Vision Therapy Goals and Procedures at Our Center

Every therapy program in our offices starts with testing. Before anyone picks up a Brock string or a Hart chart, we need to know what the eyes are doing mechanically, what the brain does with the information they send, and where the breakdown actually sits.

Here is our protocol at Vision & Learning Center: what a Developmental Vision Evaluation includes, how we turn results into goals, the procedure families we use, and an honest account of what the research does and does not support.

Key takeaways

• A Developmental Vision Evaluation combines eye health and refraction, a binocular and focusing work-up, an eye-movement recording, visual-motor testing and visual processing testing.
• Goals come from the diagnosis and the numbers, not from a standard package.
• We retest visual processing three times: at the start, at the halfway point and at the end.
• A randomized trial supports office-based vergence and accommodative therapy for symptomatic convergence insufficiency (CITT, 2008), and a Cochrane network meta-analysis reached the same conclusion in children (Scheiman et al., 2020); the largest trial of the reading question found no advantage over placebo (CITT-ART, 2019).
• Our percentile benchmarks are clinical practice, not a published standard, and we say so.

What a Developmental Vision Evaluation includes

Eye health, refraction and acuity

The first job is ruling things in or out: eye health, and whether the patient needs glasses. In our chairs, an uncorrected focusing error is sometimes mistaken for inattention. In 492 preschoolers, uncorrected moderate hyperopia was associated with lower early-literacy scores, with the largest gaps when near acuity or near stereoacuity was reduced (Kulp et al., 2016). Glasses come first when glasses are the answer.

Binocular and focusing measurements

Next we measure how the two eyes work as a pair and how focusing holds up at near: near point of convergence, fusional vergence ranges, phorias, accommodative amplitude and accommodative facility. We also use the Convergence Insufficiency Symptom Survey, validated in children aged 9 to 18, where a score of 16 or more gave 96% sensitivity and 88% specificity (Borsting et al., 2003). These are the same measures used as outcomes in the randomized trials of therapy, which is why we track them.

Eye-movement recording

We record tracking with RightEye during reading-like tasks. Recordings are useful because the fixations, saccades and regressions of reading mirror what the brain is doing with the text moment to moment (Rayner, 1998).

A recording also measures something a paper-and-pencil test does not. In 59 children, recorded fixation duration and reading rate were related to standardized reading achievement, while the paper-and-pencil Developmental Eye Movement (DEM) test was not, and the DEM predicted recorded reading rate poorly once reading ability itself was accounted for (Webber et al., 2011).

It still needs an honest caveat. Those are correlations, not causes, and because eye movements follow the moment-to-moment demands of the text, a messy recording can mean a tracking problem or simply that the passage is hard for that reader. We read it alongside everything else.

Visual-motor integration

The doctor tests visual-motor integration with the Beery VMI, in which the patient copies geometric forms, and the Wold Sentence Copy Test, a timed copying task closer to classroom work. Copying skill is worth measuring: in 191 children in kindergarten through third grade, Beery VMI performance was significantly related to teachers’ ratings of reading, math, writing and spelling (Kulp, 1999), and in 48 first graders visual-motor integration and in-hand manipulation together accounted for about 73% of the variance in handwriting scores (Cornhill & Case-Smith, 1996). Both are correlations, not proof of cause.

Visual perception and processing

The Test of Visual Perceptual Skills (TVPS) covers visual discrimination, visual memory, visual-spatial relations, form constancy, sequential memory, figure-ground and visual closure. The Jordan test looks at visual-spatial perception and letter reversals. The Test of Information Processing Skills (TIPS) covers visual memory, auditory memory, delayed recall and word fluency. The doctor also runs a Dyslexia Determination Test as a screening step.

Screening is not diagnosis. Dyslexia is a language-based disorder diagnosed by qualified educational and psychological evaluators, and the joint statement of the pediatric and ophthalmology bodies is clear that vision problems do not cause it (AAP/AAO/AAPOS/AACO, 2009). A screening result tells us whether to refer.

When we retest, and what we aim for

Visual processing is tested three times: at the initial evaluation, at roughly the halfway point, and at the end. The midpoint retest is the one that reshapes the plan. By then tracking and binocular function are usually steadier, so the move into processing work is smoother and the therapist can weight the program toward whatever still lags.

Our internal target is testing above the 63rd percentile across the processing measures by the end of the program. That is our clinical benchmark, not a published standard, and it is never the only thing we look at.

Goals by diagnosis

• Symptomatic convergence insufficiency. Near point of convergence, positive fusional vergence and symptom score. In CITT-ART, therapy improved near point of convergence 10.4 cm versus 6.2 cm with placebo and fusional vergence 23.2 versus 8.8 prism diopters, while symptom scores improved by a similar amount in both groups (11.8 versus 10.4 points, P=.21) (CITT-ART, 2019).
• Accommodative dysfunction. Focusing amplitude and facility. Three-quarters of CITT children with convergence insufficiency also had accommodative dysfunction, and therapy raised amplitude 9.9 D versus 2.2 D with placebo (Scheiman et al., 2011). For accommodative insufficiency alone, no standard protocol is established in the literature (Hussaindeen & Murali, 2020).
• Ocular motor dysfunction. Fixation stability, saccadic accuracy and smooth pursuits, with the eye-movement recording as one marker.
• Amblyopia and strabismus. Glasses come first: in 84 children with anisometropic amblyopia, optical correction alone improved acuity by two or more lines in 77% and resolved it in 27% (Cotter et al., 2006). Where patching is indicated, two hours a day matched six in a randomized trial (Repka et al., 2003). Our therapy goals center on binocular function, and these patients are co-managed.
• Visual-motor and processing weaknesses. The standardized scores themselves, reviewed at each retest.

Procedure families, and the activities inside them

Programs are built from families of procedures, sequenced easiest to hardest. That structure is not unique to us: the CITT protocol ran one 60-minute individual visit a week plus 15 minutes of home therapy 5 days a week, in three phases, with the procedures inside each phase arranged from easiest to hardest (CITT design paper, 2008).

• Vergence and anti-suppression - the Brock string and related convergence, divergence and feedback work.
• Accommodative flexibility - the Hart chart and its near-far variations, training the focusing system to change distance quickly and accurately.
• Ocular motor control - the Marsden ball for pursuits and localization, plus fixation tasks that move the eyes accurately between targets.
• Visual-motor integration - pegboard and copying tasks that put the hand under visual control.
• Visual perception and processing - the games below.

The processing games we use

Processing work stays genuinely playable, because attention is part of the skill.

Parquetry blocks work visual-spatial relations and form constancy. The patient copies a key card using differently shaped, differently colored blocks. The easiest card shows shape outlines only; the next adds color, so both must match; the hardest shows color with no outlines. Patients can build on the card or copy it beside it.

Hidden pictures work figure-ground: a list of objects to find inside a busy picture, scaled to age and ability.

Geoboard works visual closure. The patient stretches rubber bands across a peg grid to reproduce a pattern with as few bands as possible; intricate patterns need several, and matching the colors raises the demand again. Show the pattern briefly and take it away, and the same activity becomes a memory task.

Visual President works visual and sequential memory using silly pictures that cue each president in order - a lady washing a ton of clothes, for George Washington. Patients name presidents from the pictures, then from a mental image of the page, then backwards.

Slap tap works laterality, directionality and processing speed. A page lists p, q, b and d at random, each mapped to a body part: p right hand, q left hand, b right foot, d left foot. The patient reads it aloud first, then adds the movement, then follows a metronome.

What the research supports, and what it does not

Office-based vergence and accommodative therapy with home reinforcement is well supported for symptomatic convergence insufficiency in children: 73% successful or improved versus 35% with office placebo at 12 weeks (CITT, 2008). A Cochrane network meta-analysis of 12 trials and 1,289 participants reached the same conclusion for children, on the strength of four CITT randomized trials (RR 3.04, 95% CI 2.32-3.98), while judging the adult evidence less clear (Scheiman et al., 2020). Critics of the wider field reach the same conclusion about this indication, while noting that many other behavioral approaches lack controlled trials (Barrett, 2009).

What is not supported is a reading claim. CITT-ART randomized 310 children and found reading comprehension improved 3.7 points with therapy versus 3.8 with placebo (CITT-ART, 2019), and in 94 children with learning disorders, 10 sessions of therapy improved nearly every binocular measure, but that study never assessed reading or academic performance at all (Hussaindeen et al., 2018). Children with dyslexia do show accommodation deficits (55% versus 9%) and tracking deficits (62% versus 15%) more often than typical readers, but the authors state plainly that the cause and clinical relevance are uncertain (Raghuram et al., 2018).

The professional bodies disagree, and parents deserve to know that. Pediatrics and ophthalmology hold that vision therapy is not a treatment for learning disabilities (AAP/AAO/AAPOS/AACO, 2009); the optometric position is that vision problems can and often do interfere with learning, with optometric care one part of multidisciplinary management (AAO/AOA, 1997). We sit with the second while taking the first seriously: we treat vision problems that make near work uncomfortable and inefficient. We do not treat dyslexia, and we do not promise better grades.

Before you start

For the week-by-week view of what a program feels like, see what to expect from a vision therapy program; the full service overview is on our vision therapy page.

Testing is what makes any of this specific to one patient. If this sounds familiar, a Developmental Vision Evaluation is the place to start. Schedule an evaluation with our team in Coconut Creek, Boynton Beach or West Palm Beach.