient can see how much they can bring the arms back to the straight ahead position with minimal bending. Then the patient attempts to do the same with the head position. Finally, without any adjustments, the dowels are slowly brought together at the point where the patient is centering in space. Ideally, the dowels touch once they are brought together.

This is then repeated at each primary position with the dowels pointed 45 degrees downward, straight ahead, and 45 degrees upward. The patient wants to work towards doing the activity without having to bend the elbows or tilt or turn the head, i.e., using only their vision to make changes. Additionally, bringing the dowels together diagonally can be added while varying which arm is held higher. Another variation is having the patient walk and bring the dowels together every other step. The dowels are brought together in random areas in space, exploring all the cardinal positions. The objective is always to have the dowels appear the same size and aligned and to have all

four dowels meet when centering them. The head should be kept fairly stable, so it is important not to get too far into the periphery where diplopia cannot be maintained.

Questions:

1. How many dowels do you see?*
2. Do they look the same or different?
3. What similarities do you see?
4. What differences do you see?
5. If you change, where you are looking? What differences

do you see?
6. Are you breathing throughout the activity?*
7. Are you always hanging onto space?* What is different

when you hang onto space?*
8. Do you need to alter your body alignment to make

the dowels appear more equal and aligned?

Prism & Stick

Objective: To develop the ability to coordinate the information from each visual channel efficiently and comfortably, i.e., centering and identification skills; to learn accurate spatial projection; to recognize similarities, differences, and patterns; to organize spatial changes; to be able to organize a large volume of space; to see space as a unit; to learn to move the eyes in a controlled and fluid manner; and to use breathing to regulate movement.

Materials:

1. Two opposite pairs of dissociating glasses
2. Dowel (placed vertically on a stand)
3. Two 8”x 11” sheets of paper, one red and one green 4. A large “X” cut from poster board; each line of the “X” is about 10-12 inches long and about 21⁄2 inches wide
Ideally, the activity is initially done in a hallway or screened-in area, and the “X” is placed on a window if possible (a wall if no window is available). The red and green papers are placed on the side walls opposite one another, with one color placed ahead of the other (12-24 inches) so that they are not exactly opposite one another.

Procedure:

Stand with your feet under your armpits and your knees slightly bent, with at least 8-10 feet of space in front of you and facing an X positioned at eye level (Figure 7). The dowel is placed on a stand (Figure 8). If a stand is not available, children under 13 years old should hold the dowel vertically at the Harmon distance, and children over 13 should hold the dowel 13-16” in front of their face. The dowel is held with the fingertips of each hand and hands 6” apart. The top of the dowel is across from the nose.

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Figure 7. Demonstration of the set up of the procedure.

Look at the dowel with doubling glasses on. Two dowels are to be seen. Can you align them? If necessary, tilt or turn your head to align. Tilt or turn minimally, attempting to reduce tilting or turning as you do the activity. As you look at the dowels, can you see how the Xs are positioned? Look at the dowels for a minimum of 5 seconds as you breathe in diaphragmatically through your nose. Move your eyes from the dowels to the Xs while exhaling. The eyes are to arrive at the Xs at the same time while all the air is completely expelled through the nose. You want to exhale as slowly as possible as you move your eyes through space. Do both the Xs move equally and align? Does your head have to be tilted to align? As you moved from the dowels to the Xs, what did the dowels do? Inhale as you center on the Xs, slowly straighten your head, very slowly breathe out diaphragmatically through your nose, and look back across the room to the dowels. What do the dowels do as you move your eyes across the room? What do the Xs do as you move your eyes to the dowels? Do you have to tilt your head to align the dowels? Hold for 5 seconds, straighten your head, and as you are breathing out, move your eyes back to the Xs very slowly. What changes in the room do you see as you move back and forth? Remember to move your eyes only on exhaling and as slowly as possible. Report the changes as you are moving your eyes. The patient works 4 minutes with each pair of doubling glasses.

Modifications:

1. For children 6-8 years old, if there is a lot of fidgeting or difficulty breathing appropriately, the activity is initially done in the prone position. The therapist holds the dowel in front of the patient, and a target is placed on the ceiling. Emphasize moving the eyes very slowly with breathing and observing the changes the Xs and dowels make as they are moved from one to the other.

Figure 8. Patient standing in front of the near target placed at nose level height.

2. For children 6-8 years old who become fidgety, do the activity with the patient sitting erect with their feet on a stool and their forearms resting on their legs.

3. For adults and children who have difficulty verbally organizing the information quickly, it is helpful to communicate by holding their hands apart about 6” and moving them further apart or closer together to indicate the changes. The patient ideally demonstrates the changes, beginning with the length, then width, then height without pausing. The objective is to see the changes as a unit. When that can be done easily, request that the patient now do it verbally.

4. If the patient has difficulty seeing changes in the length, the therapist can stand facing the patient. The therapist stands closer than the X. The patient uses the therapist’s head as the new target. In this “shorter space,” it is often easier to see the change in length.

5. If the patient has difficulty seeing changes in the width of the room, have the therapist stand in front of one of the red or green sheets. A bigger target can make it easier to observe the room widening and narrowing.

6. If the patient has difficulty seeing the changes in height, hang an object from the ceiling and place a traffic cone on the floor below the ceiling target.

7. If the dowels or Xs do not move equally together or apart, have the patient do the activity visualizing the dowel and the X, and move from one target to the other very slowly in conjunction with breathing. Feel whether each eye is moving at the same speed and with equal smoothness. If speed or smoothness is unequal, ask the patient to visualize breathing through the eye that is not moving as well until both eyes are equal.

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8. When the activity can be done easily, the dowel is placed in front of a window, and the patient stands with the same posture and the same distance from the dowel. The distance target is now an object outside the window and as far away as the patient can easily identify an object. The activity is repeated as before.

Questions:

  1. How are the dowels positioned when you look at the Xs? What are the Xs doing as you look to the dowels?*
  2. When you move your eyes from the dowels to the Xs, is the movement slow and fluid?*
  3. When you move from the Xs to the dowels, is the movement slow and fluid?*
  4. Is one direction easier than the other?*
  5. What patterns/relationships in the space do you see?(Guide the patient to recognize the pairs in the room, i.e., 2 dowels, 2 Xs, 2 red sheets, 2 green sheets, and how the pairs move.)*
  6. Do all the objects appear double?*
  7. Do all the double targets appear real and solid?
  8. When moving across the room in either direction, do your eyes get there first, or are you out of breath first? (Expected: the eyes complete the movement, and the patient is out of breath at the same time.)
  9. How does space change as you move your eyes from the dowels to the Xs and then back? (Expected changes: as the patient looks to the Xs, the room becomes wider and shorter; as the patient looks to the dowels, the room becomes longer, narrower, and taller. If the patient is not “hanging onto space,” the opposite changes will be reported.)*
  10. How do the side targets (the red pair of sheets and the green pair of sheets) appear to change as you move across the room in each direction?*
  11. Do the length, width, and height changes occur simultaneously?
  12. What do you observe about the dowels or the Xs as they move apart and together (i.e., are they moving equally in amount and speed)?
  13. Do the dowels align easily, or do you have to tilt your head or change where you are looking?
  14. Do the Xs align easily, or do you have to tilt your head or change where you are looking?
  15. Does the room change as a unit or in a fragmented fashion?
  16. If the X is on a window, are you aware of what is happening outside the window as you move your eyes back and forth?*

KEY: As you move from one pair of targets to the other, be aware of how the other pair of targets is changing. This is the anchor for seeing all of the other changes.

Expected responses:

1. Coordinate the eye movements with breathing.
2. Eyes move fluidly without pausing or fragmenting. 3. Eyes move slowly and in a straight line.
4. Perform the movements without blinking.
5. See changes as the eyes are moving rather than when they have reached the next targets.
6. See space change as a unit.
7. When moving from the Xs to the dowels, space appears longer (length), narrower (width), and taller (height).
8. When moving the eyes from the dowels to the Xs, space appears shorter (length), wider (width), and shorter (height).
9. Dowels and Xs move apart and come together with equal movement and speed.
10. Eyes reach the next targets at the same time that all of the air is expelled.
11. Alignment of the dowels or the Xs is done easily, without head tilt or looking closer or further away.

*If there is difficulty getting both dowels and both Xs to move smoothly and equally, work with the eyes closed. We want the patient to feel whether each eye is moving slowly and smoothly. Use breathing to control the movement. The goal is feeling equal movement. Repeat the activity with eyes open and emphasize feeling the eyes making the movement without being concerned about the spatial changes. Once this is accomplished, feel the eyes moving and see the room change as a unit simultaneously, i.e., length, width, and height.

*If there is difficulty seeing the height changes, place a different color sheet of paper or a traffic cone on the floor in the middle of the space. Above the paper, place a hanging target. This will allow the patient more easily to recognize the changes.

Aniso Lenses

Objective: To learn to organize space appropriately, to enhance awareness by recognizing and becoming sensitive to spatial and body changes, to reduce body tension and to enhance static and dynamic posture by working through vision.

Materials:

1. Plus and minus lenses: +/-5.00, +/-1.00, +/-0.75, +/- 0.50, +/-0.25 (If using lens blanks, Velcro to safety frame)

2. Safety frame or trial frame

Pre-test

1. As usual, remove your shoes and habitual lenses. Stand with your feet below your armpits, parallel and with your knees slightly bent. Close your eyes. Describe

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your posture: erect, leaning forward, backward, to the right or to the left. Is your weight equally distributed or heavier on one side? Is there any muscle tension in your shoulders, neck, or back?

  1. Lie on your back. Without placing a hand there to measure, estimate how much space is between your neck and the floor and between your waist and the floor. Indicate the space by holding up a hand and separating your fingers. Do both legs feel equal in weight and length?
  2. Walk forwards and backwards and estimate the level of body tension, groundedness, ease of walking, and spatial awareness.
    First pair of glasses: OD -1.00; OS +1.00Second pair of glasses: OD +1.00; OS -1.00

Procedure:

Put on the first pair of glasses for 3-4 minutes. Stand in place and then walk and answer the questions “What do I see? What do I feel?” Initially, it is often easier to experience the changes in the body with the eyes closed walking in a circumscribed area. If the patient needs help to elicit body changes, ask the following: “Compare the sides of the body—what differences do you notice? Which side is heavier? Which side is longer? Does one arm feel longer or heavier than the other side? How about the legs?” Next, the therapist holds his or her hands with palms facing the patient about 12” apart, and the patient, standing 2 feet away, centers on the therapist’s eyes (Figure 9). The patient is asked to describe the hands they see. If the patient needs help to elicit size and spatial changes, ask the following questions: “Which hand is closer? Which hand is smaller?”

Ideally, the patient reports that the side of the body wearing the minus lenses is heavier and shorter and that objects on that side appear smaller and closer. If patients are finding it challenging to experience the appropriate responses, increase the power of the lenses to +/-5.00. Once the appropriate responses can be achieved, return to +/-1.00.

Additionally, if the patient has difficulty achieving the SILO response, have the patient hold a bean bag in the hand on the minus side near the therapist’s hand on the opposing side. Have the patient pull the bean bag closer and squeeze the bean bag as they pull it in. For the entire time, the patient is centering on the therapist’s eyes and “hanging onto space.” After 3-4 minutes, put on the second pair of glasses. Remove after 3-4 minutes.

Post testing: Repeat pretest.
Next session, repeat with same pair of lenses.

Figure 9. Patient is doing the Aniso Lenses activity with plus and minus lenses.

Next two sessions:
First pair: OD -0.75; OS +0.75 Second pair: OD +0.75; OS -0.75

Next two sessions:
First pair: OD -0.50; OS +0.50 Second pair: OD +0.50; OS -0.50

Next two sessions:
First pair: OD -0.25; OS +0.25 Second pair: OD +0.25; OS -0.25

After you go through all the lenses, repeat the entire process, one session for each set of glasses. As you go through the lenses again, the patient is often much more sensitive to what he or she sees and feels.

Expected Responses:

1. SILO
2. At the post-testing, the patient reports their body

sinking more into the ground, i.e., less separation between their neck and the floor and less separation between their waist and the floor.

Questions:

1. With the lenses on, how does the right side of your body from head to toe compare to the left side? Is it the same with your eyes open or closed, stationary or moving?*

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Figure 10. Starting position adjacent to Hula Hoops. Figure 11. Position of feet and body, with rota- Figure 12. Patient is staying adjacent to tion of hips, as orienting through the middle of the Hula Hoops as she walks.

the Hula Hoops.

  1. With the lenses on, when looking at a target in front of you, does the space on the right side or the left side of the target appear the same or different?* (It may help if you place a trampoline on its edge leaning against a wall with an X in the middle and “noodles” or chairs on either side to elicit a SILO response. The patient is asked which noodle is closer while centering on the X.)
  2. With the lenses on, are you breathing?*
  3. With the lenses on, are you hanging onto space?*
  4. What do you observe (see and feel) when you removethe lenses at the end of the activity? How does your posture change when standing or lying down? When walking, how do you experience your body and space?

Infinity Walk

Objective: To learn visually-directed and visually- monitored control of body movement through space, degrees of freedom between where centering and control of body movement, spatial and body awareness, visualization, enhanced peripheral-central organization, increased peripheral awareness, and visual-vestibular integration.

Materials:

1. 2 chairs
2. 2 Hula Hoops
3. Full-length mirror 3-4 feet wide
4. Yardstick or 3-foot dowel
5. +/-1.00 lenses Velcroed to a safety frame

Placement: Position two chairs 3 feet apart so that the floor space covered is about 5 feet by 9 feet.

Time: Activity is done for 8 minutes.

Lenses: Wear the plus lens on the right eye and the minus lens on the left eye for 4 minutes. For the next 4 minutes, reverse the lenses.

Procedure:

1. Facing the mirror, stand at the outside of either chair, centering on your eyes in the mirror. Walk in a continuous figure eight pattern, keeping the two circles of the eight well rounded. Always look towards your eyes in the mirror as you walk, even when outside the range of the mirror.

2. Walk around one circle in the clockwise direction and the other circle in the counter-clockwise direction as you cross in between the circles. Half the time the right eye and ear are closer to the target, and half the time the left eye and ear are closer.

3. Add the yardstick or dowel. Place your arms in front of your body, armpit distance apart with palms up and holding the yardstick. Continue doing the activity, keeping the yardstick in front of your body in the direction you are walking. After about 1 minute, change the position of your hands. Place your palms so that they are facing downward, armpit distance apart and holding the yardstick. Do this for one minute. Thereafter, change position of your hands after each minute.

4. Always center on your eyes in the mirror. Be aware of the space between you and your image and all the space around you both inside and outside the mirror, including behind you.

5. When all of the above can be done easily, replace the chairs with Hula Hoops with a 16-inch separation between hoops. When you are unable to view the

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hoops in the mirror, visualize them and the space

around them.
6. Do the activity again; this time in the starting position,

you are facing away from the mirror, but your head is turned toward the mirror. Each time your head is again facing away from the mirror, quickly turn your head so that your head can be facing towards the mirror while your body is moving away from the mirror (Figures 10-12).

Expected Responses:

  1. It is important to rotate your hips towards the target rather than just your head as you move through the space between the chairs/Hula Hoops. In addition, always place one foot in front of the other to avoid walking sideways as you move between the chairs/ Hula Hoops.
  2. Pace is slow and constant.
  3. Steps are the same size.
  4. Keep the same distance from the Hula Hoopsthroughout the activity.
  5. Center in the mirror on your eyes; when outside therange of the mirror, visualize looking in the same spot.

Questions:

  1. Can you always keep centering on your eyes in the mirror?
  2. Do you always maintain awareness of all the space around you, including the space outside the mirror and behind you?*
  3. Can you visualize what you cannot see?*
  4. Can you maintain simultaneous awareness of the whole room, or are you seeing the room in afragmented fashion?
  5. If you do lose centering on the mirror, where does itoccur?
  6. Is it easier to walk around one chair/Hula Hoop thanthe other?
  7. Can you feel your hips turning prior to getting to theintersection?
  8. Can you move easily in each direction as you move ina figure eight pattern?
  9. Are your feet always the same distance from the HulaHoop? (Ideally, near the edge of the Hula Hoopwithout touching)*
  10. Are your steps always the same size, or do they vary?*
  11. Does your pace change as you move in and aroundthe chairs/Hula Hoops? (Ideally, the activity is doneslowly, and the pace is the same throughout.)*
  12. Is it easier holding the yardstick in one positioncompared to the other?
  13. Does your breathing change as you walk?

14. What can you do to make a change in what you are doing with your body, your steps, and how you are seeing space?

15. Do you ever become turned around, i.e., facing in the opposite direction than you want to go?*

Balloon Play

Objective: To develop the ability to visualize; to work on timing, visual motor integration, and visual auditory integration; to process a large amount of information at one time; to anticipate and to organize information in a timely fashion; and to work on the control of body in space through vision.

Materials: 2 round balloons 9-11” in diameter of different colors, +/-1.00 lenses Velcroed to a safety frame

Procedure: Hit the balloons with alternate hands at a height between waist and chest level and with palms facing upward. Ideally, the balloons are hit at the junction where the fingers meet the palm. Count aloud simultaneously as you hit the balloons. The activity is done for 4 minutes with OD +1.00 & OS -1.00. Then reverse the lenses and complete the activity for another 4 minutes.

Expected Responses:

We want patients to be precise as to their understanding, language, and communication of space. For example, if asked “where are you hitting the balloons?” answering “up” or “above them” is not specific enough. A more appropriate response is “one foot below the ceiling.” That is also the spot or area on which they want to center, but have the patient experiment to find where it is easiest for them to center and to control the balloons. We want the patient to experiment and to find the most effective way to use their vision.

Questions:

1. Can you control the balloons equally well with either hand?

2. Are you always hitting the balloon underhanded and between chest and waist level?*

3. Are you hitting the balloon at the juncture where your fingers meet your palm?*

4. Are you hitting and counting simultaneously?
5. How much movement of your body is required to

keep control of the balloons?
6. What can you do differently to reduce body

movement?
7. Where do the balloons go when you hit them? (We

want the patient to be specific, e.g., 6” below the

ceiling)
8. Are the balloons always going to the same place?*

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  1. Where do you have to hit the balloon in order to have the most control of the activity?
  2. Where are you centering your vision during the activity?*
  3. Where do you think you have to center your vision to have the most control? (Encourage experimenting.)
  4. Do the balloons ever collide? What can you do? (For example, visualize a screen between the balloons.)

Trampoline

Objective: To learn visually-coordinated, visually-directed, and visually-monitored body coordination and rhythm, spatial and body awareness, and visualization.

Materials: Mini trampoline, eye patch, full-length mirror 3-4 feet wide, two water bottles

Time: 8-10 minutes Procedure:

Figure 13. Proper standing position to start trampoline, with arms at sides and knees slightly bent.

10. Emphasize jumping from the balls of the feet, landing on the balls of the feet, and then rolling down to the heels.

11. Emphasize bending the knees with each jump and each landing and doing the procedure without stopping.

12. When jumping with both feet in the same direction, keep the feet parallel, with each foot making the same size step or movement.

13. After each step is completed, continue to keep the knees bent and move on to the next step.

14. Never lock the knees or keep the feet locked in the bent position as you are jumping.

15. Count and land simultaneously. (If there is a problem, have the patient tap on the trampoline mat with his or her hand and count simultaneously as the hand hits the mat. Then have the patient count when the hand is in the air so that they can experience the difference.)

16. If the patient pauses between parts of each step, have the patient tap with his or her hand on the trampoline mat with and without pausing.

17. When doing each step, if the patient goes beyond repeating 5 times, have the patient count louder to exaggerate the feedback.

18. Objective: see the image in the mirror as far back as you are in front of the mirror/hang onto space.

19. When counting, count loud enough so that the image in the mirror can hear you.

Step 1:
Five hops on the right foot; count each time the foot hits the mat. Hopping is the only part of the activity that is done fairly quickly; the hop is done just a little off the ground. If the patient is not staying in one place, they need to work on hanging onto space. It is helpful to place noodles vertically on either side of the mirror to increase awareness.

1. 2.

3.

4. 5.

6. 7.

8. 9.

Do all the steps with one eye patched, and then repeat with the other eye patched.
Center your vision on your eyes in the mirror and be aware of your surroundings; i.e., inside and outside the mirror, see the space and objects in your surroundings simultaneously rather than fragmented or one object at a time.

For all steps below, stand on the trampoline 6-10 feet or more from the mirror so that you can see your entire body in the mirror and the room behind you. Begin in a balanced posture with your knees bent and with your feet placed parallel and beneath your armpits (Figure 13).

Master each step before moving on to the next step. The therapist slowly demonstrates each step for the patient.
Encourage visualizing the step in space; i.e., as if your twin was standing in front of you and doing the activity, prior to actually doing it.

At any point, if the instruction is too challenging, have the patient stop and try it first by just using their hands and then visualizing hopping or jumping and doing the step. If necessary, an intermediary step is having the patient get on their hands and knees next to the trampoline while still centering in the mirror, and do the step or sequence with their hands tapping on the trampoline.

Use the mirror as feedback to be aware of body control, arm movements, and head movements, and know where you are on the trampoline.
Do all parts of each step slowly because we want to get feedback in order to make the necessary changes.

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Figure 14. Patient looking in the mirror, getting feedback, and doing forward scissor jumps.

Step 2:
Five hops on the left foot; same procedure as above.

Step 3:
Five hops on both feet. Again, stay in the same place and land on the balls of the feet without stopping.

Step 4:
Five jumps forward; count each time you return to the starting position. Start towards the back of the trampoline and make a small jump forward, then return to the starting position and count as you land.

cross over, one foot in front of the other. Next, jump and reverse that position, finally jumping and bringing the feet back to the starting position. Count as you land.

Step 11:
Five alternating scissor jumps; count each time you return to the starting position.

Begin with the feet together, jump with one foot forward and the other foot backward, and then reverse that position. Next, jump with each foot going out to the side, then cross over with one foot over the other, then jump and reverse that position. Finally, jump and bring the feet back to the starting position, counting as you land.

Step 12:
Five jumps to the right and back; count each time you return to the starting position. Place the target to the patient’s right to center on. Jump and turn your body to the right, leading with the hips, and then return to the original position, counting as you land.

Step 13:
Five jumps to the left and back; count each time you return to the starting position. Place the target to the patient’s left to center on. Jump and turn your body to the left, leading with the hips, and then return to the original position, counting as you land.

Expected Responses:

1. Hop in the same place. If the patient is not landing in the same place, this indicates not “hanging onto space.” Play Hand Game.

2. Jumps are to be the same size. Unequal size jumps indicate not hanging onto space or tunneling, i.e., not paying attention to feedback from the mirror and the body.

3. Count and land simultaneously. If not, the timing is off. Increase the feedback by having the patient count louder.

4. Hop or jump fluidly without pausing.
5. Hopping is the only portion of the activity done fairly

quickly. All other portions of the activity are done at moderate speed. It is important not to go too fast or too slowly, to speed up, or to do the activity with pausing.

6. Complete each step standing with the knees bent. If the knees are locked, the patient will fall backwards or lose balance.

7. When jumping or hopping, the knees should move like a spring and not be locked in place.

8. When jumping or hopping, always land on the balls of the feet first, then come down on the heels. Avoid landing flat-footed.

Step 5:
Five jumps backward; count each time you return to the starting position. Move towards the front of the trampoline before beginning.

Step 6:
Five jumps to the right; count each time you return
to the starting position. Move towards the left before beginning. Jump sideways, with both feet moving equally, and count when returning to the starting position.

Step 7:
Five jumps to the left; count each time you return to the starting position. Move towards the right; jump sideways, with both feet moving equally, and count when returning to the starting position.

Step 8:
Sequence of the day twice: right foot 2, left foot 1, both feet 4; do once then repeat. Do fluidly without stopping. The sequence is changed daily.

Step 9:
Five scissor jumps forwards; count each time you return to the starting position. Begin with the feet together. Jump with one foot forward and the other going backward, and then jump and reverse that position (Figure 14). Next, jump and land with the feet together, and count as you land.

Step 10:
Five scissor jumps sideways; count each time you return to the starting position. Begin with the feet together. Jump and move the feet apart laterally 12-24”, then

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9. Arms are always to be hanging loose. If the patient is unable to relax the arms, have him or her hold a water bottle in each hand with their fingers at the top (half- filled for younger children).

Questions:

1. Are the jumps always the same size?*
2. Is rhythm maintained?
3. Are you always able to hang onto space?*
4. Are you always able to stay in the same place or to

return to the same place?*
5. Are your arms relaxed and loose, or are you tensing

your arms?*
6. Are you always keeping your knees bent and not

locking them when you have completed doing each

step 5 times?*
7. Are you projecting your voice to where you are

looking, i.e., to your image in the mirror?*
8. Is your voice staying at the same level?
9. Is your image always the same distance behind the

mirror as you are in front of the mirror?*
10. Are you always landing on the balls of your feet?
11. Are you always landing softly?
12. Are you always centering on your eyes in the mirror?

Are you simultaneously aware of the surroundings, or do you look elsewhere?*

Other recommend activities include MML (see Franke OEP papers) and Exploring Space (an Al Sutton activity).

Home Visual Training

Thumb Pursuits

See Franke VT OEP papers.10 This is an excellent activity and is highly recommended for experiencing variations in spatial projection depending on which channel we are seeing through and/or which hand we are using, developing the ability to process a large volume of information, and developing controlled and fluid eye movements.

Walking

Objective: To intentionally bring what you have learned into daily activities, i.e., hanging onto space, and to practice as an excellent maintenance activity.

Time: 15-30 minutes

Procedure: Center on an object in the distance that you can easily discern, and as you get closer, choose another object farther away. As you walk, be aware of the ground, the sky, and items beside you as you center on the object. We want to see everything simultaneously and not in a fragmented manner.

When this can be done easily, be aware of objects behind you. For example, if passing a hydrant, work on visualizing the hydrant while maintaining awareness of what is in front of you. This is very challenging, so take it very slowly. Remember to breathe diaphragmatically.

I view tunneling as a pervasive vision disorder and a common characteristic of all vision syndromes. Tunneling can occur in all dimensions of space, i.e., X, Y, and Z axes. Thus, tunneling can be a flattening or overall constriction of functional space. All of the aforementioned activities deal with vision as a process rather than working on a skills approach. Thus, the patient is being asked to work on the vision process for each activity. These activities were chosen because they stress the profound relationship between vision and posture; they maximize feedback to the patient, doctor, and therapist if the activity is being done appropriately; and they provide insight into the pervasiveness of vision in human performance.

References

1. Getzell JH. Tunneling-A Pervasive Vision Disorder. Optom Vis Perf 2014;2(1):13-6.

2. Forrest EB. The Visual Stress Response. Stress and Vision. Santa Ana, CA: Optometric Extension Program Foundation, 1988:161-70.

3. Benson H, Klipper MZ. The relaxation response. New York, NY: Harper Collins, 1992.

4. Wallace L. Treatment Protocols for Amblyopia and Strabismus. The College of Syntonic Optometry Journal of Optometric Phototherapy 1998:26-7.

5. Gottlieb R, Wallace L. Syntonic Phototherapy. J Behav Optom 2001;12:31-8.

6. Streff JW, Wolff BR, Jinks B. Eye Tracking and Locating Skills. Lancaster, OH: SA Noel Center, Inc., 1985.

7. Smith LK, Weiss EL, Lehmkuhl D. Brunnstrom’s Clinical Kinesiology, 5th ed. Philadelphia, PA: F.A. Davis, 1996:401-10.

8. Snijders CJ. Engineering approaches to standing, sitting, and lying. In: Nordin M, Frankel VH, eds. Basic Biomechanics of the Musculoskeletal System. Philadelphia, PA: Lippincott Williams & Wilkins, 2001:420-7.

9. Fox R. A rationale for the use of prisms in the vision therapy room. J Behav Optom 2011;22(5):126-9.

10. Francke A. Models of Vision and Thumb Pursuits. Optometric Visual Training. Santa Ana, CA: Optometric Extension Program Foundation 1st ser, 1988:171-5.

Correspondence regarding this article should be emailed to Jeffrey H. Getzell, OD at jeffgetzell@sbcglobal.net. All statements are the author’s personal opinions and may not reflect the opinions of the the representative organizations, ACBO or OEPF, Optometry & Visual Performance, or any institution or organization with which the author may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2015 Optometric Extension Program Foundation. Online access is available at www.acbo.org.au, www.oepf.org, and www.ovpjournal.org.

Getzell JH. Vision Therapy Procesures for Tunneling. Optom Vis Perf 2015;3(4):203-17.