As we make this last dash to the finish line of the Wachs Mental Minus series, a few important questions have been sent my way since starting this group of posts that need to be addressed:
If your patient is having trouble with one of the levels, is it wrong to move them back from the target so they have more room to work with?
To be clear, there doesn’t seem to be a right or wrong here. That is really the beauty of much of Dr. Harry Wachs’ contribution to the Vision Therapy world, very little of it lives in the sphere of ‘right or wrong’. Instead, it seems to be more of a ‘start where they are’ prospect, with the unspoken challenge to offer an appropriate increase or decrease in difficulty depending on the patient response. So, in short, as long as you know where the patient currently is and what steps you will take to help them find success, altering the specifics to match current ability levels seems just fine. After all, if there is one thing I know about Dr. Harry Wachs, it’s that he loved when doctors and vision therapists would think outside the box.
I am currently working on my COVT and am having trouble with the idea of different font sizes for different patients. Wouldn’t it be better if everyone worked with the same size letters to keep things consistent?
First of all, congratulations on your decision to complete your COVT! Surely, you will do very well!
In a perfect world, you are correct, consistency is best. The hard part is just as every patient is different so are their levels of ability. It would be hard to consider someone ‘incapable’ of finding success in this accommodative series simply over the size of the target, but that doesn’t make your point irrelevant. For me, every activity should have an attainable finish line, and if that means larger print, then so be it. The key is to note it and discuss the patient’s performance with your doctor afterwards, as my guess is, the two of you will find even more modifications to match your patient’s current skill level as well as new and creative ways to help them advance. At some point, those modifications may include smaller print.
You mention the “Where is It” circle often but I thought focusing was in the “What Is It?”. Can you explain that to me?
Thank you for asking this question. In some variation, I have received this question six times since posting Part One.
Yes, you are correct, for the most part, Accommodation is all about Identification – or the “What Is It?” circle. The piece to consider is what skills are needed to achieve successful accommodation? Some part of landing a clear target on our fovea has to be where in space to look. This becomes purely a Z-axis issue. If the object I am trying to clear is 10 feet away, and I adjust my focus so objects 30 feet away are clear, the original object at the 10 foot spot will be blurry. In order to make it clear, I need to know where it is in terms of distance from my fovea. By definition, this is a “Where Is It?” equation. Remember, though, everything affects everything. Even though we might be wearing a patch or perhaps are not trying to strengthen vergence with a given activity does not mean vergence isn’t active. Vergence and accommodation have a symbiotic relationship. Vergence (among other skills) is solving the “Where Is It?” challenge as a platform for accommodation solving the “What Is It?”.
The Finale – Bi-Ocular
Get rid of the patch, kids, things just got real.
To cover the technical – comfortably seated, Harmon’s distance, age appropriate sized font.
This level is the culmination of all skills covered in the Wachs Mental Minus series. To find success, our patients need to be able to call up each aspect gained in previous levels and bring them to the party. As the Vision Therapist, I myself feeling like a sports announcer offering a play-by-play to my patients as a means of coaching them through as they find success. You may find yourself needing to talk patients through this most advanced level.
In a comfortable posture, the patient holds the lens in front of one eye. Remember, both eyes are to remain open and gathering information. If done well, the patient should experience an overlapping of images – the smaller in the lens (assuming you are using a minus lens), and the larger through the eye without the lens. If your patient tends to suppress, we may need to find ways to help them keep both eyes seeking visual input. This may include moving their finger quickly in front of the suppressing eye, or even asking them if they can find ways to look more through their suppressing eye.
As an aside, I had a patient once who named each of her eyeballs, and when one wouldn’t cooperate, she would yell its name as loudly as she could and demand it worked harder. I don’t recall the names she chose, but do recall having a good laugh about it when she graduated as she shared one of her neighbors became concerned she was being attacked one afternoon and ran to her rescue. Good times!
With the eye looking through the lens, the patient should be instructed to clear and then blur the image. The image in the other eye is not to be cleared intentionally, and is only relevant as a means of suppression check. The image in the lens should be cleared and blurred repeatedly. As the Vision Therapist, we want to be watching for pupillary response as well as a vergence response from the eye not looking through the lens. These will be our best indicators of patient success. That, and the constant reporting of feeling tone from your patients, as by this level, feeling what is happening is a key component. If your patients experience SILO during this level of Wachs Mental Minus, even better. As always, this should be repeated with the other eye and performances compared. Ultimately, the patient should have the same experience with each eye.
Some ideas for making loading or unloading this activity might be changing your target size. Consider using a target that moves (Marsden Ball) as movement tends to help with the “Where Is It” challenge. It is also one of our monocular depth cues. Have the patient change their gravity by standing, walking, or even attempting these levels while on a balance board. Try different powers of lenses to work on JND’s. Or if your patient needs a much higher level of challenge, try having them wear binocular prism (low BI or BO) to add in a BOP and BIM component.
Wachs Mental Minus, as a series, is a very powerful accommodative challenge which seems to provide opportunities to challenge each skill area involved in efficient accommodation. As a Vision Therapist, if you have the framework of each level, and in the moment ask yourself “what skills are needed to find success?”, the benefits to your patients are inevitable.
Cheers!
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