Understanding vision development issues and TBIs with Dr. Hannu Laukkanen

Dr. Hannu Laukkanen is Associate Graduate faculty and Professor Emeritus of Optometry at Pacific University. He has many decades of experience teaching and mentoring developmental optometrists, (including some of my past guests). He is an experienced researcher and published author who has presented countless lectures at conferences and in medical facilities and provided key testimony in many court cases. He is a master teacher with unique insight who provides in-depth answers to my questions in this episode. We discuss early visual development, including ADD, ADHD and dyslexia issues, as well as brain injury, or TBIs. 

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Transcript

Denise: This is the Healing Our Sight podcast where we discuss vision issues and healing strategies from the patient perspective.

The goal of this podcast is to create an awareness of the diverse types of vision issues people experience, to highlight the types of help available, and to open a dialogue between patients to show we're not alone in our vision struggles.

As a patient who gained 3D vision at age 54 through vision therapy combined with strabismus surgery, I feel uniquely qualified to offer a hopeful, balanced perspective on the possibilities.

Please use the link in the show notes to send me a message and thanks for joining me today.

Denise: Welcome to the Healing Our Sight podcast. I'm your host, Denise Allen, and today I have with me an illustrious guest, Dr. Hannu Laukkanen.

Hope I said that right. He is an Emerita professor of Optometry and currently active as an Associate Graduate professor of Vision Science and in his previous role as Clinical professor of Optometry, he specialized in treating complex patients, especially those with brain injuries, while concurrently teaching optometry courses on brain injury, advanced perception and education.

In the 1990s, he became recognized as a content expert on brain injuries, particularly their impacts on vision. As his clinical success reputation with brain injury spread, the proportion of brain injury survivors grew to nearly 80% of all patients he served, including many who traveled from all over the country to be seen by him.

His work with brain injury patients in both the clinical and academic settings has made him a respected figure in the field and has published an ongoing research emphasizes the relationship between vision and brain injury.

He has several decades of experience in the legal community throughout the Northwest as an expert witness testifying to the presence, diagnosis and reality of brain injury when it is denied by other providers and insurance companies.

Hannu's current clinical consulting emphasis continues to be on guiding specialized care for brain injury survivors, helping them to recover and navigate the challenges of their condition.

The heart of Hannu's work is driven by his commitment to understanding the lived experience of brain injury survivors, particularly in relation to their visual and cognitive impairments. He has witnessed the profound effects of brain injuries on patients and has dedicated his career to helping them regain functional independence.

Thank you so much for coming on the podcast today.

Hannu: You're most welcome, Denise, thank you for inviting me. It's an honor to be on your podcast. You've talked to a lot of people with great expertise in the area of vision and you've done a remarkable job in schooling yourself as a as a content expert in vision problems. So kudos and I'm just happy to be Here.

Denise: Oh, well, thank you very much. I feel so exposed in your presence. We've been talking for a bit and, and I wish I had some of our conversation on the recording because it's been so enlightening.

I know that, that people are going to get a lot out of what you have to say today.

Let's go ahead and jump into what has been on my mind since we started chatting today, which is how people go about being aware and diagnosed and kind of getting to the bottom of what the issues are for them visually. Do you want to address that a little bit?

Hannu: Sure. Can you allow me a little side excursion here? I'd like to talk a little bit about how the visual system develops. And I think out of that, it'll make more sense.

And so when we're born, our visual systems are poorly developed. Babies see really, really poorly. And so, for example, if what is normal vision is considered 20/20, meaning that you can see an object at 20 ft, that normal vision should be able to see.

A baby would be seeing maybe 20/1,000, which is like, you know, 100 times worse to 500 times worse in that visual system is still getting connected to the brain. And what happens in that early period where all of these neurons connect in the visual system and allows the visual system to start operating at a higher level and allows the eyes to start working together and these sorts of things is really a miracle of creation.

And I'm always astounded by, wow, how does this happen? So in early infant development,there's something like a quarter million neurons connecting to one another every minute.

And it's just a phenomenal number of synapses that are forming. And as youngsters we have this great plasticity in that our environment is going to have a big influence on how our visual system later develops.

And so if we have conditions that can impair our sight, it can have long term consequences unless they're taken care of at an appropriate time when the brain can most easily respond.

But we can fix problems or improve problems that stem from childhood development all the way through adulthood. Plasticity and the ability to change our brains never ends. But it gets more challenging and difficult and requires more effort, more work later on. So it's best if we can discover these types of problems early on.

So let's just go through a few of these types of problems. And so our two eyes, if we want to think about them, have a certain amount of light bending power. And you've all heard the term farsightedness, nearsightedness and astigmatism.

And those all mean what we call refractive conditions. Those can be corrected with lenses, whether spectacle lenses or contact lenses. And the goal is to bring the optics of the world to the retina.

And to do that we need to bend light. And that's what lenses do, they refract or bend light. And we want to get it to the retina, the best possible imagery to the retina.

So for children who have one eye that's different than the other eye, this child will often pass as having normal vision. But they may only be using one eye.

And so these problems get missed very, very frequently, when the two eyes are different from one another. And so pediatric eye doctors who use instruments like a retinoscope where they shine a light into the eye using lenses and they can measure how good the eyes are seeing or as far as how the light is coming to the back of the retina or not.

And they can make, and they can detect these differences in between the two eyes, which is really important to correct at the proper time.

And if these problems get passed through or they don't get identified early on, it is then again more difficult. And what happens is when the two eyes don't have equal imagery, the two-eyed depth perception doesn't develop to nearly the degree that it does if the two eyes are equal.

And the eyes have more difficulty with teaming together and working as a unified team that provide more information than either eye can separately. Because we're designed with our two-eyed system is to be able to derive information about how far objects are from us and where we are from objects in our world as well as providing clear imagery through the focusing system.

And the focusing system, as I mentioned the retina is developing, there's more connections. White matter and myelination of the fibers that connect the eyes with the brain are continually evolving. And you need to remember that the retina is part of the brain.

So part of your brain lives in the back of your eye in that little gossamer thin layer of photoreal receptors. Part of the brain is telling the brain what's going on in the world. It's the brain's way of touching the world. But on the other hand, as we develop, the brain tells the eyes where to look rather than being passive. So this is a very dynamic bimodal system that gathers information about the world.

And the wonderful thing about the visual system is it's extraordinarily fast. We can, you know, information travels at the speed of light to the eyes, and we can. And it travels to the rest of the brain very quickly as well. So with sound, as you are listening to me talking, you are listening to a sequential processing of your brain because this, the speed of sound is so much slower and touch is useful, but not nearly as effective.

So what the baby has to learn how to do is to combine information from touch, from feeling, from hearing with the vision system. And before a baby is able to combine those sorts of things, the visual system information is kind of like watching a fuzzy tv. They just don't connect it.

But what our evolution has created for us is a system called sensory integration, where we're most effective when the visual system can be dominant, but takes into account information from the other senses as well.

Let me give you a specific example. When my daughter, who's now 40 years old, was an infant, I was there while her mother was at newspaper working, and I got to witness her first ambulatory movements.

So she started creeping, and we lived in a crummy old apartment that had carpet, and then it transitioned to linoleum in the kitchen. And there was a big glass sliding door out onto a little deck.

And the sun was shining through that glass door onto the linoleum and toward my daughter. And she started pulling herself with both arms forward. And I was so excited. Wow, this is development that is happening.

And so I was, where is she going? What does she. What is her brain telling her to do? And so when she got to the linoleum, you know what she did? She stuck out her tongue as far as it would go, like a windshield wiper on that linoleum, back and forth, back and forth.

So why did she do that? Why did she do that? She did that because the tongue has more nerve endings than any other organ in the body. And she was using.  And babies learn through their mouth.

And she was, what she was doing was she was combining what she saw with her vision with what she could sense with her tongue. So that was. Sensory integration was happening right at that moment.

And, you know, usually around three months of age, we start developing coordination between the two eyes. So you might have the eyes misaligned in the first six months of life. It's not really that big of a deal if it happens occasionally. We used to see that in the pediatric clinic with a lot of parents saying that, oh, my child's eyes are misaligned.

And we say, how often does it happen? How long has it been going on? Has it been getting worse, of it getting better? And usually if they say, you know, it happens like, you know, 20% of the time and say just keep an eye on it, to use a pun.

And if it gets, if it gets worse, we will further investigate, but it should go away spontaneously somewhere in between three and six months of age, which is what the case is, you know, probably over 90% of the time when the eyes are aligned.

But then what happens at the focusing system that results in our being able to see up closer? So remember, the eyes are kind of designed for focus to be at far in an ideal in the way that we've evolved.

Now that's called farsightedness or emmetropia is the lack of a refractive error. And so the worldwide natural eyesight refractive error is just a little bit of farsightedness, which allows the visual system to see clearly at far, but yet the economy system is kind of turned on so that it can respond really quickly is what the theory is for why we're all a little bit, tiny bit farsighted.

So if a baby has a lot of farsightedness, this poses a risk which we're going to talk about. So what does farsightedness, what is the risk from farsightedness with babies? Well, a farsighted child, to see clearly, they have to focus that far away more than everybody else does.

That effort at focusing drives the eye teaming system inwards. We call this convergence. And in the brain there's this relationship that's called a synkinesis, where one system stimulates the other one and vice versa. And this synkinesis, when a person tries to focus, will drive the eyes inwards.

And that is how things are supposed to be. Because when we look inward, we need to focus and we need to have our eyes both on the same target up close. And when we look at far, our eyes need to be, the lines of sight from the back of our eyes need to be parallel for distance and focusing needs to be less active or more relaxed at far.

But if a child is really farsighted just for them to focus that far, there's a tendency for the eyes to turn inward. And then when the focusing system really starts working, somewhere around age 2 to 3, those individuals who had an abnormal amount of farsightedness, they can develop an eye turn called an inward eye turn, called esotropia.

We as organisms have evolved to have two-eyed depth perception. So when we're jumping from branch to branch in the tree canopy or trying to pick fruit up high, it's good to have binocular vision, depth perception, which tells us how far away that branch is. If we see double, it's a survival threat. We could wind up falling. Or if we're being chased by a lion and there's two lions, if we jump the wrong way, the real lion might eat us.

So we don't like. The brain doesn't like seeing double. So what it will often do is it will turn off information from one of the images of the eye, the central part of the image from one eye and just become one-eyed.

And that is often called strabismus. And the eyes can either go in or they can in or another type of eye turn is the person figures out how to flip the eye outward rather than inward. And that's called exotropia. And that often happens. It can happen either in the first six months, it can happen in school. So there are different types of exotropia, as there are esotropia.

Esotropia, the most common is called accommodative esotropia because that occurs when the accommodative system matures around age 2 or 3 and the individual really starts looking up close. But there are also esotropia that's also known as infantile esotropia, which occurs in the first six months.

Those are much more challenging problems to deal with from a number of different standpoints. But we talked about astigmatism and in the clinical population, we saw there were a lot of Latino kids, a lot of Hispanic kids who come into our clinics and they have a huge amount of astigmatism.

And astigmatism from, is derived from Latin and it means without a point. Kind of like my lectures that my, that I give to my students. So, so what happens is the curvature at the front of the eye, which is called the cornea, the clear part of the front of the eye does most of the light bending or refracting to get it to the retina.

But people who have astigmatism have an unusual shaped cornea where the curves, one curve is too steep and the other one is not, is too flat. And so light comes to two different points. So you need to design a lens that is ground with two different curves.

One curve brings that sharp curved image to the back of the eye. The other one brings the image from the less curvature on the cornea to the image. And so that is astigmatism and if you don't correct that, what happens is they get desensitized vision in a particular meridian.

It might be the horizontal meridian or the oblique meridian or the vertical meridian. It just depends on what type of astigmatism that particular individual has. And curiously, out of the Hispanic population, a lot of them have what's known as against the rule astigmatism.

And with a rule astigmatism means that they are good at seeing horizontal lines, but not so for vertical lines. So how does that affect a kid? Well, there's a lot of vertical components to letters that we have to read, and so they are very difficult to interpret that the Alphabet, the language, and to learn the language at the rate that a child who doesn't have astigmatism would learn to identify and see that. And so why the Hispanics?

Denise: Yeah. How much higher is it for Hispanic kids than the rest of the population?

Hannu: We have a biased sample because probably 50% of the population here in the Washington county area in Oregon is Hispanic. And I would say that in our clinics, I would say probably 60, 70% of Hispanic kids have a significant amount of astigmatism that needs to be corrected.

So it's. Yeah, but it doesn't represent the US Population in general. And probably given what's going on politically, we're going to have a lot less astigmatism in the future.

So what the issue is also is to make sure that we get lenses, corrective lenses on the youngsters, because if we can get lenses on them four or five years of age, they'll have perfectly normal visual development and they will have no residual effects in most any cases in the future.

If we correct them later, we can get improvement, but it might not be as good as improvement as we capture them early. And so that's why looking for these problems and having your child screened by a pediatric eye doctor who really knows their stuff is so important, I think, for parents is you need to be vigilant about your own children's visual health.

It's just a much easier problem to fix. The earlier you find it in less cost, less effort, less resistance, less tears, the whole bit. And so that's a really important part of it.
So we talked a little bit about the development of binocularity. So there's a lot of reasons why the two eyes don't team together. Well, we talked about strabismus as being one of them, where they're misaligned either up, down, up, or out.

But also there's a lot of what I would call weak binocularity where the eyes kind of team together but they don't do it consistently. And the binocular stability is really shaky. Where if they might be able to see depth perception for a little bit when they start to read and all of a sudden they start seeing double or the print will blur and, and then they'll switch to just using one eye.

So these are the individuals who are most often missed as far as binocular problems that we see in schools now, how does that affect visual information processing, school performance, academic performance for the individual?

Well, in this case, if your eyes are not teaming well together and your focus is not coordinated, remember they need to have the proper relationship. The focusing needs to be pretty close to where the eyes are pointed and vice versa.

So when they're not, and the individual starts seeing double, remember the brain doesn't like seeing double. So what does it do? It turns off central vision in one eye and the person starts just using one eye. And the words can swim, they can blur, they can do all kinds of abnormal things. And so do kids complain to their parents?

No. Why? They have never seen through anyone else's eyes. They think everybody sees like I see. This is just perfectly how everybody sees. So having parents who are savvy about noticing the signs, you know, and there are certain overt behaviors which help give it away. Children who move really too close to the print or turn their head, when they turn their head, the nose acts as a block so the upstream eye doesn't see the print.

So they can operate as a one-eyed person if they get close or they turn their head, tilt their head. I had a classmate who grew long hair and he draped his hair over one eye, not knowing why he did that. But it allowed him to be very successful in school.

So a lot of behaviors, some to look for, that can mimic ADHD. So if you are struggling with your visual system, remember you only have a limited reservoir of attentional effort.

So you can spend that attentional effort in a lot of different ways. But if you're expending too much of that with keeping your visual system functioning at just a minimal level, there isn't all that much attentional effort left to processing that information once it gets into the brain.

And so learning what, putting it all together, making sense of it, you know, learning how to read versus reading to learn, those are two separate processes. And again, the learning how to read happens usually in the first two or three grades of School, and then everything transitions to reading, to learn where they expect you to read at a certain competency, fluency level for you to gather information.

Probably, you know, four-fifths of what we learn is usually through the visual system in the grades. And now why do they have large print in first, second grade? Because it's easier for the eyes to focus. They don't have to be aligned quite as well.

A little bit about eye movements. Eye movements are absolutely fundamental to being able to process text, to understanding our world. We have different types of eye movements. There are six different types of eye movements. I'm not going to get into all of those specifically right now, but the type of eye movements that are most commonly used during reading are two to three types.

When the eyes are at rest, that's called a fixation and spoiler here. They're never totally at rest because if they were totally at rest, everything would fade. In the visual system, it's called the Troxeller effect.

So the eyes are always just, even though you can't see it, they're always jittering, jiggling and drifting a little bit. But they should be doing it in tandem, the two eyes together. So that's the only time that information can flow into the brain.

So when you read, there's a series of words. You have to jump from one word to the next word and pause when you get to the next word and jump to the next word and pause and jump and pause. And when you get to the end of the line, you have to make a return sweep back to the beginning of the line down below.

Now, that sequence of fixations where the eyes are still the pauses and the saccades or saccades, where the eyes are jumping really fast, is an incredibly interesting symphony of neurological activity.

During a saccade, the eyes can travel anywhere from, anywhere from 100 to 400 degrees per second. Now, if you think of your whole expanse being 270 degrees, just imagine at, you know, 300 degrees per second, your eyes get from one extreme to the other extreme.

So during the saccade, information is muted, just like the mute button on your television. It does not flow into the brain during that saccade. And that's known as a saccadic suppression.

The brain suppresses information flow coming in during eye movement. But when the eyes come back to rest, the brain turns the information flow back on.

So what does that mean now in toto, it means that you have like a, a series of visual images, like a deck of cards. And now the brain has a deck of Cards, each has a picture on it and the brain has to derive meaning from a series of cards.

What if you have crummy eye movements where your eyes jump too far ahead, then they jump too far back, they jump somewhere in between. Those images are all out of order and it's really, really hard to make sense of what you just read. Now remember, if you have trouble with focusing and keeping your eye fixation steady, you're expending effort, attentional effort to do so.

You don't have nearly as much in attentional effort left than to process that series of images into a meaningful whole. So you get tired before everybody else gets tired and you're going to want to give up. You're going to want to. There's a fly buzzing in the corner of the room. You're going to, your attention is going to go there.

You can hear somebody's teeth clicking on the other side of the room and your attention is going to go there, anywhere. But expending this huge amount of effort to try and keep that visual system functioning at a high level.

So a lot of the behaviors that are sometimes attributed to ADHD, attention hyperactivity disorder are sometimes from a poorly operating visual system in kiddos. And so make sure that you take your child to a doctor who is familiar with not only ADHD but familiar with binocular and pediatric eye development, because that is really key.

And so vision and learning is a huge part of what I've devoted my early career to. And that's where I've done specialty work and published and done things in that. But that is just one area of vision development. But there are so many interesting areas that we can talk about. So I'm going to flip this back over to Denise and see if what, what I said made any sense.

Denise: Yeah, I was just thinking as you were talking about how easy it is to miss those cues, even if you think you know something about visual development.

Because my 10 year old daughter was not having any trouble in school. She had learned to read at the normal time. She was straight A student as far as how they grade a 10 year old, you know, no concerns whatsoever.

And I took her to the regular eye doctor and I had been concerned because she ended up in glasses at three with a turned eye like me. I knew she was just like me and the optometrist said she was fine. He said he knew about vision therapy even, but didn't indicate that she needed anything.

And when I took her to Dr. Davies after I found out I could benefit from vision therapy. She was mini me and I would have never known if I hadn't been reading a book that said ask your child if they ever do these things when they're reading.

You know, like, do you cover an eye when you read? And she said, oh yes, when I'm reading I like to read in bed so that I can have the pillow over an eye and then I'd flip myself over to have the other eye covered when I'm reading the next page.

And I would have not had any idea if I hadn't asked questions and taken her to the right doctor. And I think that that's going to be missed by more than just me. You know, when we're thinking about what we need to do for our child's visual development.

Hannu: Absolutely. And just to make a comment on eye docs, you have to recognize that the training of optometrists and ophthalmologists is very different. And I think that's the core issue of how two professionals can come up with two very different conclusions from looking at the same child.

So first of all, an ophthalmologist is an MD who decided to specialize in the eyes sub surg and ophthalmology is really a sub specialty of surgery. And ophthalmologists their approach usually is treating diseases. They are remarkably good at treating diseases.

They can do a basic refraction and when they look at a visual system, if the acuity is normal 20/20 and there are no eye diseases, their conclusion is likely going to be this visual system is fine.

Don't believe what anybody else tells you about this visual system. The person sees clearly, there's no eye diseases and everything's okay.
And again that derives from their approach and their training.

And in those cases they haven't had courses in perception, in psychology, related to visual processing or any of the typically vision development specialty areas. So that is usually how they approach it in that case. And for most ophthalmologists most of their experience they might read a few books in their residency in ophthalmology but they see cases and they do what they were trained to do in their residency and in medical schools.

So that is kind of how they differ from optometrist who in optometry is a profession where you have to have a four year undergraduate bachelor's degree to get into optometry programs.

And there are schools and colleges of optometry. There's probably 25 of them now located both as private and as state sponsored institutions throughout the country. And Optometry in North America is probably the most evolved in the the world out of what we do.

And in most cases, optometrists study not only the biology of the eye and diseases, but also get exposed to human information processing, visual function, and then specialty areas. Coursework in contact lenses and coursework in low vision and coursework in vision therapy, sports vision, those sorts of areas.

So the training is very different and also usually the testing is very different. It's for those optometrists who have an interest in pediatrics and vision therapy, brain injury. They usually get additional training even beyond optometry school, either through residency or through working with a seasoned veteran who understands that.   

So those are often useful things to keep in mind in choosing an eye doctor. And one bit of advice that I would always give is never rely on a single opinion. Always go out and shop your doctors, whether they're eye doctors or whether they're a gastroenterologist. You can call and interview, you can go online, you can do lots of different types of searches to find out is this doctor appropriate for my family's needs and my child's needs and my adult needs.

So that is the key.

Not all optometrists do vision therapy or are even trained in vision therapy. There are some schools where that is not very well emphasized and others where there's much stronger emphasis in that area. So as we always say, caveat emptor is buyer beware.

But do your homework, do your research. And I know this is very frustrating, particularly for parents who have gotten conflicting opinions from different eye care providers about what to do.

But usually your gut will tell you, you know, you will have an instinct when you talk to the doctors, do they really seem to know, have insight into my child and the behaviors that my child is exhibiting and can they explain those behaviors and do they have the diagnostic means to confirm what the suspicions are?

And is this doctor being straight up with me or is this doctor trying to sell me something? Whether it's sell you a quick exit from the office and or whether it's sell you a very expensive program of intervention, always keep an open mind, but expect that there's going to be quality differences in whatever medical or eye care provider you choose.

Denise: You've done some different things that help with screening for these kinds of eye issues, right? So can you address first maybe the how people will know whether their child has ADHD, dyslexia or binocular vision issue when they've received a different diagnosis, what, how they're going to know which way to go on that.

Hannu: Yeah, sure.

So an awful lot of ADD, ADHD, one is with hyperactivity, one is without, is often diagnosed from a questionnaire. The most commonly known one is known as the Connor's Questionnaire. I think there's, you know, 20 some. Don't quote me the number questions where parents fill it out and if there's a certain number of positive behaviors, then that child is either at risk or diagnosed with ADHD.

But the diagnosis of ADHD is not straightforward as a questionnaire. It involves understanding that the child, the child's milieu, understanding the child's family situation, understanding the child's development. Those are all factors into the ADHD because there's so many contributing issues to ADHD.

So one thing that needs to be ruled out though is, is the visual system contributing to these behaviors of distractibility. And again, finding an eye doctor who understands what behaviors are common.

ADHD behaviors are common with visual dysfunction and can rule those out through diagnostic testing is a really good first step before going the full route of medications and everything else.

So again, how does the child behave at home, at school and at play? All of those are important factors in understanding is it truly ADHD?

Denise: And you said that you can tell if someone is dyslexia just intuitively. How many people can do that?

Hannu: Okay. It's, you know, I've always been a good guesser. I've always done well on tests. And so, one of the questions that I always ask is do you have to use spell check a lot or how's your spelling?

Dyslexia is a big monster of many tentacles and many mimickers. And so again, if we were to break it down into reading problems and just call them reading difficulties, we can just say that there are non-specific reading disorders and there are specific reading disorders.

So in the non-specific reading disorders you might have a situation where the youngster had really poor exposure to language and the parents had really poor vocabularies, they didn't, shall we say, value reading. I can drive truck. I don't need reading. Right.

And so the, the environment can contribute, poor nutrition, poor hearing, poor vision. All of those, in addition to having low native ability or intelligence can create a non-specific reading disorder.

A specific reading disorder, however, is one that is more of a conundrum for not only educators, but, but also for parents. And the child here is a child who had great instruction, they had great teachers, they had, you know, their schools were not substandard.

The Child had lots of books growing up, they were read to, they went through all of this. They have really good IQ scores, they do well in other subjects like math, but their reading is way behind where it should be.

And so there are many different contributors to specific reading disorder. But dyslexia is a subcategory of a specific reading disorder. It originally evolved in the late 1800s when there was soldier who was had a bullet go through his head and he lost the ability to read.

He had been a reader before. And so that that term dyslexia was used. And then later in the early 1900s in England they did a lot of research. I remembering the researchers, Hinschel Wood called it word blindness that in other words they did well on everything else but when they just could not remember words, it was like they looked at them and they just didn't know what they were.

So dyslexia. Unfortunately, educators, school teachers don't like the term dyslexia because it's a medical diagnosis that indicates they have a brain disorder. And you can't fix brain disorders. Right.

So teachers tend to have more of an operational definition of the problem which is they have a reading disorder without attributing it to any specific cause underlying etiology.

So with again dyslexia, it's just a hard to define beast that a lot of people just don't like the whole term of dyslexia. But it's like shorthand now for you have a reading problem is kind of how it's evolved to be, but it doesn't really tell you what the reading problem is.

And so I find that with dyslexia some of the diagnostic tests that I use subdivided it into different types of disorders within the word dyslexia. One was dyslexia which was probably close to the word blindness where they individuals who are poor spellers, they just couldn't learn sight words at the rate that normal other non-dyslexic learn them.

And then there's another type called dysphonasia where the individual wasn't able to connect the sounds to the, the graphemes or the letters of the language. And so they would often have really bizarre spellings.

They often had hearing problems that were associated with it as well. And then there's the, the misnomer, the reverse, this nemkinesia where you know, letters Ps Ds, Bs, you know, were you know, reversed.

And the public tended to think that reversals were indicative, indicative of dyslexia and that's a myth. There are, you know, there's at least a half a dozen different causes for letter written letter reversals, and it doesn't mean dyslexia may be one of those causes, but it's not very definitive at all as far as defining it.

But the, the one that runs is autosomal dominant, that runs in families at a probably 50% rate is the, the dysideia one. And what is dysideja? First of all, you need to understand that when we learn how to read, we start by learning the, the letters and the sounds and we sound out and then we start to recognize words by themselves and we usually can recognize them within a couple seconds.

And we know what the word means and we know how to pronounce it. And if we see an unknown word in context during the reading process, usually 15 to 25 exposures to that word causes that word to become a sight word.

And what is a sight word? Again, it's a word that you recognize within a couple seconds and you can, you know what it means and you can usually pronounce it correctly.

And reading is highly predictive of how many sight words you have. So every grade year in school you have more sight words. And that's how they usually quickly assess reading ability of a child in school is by doing a quick sight word test.

So dyseditics in contrast, they're not very good at learning sight words. So remember I said it 15 to 25 exposures in context and it becomes a sight word. Well, with a dyseditic who has severe dysedea, it might take three to four and a half thousand exposures for a word to become a sight word.

So you can just imagine how challenging that is because every time they come to a word, they have to sound out the individual letters using phonetic skills. So reading for them is very slow.

They usually read anywhere from a third to a half the normal rate. They're usually terrible spellers. And one of the problems with the English language is the Norman invasion of 1066 where French was introduced the English court.

And so half the words are screwed up, or I should say a third of the words are screwed up. French spellings who have silent letters and are written differently than they are pronounced. So that makes English particularly challenging as you know, as an English teacher.

So yeah, So for somebody who's dyseditic, using phonetic rules is tough with non-phonetic English words, a third of which are non regular words in the English language. So that is one of the keys.

And so I always ask, is your child a poor speller? If they're a poor speller, that indicates they don't have that visual imagery for what the individual sequence of letters are in that word. And for example, spell the word ghost for me.

Denise: G, H, O, S, T.

Hannu: Yeah, you have good mental imagery because. Or the word, for example, foreign.

Denise: Yeah. F O, R, E, I, G, N.

Hannu: Yeah, if you're a phonetic speller, you would say F O, R, E, N. And again, so that is, you know how I get a sense of whether they have that processing problem.

And then I ask, are there non recreational readers on either side of the family who don't read for fun and who are painful? Find reading painful. And usually you can just see that familial pattern carrying on through with the decendants.

Denise: How do you address that problem? Because you're describing my granddaughter right now and she's been homeschooled. Her parents are both on the autistic spectrum and her siblings have all those kinds of traits.So we have this Asperger's father homeschooling the children.

You know, I look at my 9-year-old granddaughter and I say, okay, how do I even help her when she's not recognizing sight words even? You know, it just, it just sounds so much like that. And how do you go about addressing those kinds of issues?

Hannu: Well, we're not reading teachers as optometrists, so I'm not gonna wade into this area very deeply. But I will tell you that there are some methods used by educators that are hard, require time, practice, but are effective in the majority of the cases.

And the one that comes to mind is called the Barton Method. And they have a whole syndicate of people who are trained in teaching the Barton method. And the reason I bring that up is my good colleague who also has a degree in education like I do.

His wife was a classroom teacher and is now just a specialty tutor for dyslexic kids. And she found that the Barton method worked the most effectively with these kids who had severe reading problems.

And my own grandson, in the first two years of school, he really struggled with reading. And so I had my colleague's wife find a tutor for him and a year of tutoring and he's now reading at the top of the class, which was a very big surprise for me.

I didn't expect him to make such dramatic gains. But that is again, you know, those success stories are nice. Not every kid makes it to the Top of the class. But if you can get them out of that D-C range into the B range, they're going to do just fine in life, you know, and they're going to be, they're going to be okay.

Denise: She just fights reading really strongly, you know, and, and I've tried to work with her long distance, which doesn't work very well. And it's just, it's a constant battle. And so, I want to find some different options for her.

Hannu: So again, motivation is such a area of such an art form. So you have to find the magical motivating devices. Sometimes they're devices like, wow, you can earn points. And we call this the token economy. If we do five minutes a day, you earn this many points to something you really want. And it can be a physical reward, but more often just as effective is getting an intangible reward like you have just bought an hour of daddy's time and he will do your chores for you.

He will go take you to wherever you want to go. Or another one is you just bought 20 minutes later on your bedtime time. So using. Finding out what works with a youngster this age is always kind of a mystery bag of tricks. So you have to go through all of them sometimes to find out something. And you start slow with very limited exposure. And then you try and develop it, and work it up into longer and longer therapy sessions.

Denise: Okay. I know that your expertise has led you to the hardest cases, right. Which are the traumatic brain injury types of cases. And that's what you've spent a lot of the last several decades doing. Can you address a little bit how people are diagnosed with a traumatic brain injury and what kinds of results you see when you address those injuries in the proper ways?

Hannu: Sure.

So with brain injury, concussion. Concussion is just a mild brain injury. And we classify brain injury in terms of mild, moderate, severe, and profound. And those with that categorization is usually based on whether they had amnesia after the concussive event, whether they were in a coma, how long was that coma, and so on and so forth. And those on the more profound end of the spectrum usually will have lifelong disabilities.

Those who are on the mild to moderate categories, they might have been in a car wreck where they were like rear ended or something and they were a little bit dazed and didn't realize it. And then several months later they started having strange symptoms that they didn't have beforehand.

And, and again with the moderate, they might have had just a brief period of either unconsciousness or amnesia, or both. And they usually look just fine on the outside. And everybody expects them to be like they were before the event.

And it doesn't take very much of an acceleration-deceleration of the brain within the skull because it. Well, when you accelerate and decelerate the body rapidly, rapidly, the brain, which is a three pound mass of jello floating in a fluid inside a skull, will slam against the skull. And what happens is that there are two types of brain matter that have different specific gravities, which means that if you accelerate and decelerate right, the brain, that the connections in between white matter and gray matter tend to pull apart.

And we call this diffuse axonal injury. And those are often the connections between distal parts the brain, allowing you to make associations and allowing you to do lots of different types of stuff.

So these individuals, again, they look just fine on the outside, but they may have memory problems, they have problems with clear vision, they have, may see illusory movements in the periphery. They can't read to help them because their eye movements are so poor as a result of that. And again, the connections, the synapses in the brain are very fragile and the brain is not very well adapted to being whacked around.

So if you get brainwacked, it can have some profound consequences to your life. Ten percent of those who have mild brain injury or concussion become totally disabled where they can't do the jobs that they used to do, they can't pursue the hobbies and avocations, and there's like a 70% divorce rate in this group. And they have greater problems with alcoholism, drug use, homelessness.

And so it has all of these, this huge impacts on their life. They look fine, you know, everybody going, what's going on? Why should they? This is just in their head.

Well, duh, it is in their head. So in identifying brain injury, the visual system is a really helpful diagnostic tool to look at to identify whether this person has consequences from their brain injury. The brain vision occupies maybe 40% of the cortical real estate in the brain.

Every part of the brain has something to do with vision. And there are long pathways from one end of the brain to the other and from side to side and up, up and down that connect different key functions of vision in the brain.

So as a result, if you have a brain injury, your visual system is very likely going to be affected. So once you have a, a concussion, you know, there may be physical damage to some of the tissues. That's not the big causative factor that usually the big problem with symptoms is the neuro-inflammation that occurs.

So whenever there is an insult to the brain, we have a defensive mechanism called inflammation. And as part of that inflammatory response, there is a release of cytokines. It's called a cascade. And it floods the, with all of these chemicals that, whose purpose is, is to digest damaged and devitalized brain tissue and recycle it.

And often that inflammatory process destroys more, creates more problems by harming healthy tissues than it does just cleaning up the damage from the, the mild concussion. And so you have these wide ranging problems.

So after a brain injury it screws up how well the neurons function, their ability to utilize glucose. There's problems with calcium and potassium inflow and outflow, and there's a huge reduction in blood flow and the brain needs that blood flow for nutrition. And also what is disabled is the ATP to ADP transfer, which is what produces the energy that allows neurons and cells to function.

So not to go into continue this detailed look, but there are a lot of problems with the visual system in most people who have had brain injury. And I created this brain injury vision symptom survey because I had been working with patients who had brain injury for the past three decades and I had been listening to their long histories about strange stuff that was going on with them.

And at Walter Reed, where I did my sabbatical with wounded warriors, most of whom had had blast injuries from IEDs in Iraq and Afghanistan, they were pretty screwed up. And so I kind of refined my brain injury symptoms survey there and then I did quite a number of studies in validating it in establishing its test retest reliability as well as its sensitivity and specificity for brain injury.

And there's 28 questions on this brain injury symptom survey. And in the each question you rate is. Now this doesn't apply to me. Maybe mild, maybe. Yeah, maybe it happens. Maybe it happens real frequently. It's always there. And so the total score that we get from the symptom questionnaire was really useful when you add up all of the items because that is, it allowed us to calculate a cutoff score.

And the cutoff score helps differentiate those who have brain injury from those who don't have brain injury. So for practitioners who, providers who are not eye doctors or don't know anything about brain injury, if they see brain injured individuals, if they give them the BIVSS, the brain injury vision symptom survey and the person scores at a level greater than 31 points on it, that provider should refer that patient then to a brain injury vision specialist who can diagnose and treat the problems with brain injury. And so again, I think that is one step in the process.

But again, there are a lot of optometrists now who are known as neuro-optometrists with good expertise in diagnosing and treating brain injury. And with brain injury, there are some strange symptoms. Often involve balance, vision and balance. So when we balance, we have three separate systems. We use the inner ear, the vestibular system for balance. Then we get information from the body, ankle joints, muscles, that tells our what you know, the, the status is in the body, the somatosensory information.

And,then the third piece is the visual system. The peripheral vision is what allows us to know where we are in our visual space. And those three systems need to be providing consistent information to the individual.

And after a brain injury, often there is a disruption where there winds up being conflict in between what one system is telling the other system. So the visual system may not localize properly. The vestibular system may not be sending the proper signals. And so this integration that should happen seamlessly in between these three systems is lost.

And what I found given my working with optometrists for who had great knowledge in this area, is I started using prisms to first identify where the individual thought straight ahead was with their eyes closed.

And then if I could put prisms on, that would shift the visual world to match where they thought, where they felt. Their, their gut told them straight ahead was that these individuals could all of a sudden stop stumbling.

They would stop bumping into, into things. They would not have to walk along the walls with their fingers touching the walls to know where they were in their visual space.

And photophobia or light sensitivity is also just a huge problem. (Those) who have a brain injury where they can't tolerate normal levels of illumination, whether indoors or outdoors. And so I also found that using filters that reduce the visual spectrum to a certain bandwidth of colors could have profound effects on the individual's visual comfort. Where they could tolerate normal light and they could get along and go shopping, which they hated doing before being in busy stores.

And it decreased the amount of peripheral visual motion and their visual sensitivity, peripheral motion sensitivity was decreased and also getting the right lenses on them. So often after brain injury, there's a slight misalignment, alignment, vertical misalignment of the eyes.

It's very subtle and very small. And often just a tiny bit of vertical prism will instantly reduce Headaches make them more comfortable, more much happier, and then vision therapy. So my goal always in seeing brain injured patients is use whatever combination made them better as fast as possible because most of them had lost hope that anybody could ever help them or fix them because they thought that these were permanent changes to their lives and that they would have to just struggle with this for the rest of their lives.

And if I could make them with lens therapy better, and sometimes all it involves is using little tiny strips of tape that blocks out part of the peripheral vision on the nasal side that helped immediately and then get them into vision therapy and to habilitate, and again, habilitate means to get them back to where they were.

With a brain injured person, you can never restore the visual system to pre-morbid or pre-accident levels, but you can get them, you can get a lot of them way, way better than where they are at present.

And so that is my approach to vision therapy and brain injury is that it's, these are really, really complex problems and there are no two brain injuries that are alike. There's an old saying amongst my brain injury colleagues that if you've seen one brain injury, you've seen one brain injury.

Denise: I have heard that before.

It can probably apply to the rest of the population in some measure as well, as far as, you know, the strabismics and amblyopes and, you know, all of the different things. But brain injury certainly would be more challenging on a lot of levels.

Hannu: Levels indeed, because of the number of problems that in the complexity of the problems.

Denise: All right, well, I think I've taken quite a bit of your time today and we have all kinds of other things we could talk about.

Hannu: Next time.

Denise: There we go. Yeah, that would be great. I think that we're going to have to do that because I made this big, long list of all the things that I wanted to ask you about and it's not something we can do in an hour podcast, obviously.

Hannu: So your mistake, Denise, was just asking an old professor a question.

Denise: Well, a question can be answered in depth, obviously, in a way that hopefully is impactful for people and gives them a better understanding of the whole visual system. And I think that most people just don't have much understanding of the visual system and what the possibilities are for it and the challenges that can be addressed as we become aware of, you know, what is actually going on.

Hannu: Indeed. And I, commend you, Denise, for making vision problems more accessible to the general population. Help them understand and bring explanations that may help them on their journeys to a better vision. Yeah.

Denise: Do you have one last story or experience that you want to share as we wrap things up today?

Hannu: No, I think if you want to ask me back, I'll be happy to sit for you once again and chat. It's been a pleasure and I enjoy seeing your smile on Zoom. I wish that your podcast viewers could see your lovely smile as well.

Denise: Oh, well, I appreciate that. I thought about doing it as a YouTube video at one point in time, but the challenges of doing any kind of editing have stopped me. You know, I think, well, maybe if I was super confident and I didn't do any editing and it was just a live broadcast, then I'd have to get over all of that and just put it out there.

But that isn't something that I've decided that I wanted to do at this point. So I appreciate that.

We'll have to delineate some parts of what I had in mind that we can address on a future episode and do that at another time. And I just am very grateful for your willingness to share your expertise today.

It's been really, really enlightening. But thank you.

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