BEHAVIOURAL OPTOMETRY AND VISION THERAPY
What is behavioural optometry?
Behavioural optometry is a branch of optometry that deals not only with vision, but how it interrelates with learning and development. You can have 20/20 normal vision and healthy eyes, yet be unable to efficiently control where the eyes are looking, or be unable to interpret what it is that you see. Vision plays a critical role in our lives, both at home, work and at school. Vision makes up 80% of all the sensory information required for learning. If a child has a vision-related learning difficulty, they will struggle and typically lose interest and may become disruptive in class. A child that SEES BETTER will LEARN BETTER and have improved confidence and self-esteem.
A behavioural optometrist undergoes extra years of postgraduate training. They can also develop interest in sub-specialty areas such as sports vision, rehabilitation vision, strabismus (turned eyes), amblyopia (lazy eyes) and learning-related (developmental) vision problems.
The optometrist will begin by conducting a conventional comprehensive eye examination to examine your vision and the health of the eyes. Further testing is performed to assess other areas of our visual system, such as binocular vision (eye coordination and eye movement) and visual perception (how the brain interprets the visual information). The goal is to ensure that vision is clear and comfortable, and that the visual information is interpreted correctly, in order to meet the visual demands of the patient for work, sports and studies. A patient plan is formulated in discussion with you, then documented on file and updated with each visit.
In short, a conventional optometrist will measure how CLEARLY you see whilst a behavioural/developmental/functional optometrist will assess HOW you use your vision to function. In order to assess HOW clear and derive MEANING from what is seen, all the visual components must be working.
About one in five Australian children has a vision problem that can affect their learning, development and behaviour. Typically children are referred in by their doctor, school teacher, psychologist, occupational therapist or speech therapist. However adults who have had brain injuries from trauma or vascular disease may also require assessment when their eye-teaming abilities break down. If you have any concerns, you do not require a referral, however if you have any relevant reports, please bring them in.
Children’s eyes are complex. They are constantly developing and changing to meet the demands placed on them at different stages of their young lives. Seeing clearly in the distance (ie 20/20 vision) does not equate to having clear NEAR vision. Nor does it mean that the child has good focusing, scanning and eye teaming skills to ensure that the image remains clear, in order to learn and then make sense of what is seen.
Recommended eye testing times are as follows:
- Age 6months: assess for eye disease, significant refractive errors that is not normal for their age, eye turns and lazy eye.
- Age 2.5 years old and age 4.5 years old (preschool): in addition to standard testing, screening tests for binocular vision, eye movements, colour vision and stereovision are conducted
- Primary school years (5-12years old): examine every 1-2 years, assess in detail the child’s vision, health, binocular vision and developmental visual perceptual testing if learning difficulties exists. Myopia (short sightedness) is rising in prevalence in children in middle to late primary school due to increasing near activities such as reading and screen time. Assessing if the child will become myopic soon or has a low degree of myopia is critical as we have available interventions to help reduce progression for this very common disorder.
- Secondary school years (13-18 years old): examine every 1-2years. The demand on vision is highest in this group. It is not unusual to see more children become myopic or their myopia increase. Intervention is key, to prevent long-term damage to the eyes. Furthermore some visual skills may need enhancement in order for the teenager to perform to their potential in the classroom or sports field.
No child should miss their reviews as eye problems can emerge or change. Children and their parents are unable to know what normal vision is, as seeing clearly in the distance does not represent good functional vision.
Binocular vision is the interpretation of information coming from signals in both eyes. It results in the ability of the brain to coordinate the eyes to work together as a team for clear and comfortable vision, as well as have good depth perception (stereoscopic vision). The eyes need to meet at the same point in space, make the visual target clear and remain clear, and yet be aware of vision in the periphery. When binocular vision breaks down, the image can be blurry or double, or there is partial/full loss of signal from one eye.
- Poor eye tracking – this is when eye movements are inaccurate and when reading, words or whole lines can be missed.
- Poor eye-teaming or convergence – this is when the eyes do not point to the same place in space to where the actual object is.
- Poor accommodation or focussing – this is when there is a single image of the object but it is blurry.
- Poor vision in one eye – the signal is weaker and sometimes lost from one eye.
- Trauma, brain injury/disease – this can result in a variety of binocular vision deficits.
Visual perception is the ability of the brain to make sense of what we see. It is a complex processing involving different brain structures to receive and interpret the visual information, to then act upon it. Good visual processing means we can process the information quickly and accurately and also store it for later recall. Deficits in visual processing lead to poor academic performance, poor academic performance, reduced self-esteem and difficulties performing simple day to day tasks.
There are different elements to visual perception:
- Visual attention – the ability to focus on what visual information is important and filtering out those that are not/less important.
- Visual spatial – the ability to recognise that forms are the same but in a different shape. Example is chair that is turned upside down is still a chair, but the letter b and d may look the same but have a completely different meaning.
- Visual discrimination – the ability to discriminate one shape from another.
- Visual form constancy – the ability to recognise the same form when it is a different size, colour or spatial orientation and that there are variants of the form. Example is cursive and non-cursive writing.
- Visual memory – the ability to remember the visual form once it’s removed from your sight.
- Visual sequential memory – the ability to remember a sequence of items when removed from your sight.
- Visual figure-ground – the ability to find forms when camouflaged or hidden amongst many other forms.
- Visual closure – the ability to see partially formed forms when they are incompletely shown.
- Lazy eye – vision in one eye is significantly not as clear as the other eye.
- Turned eye, in or out, up or down.
- Nystagmus – eye uncontrollably moves from side to side.
- Head tilting when reading or writing.
- Covering one eye to read or watch the TV.
- Losing place when reading, skipping words or lines, or re-reading the same line.
- Poor reading comprehension.
- Headaches, or sore/tired/watery eyes when reading.
- Cannot sustain a steady flow of reading or writing after a short period of time.
- Messy handwriting, size of words and numbers and spacing between them are inconsistent.
- Reading slowly with a lot of effort, using a finger or a ruler to guide reading.
- Unable to read when the print size is small, or avoidance of near work.
- Concentration is poor, fidgeting, attention span is short, can show disruptive behaviour in class.
- Holding a book too close, or sitting close to the TV.
- Young children not writing or drawing on the centre of the page.
- Declining academic performing with each grade level, due to increasing demand on the visual system.
- Car or motion sickness.
- Slow to complete work.
- Blinking and rubbing the eyes often.
- Touching objects to understand them.
Dyslexia is a language-based learning problem. Educational psychologists can test and diagnose dyslexia. A behavioural optometrist can assess if there are visual problems that can be alleviated or lessened, due to poor vision, poor eye teaming or poor visual information interpretation.
Behavioural optometrists are trained to help those in the special population, such as patients with autism, Down’s syndrome etc. They ensure that vision is optimised by using glasses (with special lens designs) and vision therapy.
The first examination will be a comprehensive examination. All patients are bulk-billed for this, with an additional fee of $30 for a retinal scan.
If the child requires binocular vision testing, this is also bulk-billed. If the child has learning difficulties, then developmental vision information processing (DVIP) tests are required. We offer two options – 45mins $150 for standard testing or 2x45mins $250 for a more in-depth examination. These fees will include a detail report to the school or referring doctor.
Vision therapy is not a cure for learning difficulties. However by improving the child’s range of visual skills, it will allow him to focus his effects in learning, rather than exert huge efforts to seeing what is on the page, computer screen or the board. It will also improve other aspects of his life such as sports, outdoor activities and can reduce headaches and sore eyes. Vision therapy can help the child catch up and not fall further behind with each school year. It can help the child overcome any current limitations and allow him to reach a higher potential.
Although we have a program in mind for each type of binocular vision problem or vision-related learning problem, each vision therapy program is customised for the child and changes dynamically during the program. The activities include sports-type games, computer assisted games and eye exercises to improve the skills important for learning or to enhance certain skills (eg in elite sports people).
Whether you want to play social or competitive sports, without the necessary visual skills, it will be difficult to perform well and enjoy the sport. Efficient visual skills required include pursuit type eye movement, peripheral vision, stereopsis (3D depth perception), as well as the ability to focus clearly at near and far quickly.
There are different types of vision problems that can impair a child’s development and learning. Some aspects are hard-wired and some are not, as the brain is plastic throughout our life. Some vision problems are highly successful such as convergence insufficiency cases. Others may have a poorer prognosis or need longer therapy programs such as a lazy turned eye. The behavioural optometrist will indicate to you the expected time frame needed. Sometimes a program is outlined for primary school with a follow-up program for secondary school to meet the higher visual demands and optimise their learning.
Progress reports are conducted typically at the 6th or last session of each vision therapy block. It allows the parent to report any changes seen, and for the optometrist to quantify changes in the testing parameters.
A 6 week block of vision therapy, once a week in-office sessions is $540. These sessions run for 40 minutes.
Currently vision therapy is not covered by Medicare or Health Funds.