Vision therapy: A top 10 must-have list

Keep patients engaged and meet therapeutic needs

August 01, 2014

ByMarc B. Taub, OD, MS, FAAO, FCOVD

My name is Marc, and I am avision therapygraduate. I was your typical kid, except that I could not
pay attention in school and hated to read. Luckily, my second grade teacher requested that I get an
eye examination, and the optometrist recognized that I needed more than glasses. I was referred to
an optometrist who specialized in learning-related vision problems, including visual efficiency and
processing disorders. I immediately started a vision therapy program and saw tremendous
improvement in my symptoms and success in school. When I entered optometry school, despite my
background, I did not instantly gravitate toward the vision therapy department. It was during my first
job after graduation that the light bulb went off; I realized my true calling.Vision therapy has the
potential to help so many people, to change lives.

More from Dr. Taub:Treating patients with brain injuries

Over my 10-plus years in practice I have developed a core set of equipment that I cannot live
without. While some would be considered basic, others are more complicated. It is this mixture of
high and low tech that keeps patients interested and enables the uploading and downloading of

activities to meet therapeutic needs. I hope that my top 10 pieces of vision therapy equipment will
quickly become yours.

1. Wolff wands
It is amazing that a simple design can be so powerful.
Created by Bruce Wolff, the wands are two 1-foot-long
metal rods with either a gold or silver ball at the end (Figure
1). These wands can be used for activities related to
tracking and convergence, but most importantly, they are
crucial for an activity known as eye control. In any
successful program of vision therapy, the patient must
understand where his eyes are pointing in relation to his
body. Eye control is performed early in therapy and aimed at
achieving this understanding. It is the reflective nature of the

Figure 1. Wolff wands

balls on the wand that make them irreplaceable. If the

patient sees his reflection, he knows that he is pointing his eyes at the intended target.

Next: Hart charts

2. Hart charts
Hart charts can be used for accommodation, eye movements (saccades), and visual attention. There
are two charts of rows of letters, one small and one large (Figure 2). The patient typically stands 10
feet from the distance chart and holds the smaller chart in her hand. If working on accommodation,
there are three levels to be accomplished: near chart at arms length, slowing moving toward the
patient while reading, and as close as possible before becoming blurry. The patient alternates
reading a line from the distance and near charts during the activity. The activity can be made more

challenging by alternating charts every half of a line.

Video: Questions to ask in vision therapy
For saccadic work, only the distance chart is used. The
patient is instructed to read the outside two columns, one
letter at a time, alternating between the two columns. As she
becomes more proficient, she begins to read the columns in
the same manner moving inward, eventually reading the two
most inner columns.

Figure 2. Hart charts

Next: Brock string

3. Brock string
No, despite what everyone says, using the Brock sting
cannot treat conjunctivitis, but it is unbelievably useful on so
many levels in the therapy room. A key component to a
therapy program is the appreciation of physiological
diplopia. The different colored beads (red, yellow, and
green) can be placed anywhere along the string (Figure 3),
depending upon the area of fusion. When focused on one of
the beads, the patient should appreciate two of each of the
other beads. Once physiological diplopia is appreciated, the

patient can jump between the beads or do a controlled Bug

Figure 3. Brock string

on a String. The position of the crossing of the strings

provides feedback for the patient,as well as the therapist. Suppression is easily detected if two
strings do not enter and exit the bead. Red/green glasses can also be used because the red and
green beads will cancel and not be seen by both eyes.

Next: Marsden ball

4. Marsden ball
Activities that are performed with the Marsden ball are fun
and perhaps the most desired in the therapy room. We have
become experts at making our own balls using a Pinky ball
and a baseball glove repair kit. Writing letters on the ball
with a Sharpie allows for the activities to focus on visual
attention. The ball is hung from the ceiling and can be
bunted with a dowel, and hit/caught with the thumbs, palms,
and fists (Figure 4).

Figure 4. Marsden ball

Next: Vectographs

5. Vectographs
There are many different vectographs, which can be confusing for the novice therapist, but each one
has a purpose in the sequence of therapy. Whereas tranaglyphs are red/green and are subject to
lighting problems, the polarized vectographs are easily visible and not as finicky. The different
vectographs have differing visual demands and target sizes. For example, the Quiot and Gem
(Figure 5) are great peripheral targets with no central demand, while the Spirangle, Clown, and
Vortex contain both peripheral and central demands (letters). All of the vectographs enable the
patient to appreciate the SILO (small in/large out) phenomenon, which is a key aspect of a
successful therapy program.

Figure 5. Vectograph

Next: Balance board

6. Balance board
The balance board addresses the concept that while the

eyes are part of the body, they must move independently of

the head and the body. Eye movements are deemed
inefficient if there is accompanying body and/or head
movement. The balance board is a square wooden board
with a base (Figure 7). The base can be square or round

Figure 7. Balance board

and there are several levels of difficulty. The patient stands

on the board and attempts to shift his hips only from side to side. It is harder than it seems, and
some patients have to start at a lower level and stand on the board or perform the activity holding
the therapists hands.

Next: Rotator

7. Rotator
As discussed earlier, efficient eye movements are crucial to
reading and the learning process. The standing (Figure 8) or
tabletop rotator is used to address concerns related to poor
fixation, pursuits, and visual attention. Numerous plates
aimed at various purposes can be used with the device.
Some have more peripheral vs. central targets, while others
have designs in red/green to address suppression. The
speed of the rotator can be controlled and the demand
altered based on speed and target location.

Figure 8. Rotator

Next: Lenses and prism

8. Lenses and prism

Lenses and prisms are absolutely essential, and it confounds me that these items might not be on

someones top 10 list. While lenses and prisms are used early on in the therapy program with the
introduction of a single lens or prism, they are also used in a facility-type manner later on. Lens
blanks are used to facilitate an understanding that the patient, not the lens, controls her
accommodation. She must clear a minus lens with the lens in place and blur the image without the
lens in place. As the program progresses, lenses are used in a bi-ocular and then binocular fashion
in the form of flippers.
Related: Researchers use video games to treat amblyopia
Prism is used to facilitate an understanding of the eye moving in a specific direction. Strabismics
often have difficulty with this basic task. Teaching a patient with esotropia what it feels like when his
eye is pointing inward is a necessary step. Prism facility flippers are used to increase flexibility in the
vergence system as the patient alternates between convergence and divergence demands.

Next: Rotator glasses

9. Rotator glasses
These glasses come in powers ranging from 2^ to 45^. The
direction of the prism can be rotated enabling either yoked
(same direction) or dissociated (different direction) prism

Figure 9. Rotator glasses

(Figure 9). Yoked prism is very useful when working with

patients with special needs, including autism and developmental delay, as well as those who have
suffered a traumatic brain injury. When performing an activity with yoked prism, the patient has to
reorient his visual system to coordinate successful completion. The ability to alter input is a needed
aspect of a therapy program.

10. Computer programs

It is amazing how far computer programs have come in the 30 years since I personally went through
a therapy program. Yes, many of the basic concepts are still in place, but the intricacy and variety of
programs is outstanding. Computer-based activities can be performed both in the office, at home to
support office-based therapy, and as a stand-alone home-based program. The office-based
approach to therapy has been shown to be more successful,1but these programs allow greater

access for patients who cannot attend weekly sessions. Depending on the program selected,
activities can stress vergence, accommodation, eye movements, and visual information processing.
Each program is unique, and each practice should investigate which ones work best for its model of
vision care.

Next: Bonus

Bonus: Sanet Vision Integrator

Yes, I already covered my top 10, but the Sanet Vision
Integrator is knocking on the door to that list and is a hit with
the patients. It is a 52-inch touch screen (Figure 10) that can
be used with any variety of patients. Activities are aimed
mostly at eye movements but with a twist: the tactile aspect
of the touch screen brings in eye-hand coordination. The
target size, color, location, and contrast can all be
controlled, which is an asset when working with brain injury
patients or those with amblyopia. This is quickly becoming
one of the most-used therapy activities in my repertoire.

Related:Reviewing pediatric primary care

optometry
Even though vision therapy is not just for children, a high
percentage of participants are in fact young. On the surface,
some of these activities are more exciting than others and,

Figure 10. Sanet Vision

Integrator

unfortunately, that is just how it is sometimes. That does not

mean that the activities cannot be made fun by using incentives or creating a competition between
the therapist and the patient or even between patients. I suggest trying to space the higher energy,
more fun activities throughout the therapy session to keep the childs attention. Also, keep in mind
that younger children and those with attention challenges will need shorter-duration activities to
keep them engaged. If needed, the activity can be broken into two shorter parts. Vision therapy is all
about engaging the patient to enact meaningful and long-lasting change, so do not be afraid to take
off the white coat, get on the floor, and have fun!ODT

References
1. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments
for symptomatic convergences insufficiency in children.Arch Ophthalmo. 2008 Oct;126(10):133649.