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Keywords

functional vision, dynamic vision, static vision, visual regard, pupil testing, eye alignment, tracking skills, convergence, divergence, primitive reflexes, near-far fixation, suppression, visual midline, vestibular ocular reflex, Harmon distance

In this podcast episode, Dr. Sam Berne discusses the concept of functional vision screening, emphasizing the difference between dynamic and static vision. He explores various assessments and exercises that can help improve visual skills, coordination, and overall learning abilities in children. Key topics include the importance of visual regard, pupil testing, tracking skills, convergence and divergence, primitive reflexes, and the significance of the Harmon distance in reading. The episode provides valuable insights for parents, educators, and therapists working with children who may have visual processing challenges.

Functional vision is dynamic and involves the brain and body.

Sound Bites

“Functional vision is dynamic, not just eyesight.”

00:00 Introduction to Functional Vision Screening

Sam Berne (00:00.066)

We can do a number of tests that can help us determine what’s the best course of action and being able to help a person improve their vision. So again, I’m going to invite you in and part of the lecture today that we did with our class. I think you’ll find it to be very interesting. Again, if you have any questions, you can send me an email appointments at dr. Sam burn.com. Enjoy the show everyone. So this is called assessing functional vision.

And this is a this is a an assessment that I have developed over the years and I’ve given it to many occupational therapists physical therapists teachers people like yourself. And so I will give you a worksheet that you can use to actually take the notes when you actually do the testing but for today today.

We’re just going to start in on the ideas of it. So here we have a person who’s on a Boza ball and we’re working with the inner ear, the vestibular system, which is very tight into vision. And I’ll talk more about that in a few minutes.

Sam Berne (01:53.174)

They usually have what we call a stigmatism, which means that the eye is shaped more like an egg instead of being round like a ball. And a stigmatism effect is influenced by our posture head posture neck posture. So there’s that relationship head tail a stigmatism now double vision meaning I see two of something that could be related to

something called stimming coordination problems. So that could either be body coordination problems or visual coordination. So it could either be gross motor or fine motor or both a lot of times there is a gross motor coordination problem and they can even relate to some of the primitive reflex primitive reflexes that aren’t integrated and we’ll save the primitive reflexes for another lecture, but

You know, you can ask your your client. Do you ever see two of things and a lot of times they’ll say, yeah, I do and the parents are like, I never heard that. So if you don’t ask the question then you know, the child just thinks double vision is normal. Another behavior that you might see in the double vision is they like to cover or close an eye, especially when they read.

Or you can look at their eyes and their eyelids and the eyelid droops. gets heavy. Another thing you can notice is that the pupils which is the control of the light. It’s the black circle is always dilated. And if you see a child that’s always got dilated pupils, they’re under a lot of stress. There’s a there’s a big stress response in their system. So

Sam Berne (04:01.354)

either a two by four or a piece of tape that was like a masking tape that we put along the floor and they have to walk on that forwards and backwards and we observe the arms the hands the legs the feet and then there’s an exercise called the duck walk pigeon walk and this is where you ask the child to turn their feet out like a duck and start walking.

And with most of the kids that I’ve worked with when they do the duck walk or the pigeon walk is when the feet are turned in like a pigeon. You will see the upper part of the body kind of turning in or turning out as a way to try to help the feet stay in the position. You’re asking them to stay on.

You can also look at their arms and their hands while they’re walking and it’s going to clue you in that they’ve got some kind of motor developmental delay and many times it’s related to again, the primitive reflexes not being integrated if they’re in a therapy situation and I see this behavior on the pigeon walk or the duck walk.

I’ll do something called Socratic guidance, meaning that I’ll start asking them questions. Hey, Johnny, is there another way you can hold your arm or hold your hand?

Sam Berne (05:56.801)

experts of problem solving first with their body coordination and then thinking and then eventually they can transfer that to school. So when you’re doing the Socratic guidance, you’re artfully you’re skillfully asking them questions and guiding them to a place where they try something else and they’ve got the confidence because they’re not afraid that you’re going to correct them.

They’re going to be in an open space of just well, can I explore it a different way? And then when they come to the right answer you go. Well, what do you think of that? And they might go. Yeah, that makes sense. So then you’re validating their experience in solving the problem. And I see this a lot with parents where especially the mom she’s always like trying to correct her son and I have to say, okay.

Please be quiet, step back because we don’t want you to correct your son because he’s going to get this complex where he’s going to be afraid to try things. And so we teach the parents ask questions to guide the child so that they have the discovery of the answer.

Okay, another thing that you can look at while they’re walking is their eye fixation. Are they walking with their eyes pointing downward like at the ground or upward like at the sky or off to the one side or the other? It’s going to give you information perhaps on what side of the the body they they

Sam Berne (08:03.691)

It refers to the act of using your vision to locate focus on and attend to an object in the environment. It is a foundational skill in motor planning.

Okay, so I see where I need to go first and then I move my body based on the decision where I’m looking. This is so important in sports. For example, kicking a soccer ball playing basketball playing baseball tennis golf any of these when you look ahead and you know where you’re looking then you’re planning your body to move through that and there are there are exercises that you can do to improve motor plan.

Using visual regard because it’s going to affect coordination. It’s going to affect how the person is relating to themselves and objects out there and it also visually guides the hands and body. We call this

proprioception. I know where my arms and my legs are as I’m using my vision. This gets a little more interesting when we start putting them in gravity situations where they’re jumping say on a rebounder while they’re reading a heart chart as an example so that there is a visually guided movement and their body follows that particular movement.

Sam Berne (09:56.553)

You know, one of questions I ask moms a lot is does your child spill their milk? Do they spill their juice? And that tells me that their visual visual regard is not accurate. So they have difficulty judging location guiding their hands towards an object because their eye is tracking it or not tracking it. Another place will see it is in reading. So skipping words being able to follow

letters words on a page and then finally playing sports, which I talked about tracking a ball in motion calculating its

trajectory and preparing to catch it involves visual regard. And when you get really good with visual regard, you’re great at anticipating where the teammate is where the ball is and this is where the the athletes really take off when they start being able to plan ahead and they can almost tell where things are going to be before they get there.

Kids they bend over when they’re bouncing the ball, especially if I’m adding a metronome and they think by bending over they can be faster with catching the ball and throwing the ball. And so we’re always in this correcting mode of asking them the question. Well, hey Johnny, what would it be like bouncing the ball? If you just stood up straight up? What would that be like? And then he goes, wow, it’s actually easier on my muscles, but it’s the vision that’s leading the body here. It’s not the

Sam Berne (11:50.007)

I feel that the more we can get the vision into the body and the more we can get the body into the vision that really solves the issue for the kids around their learning disabilities and their reading problems because it’s not just the eyeball experience as one of my teachers used to say a vision problem is more than in the eye. It’s in the whole child and

going on to this next slide. When you look at the pupil and when you come here, we’re going to do some pupil testing. You have a pen light and you shine the light towards the eye and the the pupil should actually get smaller when the light comes to the eye with a lot of these kids. What happens is the pupil

doesn’t constrict it stays really big really dilated and then there’s the issue where one pupil is big.

With one eye say the right eye and the left eye, the pupil is small and that’s called anisocoria and that could be a neurological problem. It could be a stress problem. It could be a trauma or toxicity issue. But the pupils are there to kind of show us what’s happening on the nervous system level. And also when a child is reading a book and starts to bring it close, the pupil should get smaller as the person brings the book closer to their face.

Sam Berne (13:29.761)

And one of the tests I’m going to teach you is something called the Hirschberg test. And this is a test where you have a pen light and we’re going to talk about the Harmon distance in a little bit. That’s the distance that is about 12 to 14 inches from a person’s face. And what you do is you shine the light towards the the the person’s eyes and you look at where the pupils

The light is reflecting off the pupils. So it’s a way for you to see alignment. So you probably have worked with kids where when you look at them one of their eyes might be wandering in.

One of their eyes might be wandering out. One of their eyes might be going up. One of their eyes might be going down. So in this Hirschberg test, they’re looking at the pen light. You’re right in front of them and you want to make sure they have alignment. If they have misalignment, two things could be going on. One is double vision and two is suppression, meaning the brain is shutting off the eye to avoid double. So we have in this slide, the technical term, esotropia.

is when the eye is crossing exotropia is mean one eye is looking outward. So you’ll see the reflection of the light on the inside part of the pupil and then you’ve got the hypertropia where one eye is up and hypotropia where one eye is deviated down. So you can have a vertical split. You can have a horizontal split. I’m going to tell you this most of these kids have one of these four issues.

Sam Berne (15:39.453)

visual tracking skills that’s really important for reading. The other one is called Cicade movements and this is the jumping from one.

Position to another like like focusing from near to far focusing from the left side to the right side. So when you’re testing you can test both the pursuits and the saccades and one of the things you’re looking for is is the child able to move the eye muscles smoothly or is there jerkiness in the movement or are they having to move their head and or their body to move their eyes?

I’ve done so many, you know, kindergarten eye screenings where we we test the saccades and the pursuits and we go. Wow, they’ve got to move their head to move the tiny eye muscles. So can you imagine trying to teach them how to read? It’s going to be really stressful for them because they don’t have accurate eye movements at this point. And then we talk about something called convergence.

This is what you’re working with right now with the Brock string. Basically, it’s three beads on the string and the first bead is about 12 inches from your face and the child is holding the string on the tip of their nose.

Sam Berne (17:24.105)

When you watch the child’s eyes to see if both eyes are tracking the target or you can actually start to see one of the eyes moving out and you can ask them is this a double vision? Do you see two? We call this near point of convergence where how closely can you move the target where they’re able to keep converging and hopefully they’re able to converge.

well within the range of where they’re holding their their books when they read because if the convergence breaks down right at their reading, then they’re going to get the diagnosis convergence insufficiency. And then we’ve got divergence, which is more like the magic eye you’re doing like the jelly beans where the eyes are looking parallel. And in this particular way, this is more of a distance type coordination pattern.

So divergence is more distance and convergence is more near and you want to be able to again watch the clients child’s eyes as you’re moving the target towards their nose and away from their nose and you can start to see. Okay, what is their convergence divergence abilities build a house you start by building the basement and you build the you know, the foundation and the basement and the foundation would be the primitive reflex.

It would be working with their balance. It’d be working with their gross motor coordination.

Sam Berne (19:18.741)

balance the bilateral coordination skills are foundationally more solid. It’s absolutely that’s why there’s a certain sequence in when you introduce these certain activities. This is a mistake that most behavioral optometry and vision therapy practices make. I’m sorry to say this, but I see the mistakes. I’ll have people come to see me.

I say I’ve worked in vision therapy for two years and I have not seen any improvement. And within four to six sessions of working with me in this particular method, the child’s reading they’re playing sports their problem is solved. So one of the issues is that the the vision therapy exercises they start too high up in the

motor development and the child is not ready. So they learn a splinter skill, you know, they can cross their eyes or move their eyes, but they’re not really working with, you know, fixing the developmental delay which started way back more in the preverbal period. So you are right and not introducing convergence divergence until you think they can have some success at it. You need to stay more

with the basic things and actually you’ll get a lot more benefits by doing that than trying to force them into

Sam Berne (21:24.971)

The other thing is the recovery of the double vision because you want them to be able to recover from the double vision pretty quickly with a lot of kids. Their recovery is very low. In other words, you have to push away or push away away from them.

or pull it way away from them before the two goes back to single and what that tells you is they’re depleted. They don’t have enough in their energy reserves to be able to turn the two into single and this is where then you can start doing some muscle testing educational kinesiology, which will come later and maybe testing the child where they need either change in their diet or supplements.

And again, in one of the clinics I work with the occupational therapist does educational kinesiology to find out what are the targeted supplements that will give that child more energy. So their recovery is better. Their developmental growth is going to be faster because they have more energy on the cellular level to make the changes that we’re asking them to make.

Now, another thing we like to look at is something called near far fixations. This would be like sitting at your desk, looking at the board and being able to copy what you see at the board. Now, the way we simulate that is through a small printed heart chart, which is at 12 inches and a large printed heart chart.

Sam Berne (23:34.293)

at the distance chart and they’d be able to go back and forth with it. When they get good at it, you can bounce a ball and do it. You can even do it with the eye patch. But this near far fixation exercise is really great for getting them to improve their copying. Now, just as an aside, and I didn’t write this in one of the primitive reflexes that most effects

The near far fixation is the symmetrical tonic neck reflex and we’ve done studies where we kids have difficulty copying. So instead of doing the near far fixation exercise, we do the symmetrical tonic neck reflex and that reflex.

Allows the brain to move more into the frontal part of the brain. And so the near far fixations automatically get better without having to do any exercises in the near far fixations. That’s how potent the primitive reflexes are and being able to change the visual skills and

In this near far fixation procedure, we’re asking the child to shift their focus from the near chart to the far chart. And sometimes you can add a metronome. Sometimes you can put them on one of those Boza balls or a trampoline or so you can bring in a vestibular component to it while they have to jump their eyes back and forth. It’s a form of what we call saccades. Cicades. Remember we talked about eye movements that are jumping from one

Sam Berne (25:22.381)

six, we probably wouldn’t do a lot of near far fixations except maybe the Marsden ball, which is the swinging ball and they’re just hitting it and they’re tracking it. That would be a gentle way to start the near far fixations. But once you get into the heart charts, that’s where they’re already in a language based situation. And so they’re ready for that.

Sam Berne (26:18.217)

and then the right eye has to do all the work.

So in the bottom of the slide is something that I know you’re very aware of and that is the red green charts and the red green glass for sure because in the special needs world, if you go to a conventional doctor, they’re just going to say, well, you’ve got this condition live with it and there’s no there’s no help whatsoever. There’s no understanding that the person has some level of neuroplasticity to learn and

know, even in this suppression, if we go to the next slide where you have the child wear the red green glasses and just look around the room.

Just the awareness of then being able to see the different colors, the red, the green. This is a really great way to start. But what I like to do is just to put the red green glasses on and just see what their response is. Number of kids will say, I just see the red or I just see the green and that tells me right away that there’s probably a very good deal of suppression and as they progress.

Sam Berne (28:02.197)

Another way that you can do this the red greens is by using heart charts with strips.

vertically alternating red and green and red and green and again, they’re at that Harmon distance, which is about 12 to 14 inches and you ask them to read across the row and I know you’ve done that because we’ve done it with you and it’s a really great I think even we did with your kids and so this is another great way, especially when they get into reading and language. Can they have that alternating situation?

And then we move to something called visual midline. I was working with this today with a client and the purpose of this is to see if the child is actually. Balanced between the right eye and their left eye because in a lot of cases if a child is right-handed.

On a visual midline, if we think of that as our steering wheel, our GPS system, a lot of times the steering wheel will start sliding more towards the left.

Sam Berne (29:42.281)

now.

That’s going to tell you where their visual midline or visual midline shift is. Now, there’s a vertical right to left where you’re standing on the right side of the child’s peripheral vision and you hold the pencil or the pen oriented vertically and move the target slowly through the midline from the child’s right side towards the left side and ask the child to say now when the target is in front of their nose. So a lot of times they will

miscalculate you’ll see it as my goodness the pencils way over on their left side, but they’ll interpret it as yeah, the pencils in the middle of my face. Well, it’s actually not so the

The vertical right to left is good to do the vertical left to right is good to do where you stand on their left side and you move that vertical pencil from left to right to where they think it’s a in front of their nose. can also do horizontal vertical.

Sam Berne (31:21.993)

And so I’ll give them a prism that lifts their vision up and there have been life changes when they they start to have that horizon line match where the true horizon is and at a later session. We’ll talk about prisms and and those kinds of things. But for now.

The midline whether it’s horizontal or vertical is something that you could start to play around with and cognitive ability and you know on the testing side of it is you certainly could try it and if you’re not getting an accurate response, then you just say this. This isn’t the right test to do now, but with some of your kids.

something called the vestibular ocular reflex VOR and the VOR is a test to see how much is the vestibular system meaning the inner ears helping a person with their balance. So we’ve got two sensory systems that help us with balance really three we have the eyes.

For balance. have the ears for balance and we have the feet for balance. It’s like a triangle and what happens with most people is that if they have an under sensitivity of the vestibular system, meaning the ears are not helping the eyes in balancing.

Sam Berne (33:33.301)

So in terms of testing the vor because that will give you an indicator on whether the the ears and the eyes are balanced or one system is overworking the other. So you have the child sitting in a comfortable. They’re in a comfortable standing position and you’re in front of them. And what you do is you hold up a target vertically at midline in front of the child and you instruct

the child to focus both eyes on the target and slowly turn the head to one side as far so they’re turning their head while they’re tracking the target and they go as far as they can with their head on one side and on the other side and you have them do that total of 10 times five on each side. So you count one one two two.

all the time. They’re maintaining the focus on the target. And so you do this five on each side and then you can also do it vertically. Okay, up and down same thing where they’re moving their head up moving their head down five five in each each direction. So now once once you do that.

What you’re looking for is a movement called nystagmus. That’s where the eyes oscillate back and forth. And if you see no oscillation, okay, no oscillation or the oscillation is less than five seconds, then they have an under acting vestibular system. Okay.

Sam Berne (35:49.425)

The vestibular system is under acting. So you need to do some vestibular stimulating things. We’ll get into this in a later session, but it could be something as simple where you’re you’re having them swing. They’re swinging. They’re rolling. Sometimes we’ll do

jumping like on a rebounder. Sometimes we’ll roll them on a physio ball. So we get a big physio ball and we’ll roll them. We’ll use a Boza ball and they can either sit on it or stand on it. So in other words, what we start doing in the therapy is we bring in vestibular stimulating things while they have to do visual focusing things. So it teaches them to bring in the ears to the eyes with the feet. That’s the proprioception.

And it’s a very important connection, especially when a child learns to read.

Because in reading when they’re tracking there is a little bit of vestibular connection. There is a little bit of proprioceptive connection and it’s also very tied in to the moro reflex. So if somebody has not integrated the moro reflex a lot of times their vor the vestibular ocular reflex will show a very underacting vestibular system and this can be related to birth trauma. So either

Sam Berne (37:47.279)

deceptive and their inner ears. And so then the visual is overworking and this creates situations where then they might need some glasses like they need a prescription because their eyes get so fatigued from over focusing so they might become farsighted. may become nearsighted. So that’s the kind of the the progression of why kids start to need glasses, especially early on or another reason why they start developing

developing an I turn crossing in or crossing out.

So again, the way I’m teaching this is you’re noting these signals and symptoms and putting it together in the history, but you’re trying to treat the cause and not the symptoms and what I doctors do is they want to fix the symptoms. Well, guess what you fix the symptom and you drive the cause further in this is why when you start doing the physical therapy and you treat the cause the symptom goes away and it never comes back.

but it also creates a better processing of information and learning and it’s just a very exciting transformation. So I’ll have more to say about the vor but this is basically just getting, know, your feet wet with it. Then the last thing I want to talk about today is something called the Harmon distance. So

Sam Berne (39:46.507)

and Harmon did a series of studies. I believe in Ohio State where they took a look at what is the optimal distance you should be holding your books.

Now your tablets when you read and what kind of angle should it be at? So how far away should it be from your face? And what’s the angle and what he found in this diagram shows it is that if you are propping up the reading material at about 22 degrees in a slant board, what that does is it creates a

90 degree angle in a way where the child or the adult has the optimum potential to learn and read better. And so this 22 degree incline, it could be just propping their, you know, their tablet up on a some books so that they’re at a 22 degree angle. Approximately what this does is this is going to

take the stress off their posture and allow them to learn better. Now, there’s a little picture up here, which is a picture of this arm. Okay, there’s a fist. There’s an arm and it’s like an L and what Harmon proposed is you take that fist and you put it under the chin and that measurement from the end of the the knuckle to the elbow, which is now under the chin.

Sam Berne (41:42.693)

And that’s based on how long the knuckle to the elbow is and it’s placed under the chin and then you kind of look at okay, that’s my Harman distance. One of the problems that happens with kids and you’ve probably observed this is you give them something to read and you watch where they habitually like to hold it and when kids hold their reading material closer than the Harman distance.

You can bet there’s going to be a vision problem. Again, vision is tracking focusing visual coordination. It’s the brain. Eye brain body connection. It’s not eyesight. It’s vision. When they bring that in closer than the Harmon distance, that is a great screening device. That’s going to tell you right away. they have a vision problem focusing problem coordination problem. And so you want to instruct them.

to have that 22 degree angle and get into the Harmon distance. And this is something I tell every parent that they have to do this. Okay. Now sometimes they might need some low plus learning lenses to help them stay at that Harmon distance or if they’re wearing a distance prescription, we might have to reduce the prescription or increase the prescription to allow them to have the clarity that they need at the Harmon distance. But

With all your clients, you should be talking to them about the importance of the Harmon distance. You could actually Google Harmon distance, Darrell Boyd Harmon, and you get a whole page of different things that Harmon did about as a pioneer to create this this idea and it’s you know, even today because we’re talking it’s you know, almost 80 years 90 years.

Sam Berne (43:58.365)

So focusing closer than your Harmon distance, I guarantee you in six months, you’re going to become near sighted because you’re in a visually constricted spatial situation and it’s the worst thing the kids can do. They start pulling it in because they think, you know, if I pull it in, I’m stressed. I can learn better. I can focus better. But what it’s doing is it’s tensing the eye muscles and it creates that visual confinement which creates myopia.

And so and then you got the kids that are farsighted and they’re pushing the world away and you know, that’s a whole other thing. So functional vision screening.

You know, I wish more school nurses and different institutions included functional vision in their eyesight screenings because most eyesight screenings only measure the optics of the eye at distance. And this is an uphill, you know, battle because very few professionals even think about vision, which is the brain.

Okay. Well, that’s our show for today. I want to thank you so much for tuning in until next time. Take care.