Vision Therapy Activity: Spot It

To the average shopper, Spot It looks like an ordinary matching card game: a tin of round cards covered in cartoon symbols. To a vision therapist it is one of the fastest, least intimidating ways to see how someone’s eyes behave under a little pressure. That is down to the deck’s one design rule: any two cards share exactly one symbol. The answer is always there, so the only thing that varies is how efficiently the eyes and brain go and get it.

Key takeaways

• We use Spot It in vision therapy as an observation tool and a loaded practice task, never as a treatment on its own.
• One round shows fixation, saccades, pursuits, visual discrimination, figure-ground and processing speed working together.
• We change the demand, not the game: fewer cards for a five-year-old; timing, patching, movement or balance for an older child or adult.
• Reading runs on fixations and saccades (Rayner, 1998), and eye-movement and visual-motor scores track with school performance (Hopkins et al., 2019) - an association, not proof that a card game improves schoolwork.
• Trials support the full office-based program for specific diagnoses (CITT trial, 2008) and found no reading benefit over placebo (CITT-ART, 2019).

What a therapist watches in one round

Fixation: can the eyes stay put?

To find a match you have to hold your gaze on one symbol long enough to identify it, then hold the next one long enough to compare. What we typically see in the therapy room is different: a patient looks at the first card, breaks away to glance around the room, comes back, and by then the comparison starts over. In our clinical experience that break is not laziness; we read it as a fixation system that cannot hold comfortably and keeps resetting. That is our clinical impression, not something the research settles.

Saccades: do the eyes land where they mean to?

The rapid back-and-forth between cards, symbol by symbol, is a string of saccades - the same class of eye movement reading depends on. Reading is not a smooth glide along a line but brief fixations separated by fast jumps, and those patterns reflect moment-to-moment processing (Rayner, 1998).

What we often see when saccades are inaccurate is a patient who bounces between the two cards, plainly looking at both, and still cannot call the match as fast as you would expect, going back over symbols already covered. We work that skill more formally in activities such as four-corner fixation.

Pursuits: can the eyes follow?

Now slide one card gently while the search continues. The patient has to follow a moving target with smooth pursuit while still fixating individual symbols and saccading between cards - all three basic eye movements at once.

Discrimination, figure-ground and speed

Spot It also loads the perceptual side. A symbol appears in different sizes and rotations from card to card, so the brain has to recognize it as the same thing anyway. Picking one target out of a crowded cluster is figure-ground, and beating an opponent to it adds a speed demand - skills we cover in our guide to visual perceptual skills. We time rounds to look for consistency, not to crown a winner: someone who finds the first match in two seconds and the seventh in fifteen is telling us about visual endurance.

Changing it by age, and playing at home

We use the same principles from roughly age five into adulthood, adjusting the load rather than switching games, because visual search itself changes with age. Across 298 people aged 6 to 89, search was slower early and late in life, and children were affected particularly by the mere presence of distractors (Hommel et al., 2004); in 293 participants aged 4 to 25, accuracy matured earliest and search efficiency last (Gil-Gomez de Liano et al., 2020).

• Ages 5-7: a junior deck or a trimmed set, no clock, naming the symbol out loud instead of racing.
• Ages 8-12: the full deck and timing, then added demands such as naming the symbol’s color out loud, standing on a balance board, or patching one eye when the plan calls for it.
• Teens and adults: longer sequences and dual tasks. After a concussion we go the other way - short bouts, stopping at the first symptom.

At home, play it as a family game whenever you like, but use it as assigned therapy only if your therapist has set it up for you. Office-based programs are built that way on purpose: the trial protocols paired weekly visits of about an hour with roughly 15 minutes of home practice five days a week, with procedures sequenced easiest to hardest (CITT protocol, 2008).

What is and is not known about training these skills

The skills Spot It touches do travel with school performance. Visual-motor integration and eye-movement timing were the visual measures most associated with reading and math in 222 second-graders (Hopkins et al., 2019), and visual-motor scores tracked with teachers’ ratings of reading, math, writing and spelling in 191 younger children (Taylor Kulp, 1999). Children with dyslexia showed tracking deficits far more often than typical readers, 62% versus 15%, though those authors called the cause and clinical relevance uncertain (Raghuram et al., 2018), and children referred for reading and writing difficulty had weaker focusing and vergence facility (Dusek et al., 2010).

Those are associations, and they cut both ways. Once reading ability was accounted for, a standard eye-movement test was a poor predictor of reading rate (Webber et al., 2011). In a cohort of 5,822 children, four of every five with severe reading impairment had normal ophthalmic function (Creavin et al., 2015). When children with learning disorders received vision therapy, what improved were binocular vision measures, not academic ones (Hussaindeen et al., 2018). And in 310 children with symptomatic convergence insufficiency, reading comprehension improved 3.7 points with office-based therapy versus 3.8 with placebo (CITT-ART, 2019).

What controlled trials do support is the complete office-based vergence and focusing program, with home reinforcement, for specific diagnoses: 73% successful or improved at 12 weeks versus 35% on office placebo in the 221-child CITT (CITT trial, 2008), confirmed by a Cochrane network meta-analysis of 12 trials (Scheiman et al., 2020). We know of no trial that has tested Spot It on its own, and we would not expect one.

The professional bodies disagree here too. A joint statement from pediatrics and ophthalmology groups holds that vision problems can interfere with learning but do not cause dyslexia, and that vision therapy is not supported for learning disabilities (AAP/AAO/AAPOS/AACO, 2009). The optometric position is that vision problems can and often do interfere with learning, and that optometric care is one part of multidisciplinary care (AAO/AOA, 1997). Our clinical perspective, offered as ours: when a patient is uncomfortable or inefficient at near, finding and treating that is worth doing on its own terms - never as a substitute for reading instruction or tutoring.

Where Spot It fits in a program

Spot It is never a plan by itself. It sits inside a sequence built from an evaluation, alongside the procedures in our overview of vision therapy goals and procedures and our learning-related vision care. Its jobs are to show us how the eyes are working, and to hold attention long enough for the real work to happen.

So the next time your family plays at the kitchen table, watch the eyes rather than the score. If someone repeatedly loses their place, says the symbols swim, or gets a headache after a few rounds, that is worth a proper look. A comprehensive developmental vision evaluation is where we start. Schedule an evaluation at our Boynton Beach or Boca Raton office.

Originally written by Abid Khan, Vision Therapist, at Vision & Learning Center. Updated by our clinical team.