Blurry Vision and Leashes–Re-publishing A Blog From January 2011

Blurry Vision and Leashes?

I’ll have to admit when I first started seeing patients with Ron in the clinic I was having a little trouble mentally with the concept of blurry vision. As optometrists, we are taught to make people see clearly. Let’s face it. The number one reason why a patient comes into our office is that they want to see more clearly than they currently do. If you are the doc who gives them 20/15 vision, which means they are able to discriminate details smaller than the “20/20” standard you hear about, they are happy. Think back to experiences you have had when you picked up your new glasses or contacts and put them on. Many of us, myself included, have probably even said “Wow, I didn’t realize what I couldn’t see” to ourselves.

Coming from a background in behavioral optometry, I was already comfortable with prescribing lenses for function. My own two children use lenses for reading that don’t change the clarity of the words, but allow their visual systems to do near work more effortlessly. However, for the patient who has headaches at the computer, but can see clearly, it is hard to make them understand why a different prescription for computer use can help their headaches. The vast majority of us believe if our vision is clear, then there isn’t anything that warrants change. As an optometrist, you must ultimately satisfy the patient’s desire for clear vision.

So when I first started seeing patients with Ron, and the lenses the patient needed to achieve PRI-defined neutrality made their vision blurry in the distance, I was very nervous. Not that I didn’t know we were doing the right thing for that patient, because I did believe it. Whole-heartedly. The problem was that the traditional eyeglass and contact prescriber in me was concerned about how the patients would react to their new way of seeing. Would they keep wearing their new lenses, allowing them to progress through their PRI program?

Now, after five full months of seeing patients a couple days each week with the Hruska clinicians, I am almost more nervous when the lenses that allow the patient to be neutral also allow them to see relatively the same as with their current lenses. Why? Because we know more now than we did five months ago. We’ve had the opportunity to see patients do what humans are so good at doing: adapt! What adaptation means, in terms of what we are doing, is that they stay neutral for a period of time with the new lenses, but then they either go back to their old pattern or perhaps a less severe version of that pattern. For some, that period might be two months; for others, it might be two weeks. These patients are generally compliant with program activities, exactly as they were instructed. The point is, something allows them to get a hold of the old neural pathway and old muscle memory associated with the old pattern. That something might be as innocuous as picking up their violin for a few practices.

This is what has led us to develop some variation on when we tell the patients to wear their “training” glasses. Your patient’s wearing schedule will reflect a few things. If we had to make a dramatic change to their prescription to get them neutral, likely we will have them wearing the glasses only for physical activities. We may even tell them we don’t want them to wear them if they are going to look at things farther than 15 feet away. This is where the concept of blurry vision is most critical. Some patients are so strong in their old pattern, that any time they engage far away vision, they lose neutrality. So, we start with them trying to maintain neutral in a smaller area, so distant vision doesn’t engage. As they improve and are able to hold that neutrality given those limited conditions, we will continue to extend their range of clear vision out further, slowly progressing them towards more clear distance vision. We affectionately refer to this slow increase in visual space as a “leash.”

There will be patients that are using their new prescription full time. They may habitually not wear any correction, or maybe the new correction blurs their vision a little, but not enough to have them reject it. There are others that require that full-time reinforcement at all distances of visual space to be able to make a change. How do we know which ones can handle which option? Again, we are learning an immense amount, and there will certainly be times that our best-educated predictions are wrong. We are, after all, humans trying to predict the neurologic behavior of other humans. Not exactly what we’d call an “Exact Science”. Yet you can rest assured that we are constantly re-evaluating our approach and taking advantage of every learning opportunity a patient’s experience gives us to provide improved, more predictable patient outcomes.

What I have come to realize is this: How can I expect someone to do something different if I allow them to have relatively the same visual reaction? There are always exceptions to these “rules”. Lazy eyes, high amounts of astigmatism, and strong Functional Cortical Dominance, which we will talk more about in the spring Integration Course, are all variables that make the need for visual change that much stronger. As we peel away the layers of some of these patterns, we are finding other sometimes undiagnosed strong visual patterns that will have to be addressed through more vision-specific training.

We do our best to make sure patients leaving the clinic understand we are trying to provide vision that forces them to develop different neurological and muscular patterns, not make them see more clearly. We have them identify a pain or tightness that is present on the day of their visit before we start changing lenses. That pain or tension is either gone or diminished when we have on our “final” prescription. We absolutely LOVE when a significant other accompanies the patient to their visit, so there is a second pair of eyes and ears to remember what changed for them in that treatment room. Reinforcement of those concepts from their PRI physical therapist is crucial.

The ultimate goal is to have the patient maintain neutrality regardless of what prescription they do or do not have on their eyes. To achieve that goal, it takes motivation, consistent repetition of program activities, patience, relatively blurry vision, and sometimes, even a “leash”.

Here’s to progress through integration!

Heidi Wise, OD

Originally Posted 01/20/2011 by Heidi Wise.

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