A Sit Down – with Dr. Carl Garbus
This post appears as part of a series called Sit Down – candid conversations with real people detailing their journeys and experiences with Vision Therapy.
A Sit Down – with Dr. Carl Garbus
For the benefit of our readers, can you explain how you are involved in Developmental Optometry?
I graduated in 1980 from the Southern California College of Optometry and joined my father in private practice. I have been practicing optometry for 33 years. The first 20 years I was more involved with general practice and contact lenses due to the location of the practice in downtown Los Angeles. My father and I had been partners during that time. Our patient base emphasized more adults because of our work environment. When we moved the practice to Valencia, CA the whole picture changed due to the demographics. Now we have two practices. One office emphasizes adult and pediatric care along with vision therapy. The other office is dedicated to serving the brain injury population including stroke, autism and head trauma. Working with children has been a real blessing and fun! The practice move to Valencia, CA opened the world up to providing vision therapy and neuro vision rehabilitation. We provide a wide range of therapy programs including Interactive Metronome and the Sensory Learning Program.
How did you first hear of Developmental Optometry?
In optometry school there was little opportunity to learn developmental optometry. We did have access to the Studt Practicum and some OEP meetings. After graduation I started attending COVD meetings. Today students have an advantage of being exposed much earlier to developmental optometry, and the three important organizations that support developmental optometry.
After completing your undergraduate degree, what was it that led you to Optometry School and why?
When I was in high school I was already working at my father’s optometric practice in Los Angeles. My pre-optometry undergraduate work was at California State University, Stanislaus. This was a small rural college in Turlock, CA. I was so fortunate to have my father in the optometric field because it was a constant reminder that this is the best profession. I learned a great deal from my father, but one thing that sticks out was that you really need to communicate well with your patients.
How do you describe Vision Therapy to your patients?
Vision therapy is the best kept secret as most parents have not heard of this program. The education process starts early in the examination when we review the COVD Lifestyle Checklist. I also have the teacher – student questionnaire courtesy of Bob Sanet. This questionnaire is given to the parents to take to the child’s teacher. During the examination I usually have the child read a short paragraph/ story out loud. This gives me an opportunity to observe body posture, working distance, head position, and how well the child is able to complete the task at hand. Then we will ask some questions about the story. This presents some insight as to the efficiency of the child’s functional reading. It also provides an opportunity to discuss academics to the parent(s). If time permits we will run a Visagraph. Vision therapy may be discussed, but usually not until after the Visual Information Processing battery is done. During the parent conference we discuss vision therapy in detail. It is important that the parents understand how vision plays a role in learning. This is where the education comes into the picture. Using examples about how the child struggled with reading during the examination or how the child does not know their right and left directions illustrate the learning issues. Explaining how the test scores relates to school academics and learning helps to paint the picture for the parents.
What is NORA (Neuro-Optometric Rehabilitation Association) and what is their mission?
The interest level in NORA will continue to rise as the rehabilitation world becomes more aware of the importance of the role of vision. NORA is the organization that is the bridge between optometry and other professions dealing with rehabilitation. NORA is a diverse group of professionals dedicated to advancing the art and science of rehabilitation of the neurologically and cognitively injured and disabled survivor population and their families.
NORA emphasizes treatment modalities designed to optimize the frequently neglected visual-motor, visual-perceptual and visual information processing dysfunction in the neurologically affected person. There exists, within the profession of optometry, a group of concerned and highly trained professionals uniquely skilled and experienced in the technologies of neuro-optometric rehabilitation/habilitation of the persons affected. Integration of these unique Neuro-Optometric treatment modalities maximizes the potential of the rehabilitation team within a multidisciplinary approach.
Working relationships with other fields are an important piece of why NORA exists. Our job is to get the message out, so that more patients can be served by our practitioners and therapists. For NORA members, students and guests we strive to present a comprehensive educational program on annual basis. The organization has been in existence for 23 years and going strong.
You serve on the Board of Directors of NORA and currently sit as President of the organization. Why was it so important to you to participate in NORA’s infrastructure?
NORA is near and dear to me. My wife, Jenny (pictured), and I joined about 14 years ago. The first conference that we attended was in Breckenridge, CO. I remember that Josephine Moore, OTR, Ph.D. was the first speaker that day. She was incredible, as she reviewed the neuro anatomy and physiology of the brain. The majority of the audience was in awe because she could write and lecture at the same time. She was quite the artist with the chalkboard and she would not miss a beat as she was lecturing. Everything was perfectly timed. I was blown away by her knowledge. The meeting combined talents of many individuals outside of optometry. This is where I learned that a multi-disciplinary approach was the path to success for our patients with brain injury.
Since that first NORA meeting I have continued to attend every year. My friend and colleague Eric Ikeda, O.D. was very active in NORA. He was president back in 2003 and he assigned me to the curriculum committee. From there I continued to become more active with NORA and moved onto the board in 2005. Now I am finishing up my last term as President of NORA, having served 4 years. Over the last few years we are seeing signs that NORA is becoming better known nationally and internationally. We attracted attendees from seven different countries at our last NORA conference in April. NORA has something for everyone including students, survivors, therapists and doctors. NORA is a unified group and we listen carefully to what our members are telling us.
What constitutes a brain injury and what are some of the symptoms one may experience in the days and weeks that follow?
Brain injuries are more common than we think. Any insult to the head has the potential to generate a more permanent injury, especially if the individual has a history of past trauma. Coming through the birth canal can cause trauma. Toddlers frequently fall and hit their heads, but most of the time they are fine. A head injury in a young person (under the age of 20), will have different consequences than an older patient. The reason is that the frontal lobe has not completely developed at a younger age. The frontal region affects saccadic eye movements and executive function including decision making. It also affects personality and emotions.
Approximately 2.6 million people suffer a traumatic brain injury or acquired brain injury annually. The most common cause of traumatic brain injury is an automobile accident and the most common cause of an acquired brain injury is a cerebral vascular accident or stroke. The TBI causes damage to the brain that may or may not appear on an MRI. Many of the mild brain injuries (mtbi) do not show up on brain scans.
The symptoms can vary from light sensitivity and poor binocular control to double vision and veering off in one direction when ambulating. Speech and language skills can be affected, as well as, cognition. Daily living skills including dressing, eating, bathing and driving are often affected. The two areas that patients complain the most when they come to see the eye doctor is that they cannot drive and/or read which was their passion before the injury or stroke.
A brainstem injury can come from a simple whiplash in a car accident at slow speeds. The patients may develop symptoms that can occur 24 to 48 hours after the event. In the cervical region of the neck there are muscles, tendons, blood vessels and nerves. With the whiplash the muscles and tendons get stretched, as well as the nerves. The swelling that occurs is microscopic and takes about 24 to 48 hours to develop. The patient can experience dizziness, nausea, vomiting, photophobia and balance problems. It is possible that these symptoms will continue long after the accident has occurred.
In the case of a stroke there are regional affects. A stroke on the right side of the brain will affect functions on the left side. The patient may have a hemi-paresis on the left side or problems coordinating movements on the left side. If the right parietal lobe is involved, the spatial map is affected. This would influence navigation skills and localization. Speech and language is located on the left side of the brain.
Why are some brain injuries so devastating and some far less debilitating?
The location of the insult makes a difference. In a TBI multiple brain areas are affected because of the anatomy of the brain. The brain sits inside the skull and has three protective coverings known as the meninges (duramater, arachnoid and piamater). These are thin coverings. On impact the brain moves back and forth inside the cranium. The brain can easily bump into the cranium on each side. There is an acceleration and deceleration forces that takes place. In the process of hitting the cranium there can be shearing of nerve fibers and breaking of blood vessels in multiple locations. The aftermath that occurs takes a few days and during that time a cascade of chemical events takes place which causes further damage to the tissue. Release of enzymes will cause more destruction. Repeated CT scans are done to check the extent and location of the damage.
Other factors that affect the damage would be the age and overall health status of the individual. Someone with diabetes and hypertension that sustains a head injury or stroke is more likely to take longer to recover and have more deficits than a young athlete. If the patient has history of head injuries there could compounding of the damage in the same area that was affected previously.
Why is Vision Therapy effective with Traumatic Brain Injuries?
Let’s take a quick look at the vision pathways in the brain. The primary visual pathway takes vision information from the retina via the optic nerve and this information travels through the thalamus, temporal and parietal lobes before it reaches the occipital lobe. There are hundreds of additional pathways that circulate vision information. Every lobe in the cerebrum receives this information, as well as the brainstem and cerebellum. There is vision integration with other systems in the brainstem and all other brain areas. Links between vision and auditory and vision with vestibular form very effective networks when they working properly.
In the last few years, much more awareness has been called to the diagnosis and treatment of head injuries, specifically in sports. As a Developmental Optometrist prescribing Vision Therapy, do you find that simultaneous treatment of the visual system and other sensory systems works best, or is it more advantageous to treat one at a time?
Some of the practitioners out in the field like to use the term neuro vision rehabilitation or neuro optometric rehabilitation. The rehabilitation process needs to involve vision, if there is going to be the most complete recovery of function possible. Other sensory and motor systems are tightly linked to vision. If the vestibular system is ignored, our success rate for rehabilitation would be much lower. The integration of vision, vestibular and somato sensory systems is what makes the difference. With this in mind optometrists should be working hand in hand with occupational and physical therapists, as well as vision therapists. The rehabilitation team should include as many practitioners as it takes to get the job done. If we limit our scope to vision alone, then our potential for the highest level of rehabilitation maybe limited. Simultaneous treatment is the key for best results. This is the model that is used in the hospital setting.
Since Autism has been on the rise over the last decade, does NORA work to raise awareness of the benefits of Vision Therapy to those patients on the spectrum?
For the past three years NORA has incorporated a section on Autism during our annual conference in the clinical skills program. Our membership is very in tune with the importance of serving this population of patients and the impact that it will have on the child’s future. NORA will be looking into adding more information on our website to address the need to educate the public about Autism. In the future we will be having another program on Autism during our general conference, so there will be more exposure. We are always open for suggestions from our membership, as to what speakers would provide the most up to date information.
The late Dr. John Streff played an integral role in the formation of NORA. Can you speak to his influence on the organization on how NORA might be considered a piece of Dr. Streff’s legacy?
John Streff was one of the original seven who met and NORA was born. Others included William Padula, Vincent Vicci, Daniel Gottlieb, Gus Forkiotis, Todd Davis and John Thomas. John played an important role in the organization in many ways.
His early days at Gesell with Dick Apell provided an opportunity for interaction and discussion on the development of vision and the use of lenses. When one thinks about the population base of NORA, we often see many similarities with child development. It was through these thoughts that John influenced the beginning of NORA with the emphasis on one’s visual space world.
The important areas included the concepts of orientation, tracking/locating, focusing, eye teaming, visual span/volume of awareness/localization and visual unification. The unique insights into visual behavior and the use of lenses and prisms helped John to see things no one else had seen. This set a foundation for more appropriate treatment strategies and recommendations for visual guidance. The importance of lenses is based on the adaptations the patient has already made as well as what they do with the new lens or prism that has been provided them. One of the important aspects that John always emphasized was that lenses provide a unique opportunity and that optometrists use them in a much more important fashion than simply for refractive purposes.
For me, one of the key elements was his use of Socratic thinking. Rarely did you get an answer from John, but rather he would often respond by asking questions that led to a better understanding. One might ask what is important in localization and John might get you to think about the x,y and z axes…thus the volume of space. But then would ask if you were also including an awareness of where you are in space, and then what about if you add the concept of time. The one thing John always made you do was to think and to try to develop a better understanding of what the patient was experiencing and of course how to communicate that so the patient could better understand how to make appropriate changes. Thus making vision a personal thing and one can look for opportunities to self discover and use vision to become more efficient in their daily lives. I would suggest that in NORA, we continue to push for better understanding and treatment strategies that will provide an opportunity for patients to reach their maximum potential. There was collaboration with Curt Baxstrom O.D. with respect to this question.
NORA’s next Annual Meeting is coming up in April, to be held in Cary, NC. What might the attendees look forward to?
Our next conference will have several very interesting topics on concussions, visual field loss and treatment strategies and nutrition. We are going to tow speakers lined up for each topic on this subject, plus a panel discussion on visual fields. In addition the group that created and implement the concussion program IMPACT will be presenting a two day program during the Advanced Curriculum section. This may turn into a certification course on how to use IMPACT. On Friday night a special program incorporating therapeutic techniques used in Pilates for rehabilitation will be presented by Dr. June Chiang. NORA is an action packed conference over 4 days that leaves no time for rest. Collaboration with colleagues is one of the benefits of coming to NORA. Look for more information on the NORA website coming soon.
What educational opportunities does NORA provide to professionals, brain injury survivors, and their families?
Our annual conference is the highlight of the educational programs that we offer which is available for everyone. Survivors and their families do attend our conferences. Over the last several years we have made some significant updates to our website for our members. On the Members Only Section, one can access tons of information including how to obtain hospital privileges, medical coding, power point talks, clinical pearls, up to date bibliography and soon we will provide nutrition information. Currently we are building our student membership base and have over 500 student members. Six optometry schools have NORA Clubs and have put on lecture programs to bring the students into the field of rehabilitation.
How can readers support NORA’s mission?
We encourage vision therapists, patients and family members to become active in the NORA organization. One can join as an individual or as a group member. Group memberships are part of an organization, hospital or school. Access to the website (for members only) and reduced fees at the annual conference are benefits. Become active on one of our committees to interact with colleagues. This can be a very good networking opportunity. NORA is multidisciplinary and NORA is an educational organization, which helps to create a very unique learning environment. Come join the family.
Thank you for the opportunity to talk about NORA. For those of you who would like to get to know NORA better and to receive our E-new and E-Blasts contact firstname.lastname@example.org. Our conference is April 3-6, 2014 in Cary, North Carolina. Please join us. My email address is email@example.com.
Some Closing Thoughts – A special thank you to Dr. Carl Garbus for taking the time to complete this interview. I first met Dr. Garbus and his lovely wife Jenny circa 2004-2005 at one of Dr. Bob Sanet’s seminars in San Diego, CA. Dr. Garbus and his wife are wonderful people and amazing contributors to both Developmental Optometry and NORA. We are very lucky to have them on our side! Please join me in wishing Dr. Garbus, Jenny, and their entire staff the absolute best!