Seeing Is Believing: Part 3 – The Nuts and Bolts

In Part 2, we looked at the importance of asking questions over giving answers while administering Vision Therapy, a concept to be revisited in the conclusion to this series.  For today’s entry, let’s discuss strategies for walking patients through Vectograms. The do’s, the don’ts, and the now whats?

For as much importance as we put on our influencing patient’s lives, we try very hard not to influence their answers. It’s an interesting dichotomy and definitely a delicate dance. This is why when training new therapists, my discussion points are pretty straight forward. For now, let’s view it through the eyes of a therapist administering Vectograms.

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Know Your Audience –  Dale Carnegie makes a point that before giving a speech, you should do your best to understand who will be listening. This may seem like a no-brainer to some, and maybe not so much to others. Although we’re not giving a great speeches in the therapy room, the premise definitely applies. Know who you’re speaking to: how old they are, their diagnosis, any significant medical problems, have they suffered a brain injury, do they suffer car sickness, do they enjoy 3D movies, have they ever seen three dimensionally before, are they on medication, do they have emotional concerns (you’d be surprised how many people I’ve made cry with Vectograms) and are they prone to headaches?  These are but a few, yes only a few, of the items I’m looking for in preparing for this activity.  For newer therapists, and even the more experienced, Vectograms becomes a lot easier to administer when you have a strong idea of the patient’s makeup long before they enter the VT room.

Keep Them Talking – Even with the best preparation, you may be surprised what question, response, hiccup, fidget or squirm may elicit a given response. I once had an adult patient with perpetual flat fusion tell me about her entire weekend at a winery while viewing the Vectogram. At the end of her 5 minute story, she asked “when I moved the circle closer to her?” (I was seated behind her and out of view the entire time), and I explained I hadn’t moved. She was experiencing SILO.  Obviously, we want to steer the conversation towards the activity, but sometimes those little diversions are helpful because by not focusing so hard on the problem, and maybe even relaxing a bit, her awareness changed. Get them talking about the picture in front of them, the small details, the gross details, all of it. Your new favorite phrase should be “tell me more”.

Quoits for Blog

Paralysis Through Analysis – Get their mind off the “the right answer”. When I was a little less confident in my abilities, I would tiptoe around this one, always trying to divert the conversation elsewhere when asked the “what am I supposed to see” thing.  Nowadays, my answer is simple: there is no “supposed to”,  seeing is different for everybody.  It may seem a bit direct, or even edgy, but it quickly closes the door before something begins to fester.  I don’t want the patient over analyzing the situation, trying to figure out why they’re not seeing the invisible purple elephant and becoming more frustrated as time goes on, it doesn’t help.  Report the image back to me as it appears and let me do the heavy lifting.

Consider Your Background – This one is big for me. If you’re lucky enough to have a window in your VT room, you may have noticed that the Base In targets are much easier to work when affixed to that window.  For me, this is true for a few reasons.  First, looking far away (divergence) is more real when it is done in real space, as opposed to when seated in front of a Vectogram holder.  For patients who struggle with the visual vs. logical conundrum, convincing themselves that the virtual image is beyond (or through) the big white piece of plastic in front of them is tough.  Especially since they know the cards are in front of that plastic.  The outside view provides as much depth as they need to diverge.  In my view, divergence exercises on the window also help with the skills transferring from your VT room to the real world, because they seem more real to the patient.  Base Out targets (pushing convergence) tend to work better on the Vectogram holder because that big white piece of plastic offers some necessary spatial and visual grounding, among other things.

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Know Your Targets – Quoits, Clown, Spirangle, Chicago Skyline and Mother Goose all offer different challenges. Will your patient benefit from a target with more detail (like the Clown) which will pull more attention to their central vision, or will they benefit from less detail (like the Quoits) which will allow them to be more peripheral? Will they benefit from the target being larger -yes, size matters here – since we can project it onto a screen?  With some patients, our choice of target is less important, and with some it is everything. If you’re unsure, my guess is there’s a doctor down the hall that can help 🙂

Make It Dynamic – A few years ago, I attended the Southwest Congress of Optometry in San Antonio, the year Dr. David Cook was the keynote speaker.  Dr. Cook – who, by the way, is nothing short of amazing – did some interesting things with the Vectograms. Most notably, he violently shook the picture in front of the patient’s face, which seemed simple and brilliant at the same time. When I got home, I tried this technique with a few of my tougher patients who did not report SILO, and it helped the majority of them.  Dr. Cook explained that the movement of the targets helped to stimulate peripheral awareness, which of course assists with depth awareness.  Something to else to try.

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Change Their Space – This one is by far the best for me. Do walkaways, even if they report little or no awareness of depth.  First off, backing away from the target lowers the demand which makes it easier.  Secondly, asking them to be aware of the changes in space between their body and the target as they back away opens periphery and calls attention to areas of vision most responsible for depth awareness. For those that struggle with the logical input vs. visual input issue, moving through space almost gives them “permission” to see depth because they are changing the picture with their movement

Spirangle for Blog

Know When To Quit – Sometimes, nothing works. As with everything in your VT room, there is a threshold between benefit and detriment.  If you’ve exhausted your tools and the patient has had little or no success, time to punt.  Protect the patient’s emotional well-being and visual dignity, and move on. We can always review our strategies with the doctor and circle back to this after other individual skills are improved.


Posted on January 8, 2014, in From My Perspective.... Bookmark the permalink. 2 Comments.

  1. Hi Robert:

    Just wanted to let you know that I’m really appreciating this sequence on Vectograms. Not that I’m not aware of most of this, but it seems to really help me remember helpful tips that have slipped to the back of my mind. Reading your experiences also brings to mind some of my own patients and gives me some new ideas to try – so many thanks. Jenni


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