Colin J. Kageyama, O.D., FOVDR - Los Altos

Binocular Vision Dysfunction is a generic term for any condition in which the patient is unable to target the two eyes accurately at any distance or at any time. Some of the most common binocular disorders are: Convergence insufficiency Reduced tendency to converge eyes when looking at near Convergence excess Excessive tendency to converge eyes when looking at near Accommodative insufficiency Reduced tendency to focus eyes when looking at near Accommodative excess Excessive tendency to focus eyes when looking at near Strabismus Visual posture of the two eyes far enough out of alignment that visual fusion does not take place Amblyopia Structurally normal eye that loses the ability to see clearly A patient who recently developed binocular vision dysfunction tends to be very symptomatic and uncomfortable. Patients with long-term binocular dysfunction often have no symptoms or awareness of double vision because they have adapted compensation.

Convergence insufficiency is a condition that affects 7% of the population. Patients with convergence insufficiency can have poor voluntary abilities to point their eyes inward when looking at objects or print at near. Patients with recent onset convergence insufficiency are often symptomatic with complaints of blurred vision, double vision, eyestrain, or headaches. In its early stages, convergence insufficiency is the most treatable binocular dysfunction. Studies have shown a 70-95% success rate in treating convergence insufficiency.

Experts estimate 80 percent of what we learn is acquired through vision. When an adult or child sees 20/20, that does not always mean that the eyes are working together properly. There are many types of vision dysfunctions. Some can cause eyestrain, double vision, blurred vision, headaches, motion sickness, or dizziness. Some are visual impairments such as Amblyopia and Strabismus (eye turn) issues. In its early stages, convergence insufficiency is the most treatable binocular dysfunction. Studies have shown a 70-95% success rate in treating convergence insufficiency. Vision Therapy is the preferred treatment for many of these dysfunctions Both children and adults can benefit from vision therapy for the treatment of binocular (two eyes) dysfunctions, Strabismus (an eye that turns), Amblyopia (reduced vision in one or both eyes), eyestrain from computer use, and for general visual enrichment. Some of the signs and symptoms of having vision problems are listed below: Frequent headaches Eye tire quickly when reading or doing homework Head moves when reading across the page A finger is needed to keep place while reading Skips lines, words, or letters when reading Closes or covers one eye for near work Difficulty copying from the board Complains of double vision Rubs eyes when reading Excessive blinking Holds book close to face when reading Reduced attention span, can only concentrate for a short amount of time Covers one eye by leaning on a hand Spends a long time doing homework that should only take a few minutes Must re-read material several times to understand what has been read Avoids activities that include reading or close-up work Avoids academics If you would like to explore how Vision Therapy can help with any of the above issues, make an appointment with Dr Kageyama for a free consultation or Full Functional Vision Performance Evaluation.

3D Vision has become a very hot topic. "3D vision" refers to the ability of a person to fuse the information received from the two eyes together. This fused picture can be used to recognize whether the object is moving toward you, its distance, its depth, its velocity, and its projected destination. Stereopsis is only possible when accurate and precise visual binocular fusion is present. In cases of strabismus and lazy eye, many patients are unable to appreciate stereopsis. Stereopsis is seldom present in patients who underwent eye muscle surgery in an attempt to correct their strabismus. Stereopsis has also become a "hot topic" in education Because it has been shown to be an extremely effective method of teaching certain types of complex educational material. Some educators have won national awards for the work in creating 3D Vision presentations of educational materials. Dr Colin Kageyama's optometric practice finds that 3D Vision is a good indicator of the quality of binocular vision. A patient can have eyes which are cosmetically straight, but not actually use both eyes at the same time. Such a patient would have little or no stereopsis. When these patients are taken through a program of vision therapy and true fusion is achieved, one of the best indicators that progress has been made is their increased ability to see depth on 3D targets.

Strabismus is a vision condition in which a person cannot align both eyes simultaneously under normal conditions. One or both of the eyes may turn in "cross eyed" (esotropia), out "wall eyed" (exotropia), up (hypertropia) or down (hypotropia). An eye turn may be constant (when the eye turns all of the time) or intermittent (turning only some of the time, such as under stressful conditions or when ill). Whether constant or intermittent, Strabismus always requires appropriate evaluation and treatment. Strabismus most often develops in infants and young children although it can occur in adults. It is estimated that up to 5% of all children have some type or degree of Strabismus. Treatment for Strabismus In most cases the problem does not improve on its own as the child grows. Treatment varies depending on the cause of the eye turn and may include: Eyeglasses Vision Therapy (Non-surgical approach) Eye muscle surgery Vision Therapy can in some instances correct the Strabismus muscle. Surgery can sometimes straighten the eyes, but a program of Vision Therapy is often necessary to restore full visual function.

One of many reasons why infants/ children/adults should have a comprehensive eye exam with a Developmental Optometrist is the possibility of Amblyopia. Amblyopia (often misnamed "lazy eye"), is a condition where one eye does not see nearly as well as the other. This condition is not correctable by glasses or contact lenses. Amblyopia is not due to any eye disease. The brain does not fully acknowledge the images seen by the Amblyopic eye. The favored eye compensates for the Amblyopic eye so the child/adult may not be aware of the problem. This may lead to other dysfunctions such as poor depth perception (3D). An infant/child can look perfectly normal, even if one eye has amblyopia. Treatment is often delayed because the parents think that the child is fine and that there is no reason to see a Developmental Optometrist for a comprehensive eye exam. As a consequence, the child or adult may be more difficult to treat and correct in later stages. Causes of Amblyopia Anything that interferes with clear vision in either eye during the critical period (birth to 6 years of age) can cause Amblyopia. Listed below are reasons why Amblyopia can develop in childhood: Misaligned eyes or constant Strabismus Significant differences between the clearness of the images seen by each eye due to farsightedness, nearsightedness or Astigmatism An obstruction of vision within one eye due to injury or disease Treatment of Amblyopia Early treatment is usually simple, often employing glasses and Vision Therapy. Prolonged eye patching is usually not a part of Amblyopia treatment at our office. While detection and correction before the age of two is considered to offer the best outcomes, recent scientific research has disproven the long held belief those children over seven years old cannot be successfully treated. For more information, see the press release at National Institutes of Health.

A binocular problem of recent onset tends to make a person uncomfortable at certain distances and while doing certain tasks. In the early stages, a binocular problem may affect the comfort, effort, and duration over which a person can work visually at a given distance or task. If the issues of visual comfort, effort, or endurance become excessive and long-term, a patient may develop compensations to address these issues. If the visual act of reading is uncomfortable, a person could simply prefer to stop reading. This can result in reading problems developing due to a lower volume of reading. Visual Performance Problems It is also possible that patient may not be able to multi-task and keep all aspects of their vision working simultaneously. A patient might prefer to eliminate either blurred vision OR double vision. The area of lesser emphasis may develop issues of speed, endurance, accuracy, or agility. These become "visual performance problems." Visual Attention Problems A patient may learn to ignore visual information that is inconsistent. These become "visual attention problems." Visual Intelligence Problems A patient may learn to concentrate on the sensory systems that are working well… taste, touch, or hearing… and not develop advanced skills in vision. These patients may never develop "high visual intelligence". Go over the following checklist and see if any of the following applies to your child: Blur when looking up close Headaches when looking up close Falls asleep when reading Writes uphill or downhill Poor reading comprehension Holds reading material very close Clumsy/knocks things over Homework takes "forever" Low IQ "processing speed" Reverses b/d and p/q Smart in everything but school Double vision when reading Words run together when reading Skips/repeats lines when reading Tilts head/close one eye when reading Omits small words when reading Avoids sports or games Labeled "lazy," "slow," "ADD," or "dyslexic" Reverses was/saw, on/no, or 12/21 Poor handwriting Struggles with reading/writing, better at math/science Low IQ "Perceptual Reasoning" If your child is experiencing more than one of these problems, your child could have a Functional Performance Vision problem.

Performance of any type can be measured by certain parameters... speed, endurance, agility, accuracy, and the ability to perform these functions under stress. This concept can be applied to many types of visual skills. Visual speed can measure how quickly a patient can: focus their eyes to see clearly, converge their eyes to fuse the information into a single picture (eliminate double vision), and visual track by moving their eyes from place to place (either left to right, far to near or a combination of the two). Visual endurance can affect how long a patient can stay on task and may affect their performance over time in reading, writing, or sports. Problems of visual endurance can cause a student to start out well but quickly get tired or "lose interest" when reading or writing. Problems of visual agility may make the task of copying material from board to desk very difficult. Problems of visual accuracy may affect a child’s ability to accurately judge visual location. These problems may affect a child’s ability to: write neatly, keep proper spacing between letters, words while writing, learn the alphabet, or recognize sequences of letters to spell words. Problems with visual skills breaking down under stress can result in a student having difficulty studying in noisy conditions or being very poor at test taking. Dr. Robert Pepper developed a test that was called the Pepper Concentration Profile to measure the breakdown of visual skills under stress. Speed, endurance, agility, accuracy, and ability to do well under stress become increasing important in grade 4-College. They are often not as much an issue in grades K-3.

There is a common saying that some people see the forest, while others see the trees. This means that some people tend to pay attention to the big picture, while other people tend to pay attention to all the little details. To have a static set of behavior by which a person pays attention to either the forest or the trees would be beneficial in some activities and a handicap in others. Static patterns of visual attention may mimic such conditions as ADD, PDD, or high functioning autism. The most functional pattern would be a person with have a dynamic set of behaviors, who could shift visual attention from “big picture” to “details” when appropriate. Poor Central Visual Attention (Paying Attention To The Forest) Other children develop just the opposite adaptation for binocular vision dysfunction. They may learn to concentrate on the big picture visually and ignore the details. Such a child may appear to be careless or “lazy.” It is frustrating their parents, because they may see a child who can pick up general concepts easily, achieve moderate success learning very quickly, but seem to have difficultly ever achieving excellence. In general, eye movement issues in conjunction with patterns of visual attention disorders are more difficult to treat. Peripheral visual attention disorders are more difficult to treat than central visual attention disorders. Does your child exhibit any of the following behaviors? If left alone, homework is completed quickly with frequent apparently careless mistakes Quickly gets organized and starts get projects (fast starter), but may have difficulty completing them accurately. Reads quickly but often doesn’t read what is on the page, clipping letters off the ends of words, or apparently guess on words that are not known, as opposed to sounding them out. Good comprehension for concepts but missed the details Gets the general idea of projects quickly but fails to achieve mastery or excellence Writing is fast and messy Reading speed is often fast with poor comprehension Often good with sports but having difficulty in school Poor Peripheral Visual Attention (Paying Attention To The Trees) Children who have excessive concentration on central visual information are often easy to identify because on apparent inconsistencies in academic performance. These children can appear to be "perfectionists" and given enough time, may be capable of producing incredibly detailed work. Problems can occur because they can be slow to finish their work and may sometimes appear to miss central concepts of their assignments. Young children with excessive central visual attention may find that is easy for them to identify words, but hard for them to find the words, and read them in text. They may find it difficult to pay attention to location, which can results in errors of location, orientation, sequence, or direction when writing or reading. When oral reading text, it is common to see young children with excessive attention to central visual information be able to read large (advanced) words, while making frequent mistakes with "small" basic kindergarten sight words. If these patterns of visual attention are found in conjunction with one of a dozen patterns of binocular vision dysfunction, it is likely that there is a relationship between the two. Binocular vision dysfunction may result in discomfort when reading and writing. A child could learn that concentrating on visual details and ignoring “the big picture” could result in less awareness of double and greater visual comfort. Children who settle on this option, assume a pattern of behavior that makes them more comfortable, at the expense of making them less functional for certain activities. Does your child exhibit any of the following behaviors? Homework that should be done in a few minutes often takes hours to complete Takes a long time to get organized (slow starter) Reads large words in words lists but misses small words in text Skips words, skips lines, or re-reads words in text Perfectionist and slow but often has difficulty grasping concepts Trouble writing on the line, letters of different size, spacing is poor Slow reading speed or lack of fluency, reads one word at a time Difficulty with letters involving sequence or direction, b/d, was/saw, or 12/21 Difficulty playing ball games or with hand-eye coordination

Neuro-Psychology recognizes that there are many different types of "intelligence," the ability to learn new skills through different modalities. The WISC-V is an example of an IQ test that measures multiple types of intelligence. This test breaks intelligence into four parts: The ability to learn from listening (Verbal IQ) The ability to learn from information from the peripheral visual field. (Visual/Spatial) The ability to learn from information from the peripheral visual field. (Fluid Reasoning) The ability to remember information (Working Memory) The ability to perform tasks quickly (Processing Speed) Many children who score poorly on tests of Working Memory and Processing Speed have IQ tests scores that are artificially lowered by problems of visual attention or visual performance. The parents of these children are often told their child has a non-verbal learning disability. This means that the child’s verbal skills are good, but their scores on visual IQ or processing speed IQ are low. It is not unusual to see a child’s low scores in visual IQ or processing speed IQ raised 20-30 points after completing a vision therapy program that successfully enhances visual performance and visual attention. When a child scores poorly on a given section of an IQ Test, some professionals jump to the conclusion that that represents that something is physically wrong with the child, that the child somehow lacks the brain “hardware” to learn in certain ways. This is not always the case! When a child scores poorly on a given section on an IQ Test, is simply means that the child did poorly on that particular test. It does not identify WHY the person did poorly on that test. We have identified several patterns of scores on visual performance testing that identify patients who will have large increases in non-verbal intelligence (and learning ability) following successful enhancement of these visual skills.

What is Vision Development? Vision Development is a learned PROCESS that begins before birth. It is a dominant process in the development, growth, and daily performance of people and involves approximately 70% of the pathways of the brain. It is estimated that 80% of our learning happens through our vision. Processing visual information requires involvement of every part of the brain. Eyes are not physically developed fully until at least four (4) months of age There is research which supports that stimulation from the world plays a part in allowing a baby the ability to see clearly (20/20). Further development of vision occurs in an orderly sequence, though milestones are reached at different times for different children and in some cases, adults. Reaching these developmental milestones is crucial in creating a solid foundation for optimal seeing, observing, visualizing, remembering, learning and being efficient in employing life skills. We do not typically observe signs to measure progress of vision development, but rather evidence of problems once they have occurred. Other good components of good vision include healthy eyes, visual acuity that is age appropriate, visual integration and visual skills such as eye teaming, focusing and tracking. At the office of Colin J. Kageyama, O.D, FCOVD, we evaluate these vision components, the first step in helping people in all stages of life reach their optimal vision potential.

Vision Therapy (also known as VT) can benefit people of all ages. Performed under the Doctor's supervision, Vision Therapy is a progressive program of vision procedures individualized and updated to fit the needs of each patient. Unlike other forms of exercise, the goals of Optometric Vision Therapy does not include strengthening the eye muscles, because your eye muscles are already very strong. Although Vision Therapy activities do cross over into the areas of Occupational Therapy and Educational Therapy, what separates vision therapy from other therapies is the exclusive use of lenses, prisms, flippers (a kind of double-lens tool) and anaglyphic (3-D) filters. Other tools used in Vision Therapy include occluders (patches), electronic targets with timing mechanisms, balance boards, customized VT computer programs (including reading, visual memory, perceptual skills and much more), board and specialized card games, building activities and a wide variety of books. Powerful changes are created in visual perception and spatial awareness with the tools used exclusively in Vision Therapy. Over several decades, Behavioral Optometrists have developed and used Vision Therapy in combination with the appropriate tools for the purposes of: Preventing vision and eye problems from developing Developing visual skills to perform more effectively in school, work and play Enhancing abilities on tasks requiring sustained visual effort Remediation or compensation for existing vision and eye problems There are five key areas of function that Vision Therapy addresses: Visual Motor Guidance (gross motor and fine motor) Eye Tracking (ocular motility) Eye Focusing (near and far accommodation) Eye Alignment (binocular convergence and divergence) Visual Information Processing (includes visual memory and visualization) Our programs differ from many others in its emphasis. These last five functions are often taught as five separate skills. Our therapy is organized in a different fashion. It starts with a revolutionary statement: "Binocular Vision Dysfunction can lead to adaptations. It is essential to identify which patients have developed adaptations to binocular vision dysfunction that affect academic performance." Visual Performance: Some adaptations affect the speed, endurance, accuracy, consistency, and agility with which the patient can input visual information from the two eyes. Problems in these areas may result in low scores in the Working Memory and Processing Speed sections of common intelligence tests, but these problems occur at the visual data input level, not the brain processing speed level. Visual Attention: Other adaptations to binocular dysfunction affect visual attention to either visual detail or visual location. These problems often mimic developmental issues such as ADD, learning disability, or high functioning autism. Visual Intelligence: The ability to learn from what is seen. Problems in these areas often depress the child’s scores in the Working Memory and Processing Speed sections of common intelligence tests. These adaptations can then result in reduced ability of the child to act upon the information received from the two eyes. This can often mimic such conditions as dysgraphia and dyslexia. We succeed! We feel that in order to achieve the elusive goal of consistent results, we must first identify the patients who have developed adaptations to binocular vision dysfunction that affect academic performance. Then at the proper time, we address the problems that exist in the areas of visual performance, visual attention, and visual intelligence. It’s not something that we could teach an assistant to do with 30 or even 300 hours of instruction. It was a long process that took us over 27 years, and 30,000 hours to learn. It is the core of what we do and the reason that we are advocates of the concept of "Doctor Provided Vision Therapy." Helping your child is a responsibility that we take very seriously! It is the reason why both Dr. Colin Kageyama and his son Dr. Kelly Kageyama spend over 70 hours each week personally doing and directing vision therapy.