What Makes Vision Therapy Work? with Vision Therapist Thomas Headline

 In this episode of Healing Our Sight, Denise talks with vision therapist Thomas Headline about what really helps people make progress in vision therapy—and why that process looks different for each person. Drawing on more than 30 years of experience, Tom shares practical insight into how therapy works, what patients need to succeed, and how therapists adapt along the way.

They also explore how the field has evolved, why individualized goals matter, and what both patients and parents should understand before starting the journey.

In this episode, we discuss:

• What makes vision therapy effective
• Why patient awareness and follow-through matter
• How therapists adjust for different needs and challenges
• More complex cases, including anomalous correspondence, and how therapists approach these challenges in practice.
• What can slow progress or lead to plateaus
• How vision therapy is changing over time

Connect with Thomas Headline: https://headlinevisionenterprises.com/faq.html

Connect with Denise Allen:

Website: https://healingmysight.com

Healing our Sight Facebook Group: https://www.facebook.com/profile.php?id=100063570817348

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Transcript

Denise: Welcome to the Healing Our Sight podcast. I'm your host, Denise Allen. Today my guest is Thomas Headline. He is a vision therapist with over 30 years of experience in the field. I'm very excited to have him speak with us today. Tom actually began his journey working as a vision therapist while putting himself through college. And after graduating from San Jose State with a degree in business finance, he chose to continue in this work because of the impact it has on people's lives. He went on to spend 20 years as director of vision therapy with Dr. Bradford Murray. And today he continues working in clinical practice in the San Francisco Bay area with Dr. Carol Hong and Dr. Benjamin Papilski. In addition to his clinical work, Tom has played a major role in training and mentoring vision therapists. He co-authored the Vision Therapist Toolkit and founded Headline Vision Enterprises where he develops materials to support therapists in their work. He's taught vision therapy internationally, helped lead educational initiatives through COVD, (now OVDRA), and has received multiple awards recognizing his contributions in the field, including Vision Therapist of the Year and most recently, the OEPF Therapist Star Award. What I'm especially excited about today is the perspective that he brings, not only from decades of hands-on experience with patients, but also from training therapists and helping improve outcomes across the field. Tom, welcome to the podcast.

Thomas: Thank you very much for inviting me. I'm happy to be here.

Denise: Yeah, I'm very excited. Tell us a little bit about what drew you into vision therapy to start with.

Thomas: I think a lot of us that get involved in vision therapy sort of discover it by accident and fall into it. So, in my senior year of high school, a friend of mine was working in an optometry office and they were in the process of. Of putting their patients into their computer system. This was back in 1985, and my friend knew that I knew things about computers because I had taken the computer class in school, so I was only supposed to do a three-month job just kind of entering their patients into the computer. And they realized after I had done that that I was the only one who knew how to use the software for the computer. So, they asked me to stay on. So, I was able to have that as a job to help me work my way through school and doing that computer work. And back in those days, computer monitors only came in three colors, like gray, amber or green. You know, that was it as far as the text and the background was black. And I was taking some honors humanities courses, and we had to do things like read the Iliad between a Tuesday and a Thursday and be able to discuss it in my other courses. I was getting really bad headaches and eye strain. And the doctor said, did my exam and said, oh, well, you have convergence and efficiency. We could do some vision therapy on you. And I had heard that term back when I was in fifth grade. There was a doctor who had examined me but had given me glasses. And so, I had had glasses for a while. And so, I went through vision therapy as a patient. And then the doctor liked how I followed through with patients and did things. And, you know, there were a lot of people that were wanting to start vision therapy. And he said, would you like to learn how to become a vision therapist? I went through the training that he offered, and then we also send me to conferences and things to learn more about vision therapy. And I started working in the field, and when I graduated college, I had a chance to go through on campus interviews and was interviewed by Merrill Lynch and with HP and had some opportunities there, but I was working with some patients in the clinic I was in, and they were like, well, if you leave, who's going to work with us? I was like, well, okay. So, I wanted to stay in the field, and they were wonder people, and I've just stayed in it ever since. So, it's been very rewarding to help people improve their vision and improve their lives.

Denise: Yeah. And you experienced it firsthand, too, like a lot of people that I've talked to, actually.

Thomas: Yeah, yeah. And I think that that's really helpful because it's one thing to know theoretically what the activities are doing and things like that, but when you have to go through it yourself and, you know, what you're experiencing, like what you had to do to try to make, you know, the procedure that the therapist is to do successful, I think it's helped me in my ability to coach my patients and also understand when I can push a little bit harder and when I really have to back off, you know, so that way the person isn't going to go through, like, an unpleasant kind of experience, you know?

Denise: Yeah. Well, you've had an opportunity to see vision therapy change over all these years, too, right? How is it different now than it was when you started?

Thomas: I think the core concepts are similar in. In terms of, like, how we proceed. I think that some, you know, there's new, you know, gadgets that we didn't have access to, you know, back in the time, you know, when I first started. I remember our computerized vision therapy at that time. When we started, we had an Atari computer system. So those of you that want to Google the company Atari and see what that was, but had these cassettes we'd put in, and a lot of the programs we could use red blue glasses with so we could do some work on binocularity while they were working on another skill simultaneously, you know, so that was our computerized vision therapy at that time. And nowadays there's, you know, virtual reality things and other devices like that. But, you know, I still find that having a person know how to control their vision outside of an instrument is very important, you know, and so computerized devices are wonderful, and a lot of people can engage with them, but they're another tool that we have available to us in our vision therapy. I think another thing that's changed since then is more and more fields outside of optometry, especially like neurology, have been looking at what, you know, how the brain is plastic and what can be going on. So, a lot of the research they're doing is confirming things that we have known, you know, for a really long time. And so, to see that validation come in has been really helpful. And I think one of the other changes has been sort of some of the approaches into treating conditions like amblyopia. And that, you know, research is showing that a binocular approach to amblyopia seems to be more efficacious than traditional patching regimens and things of that nature. So, I think that seeing that that research is coming out and showing that, so it's kind of helping everyone's thinking, moving in a new direction.

Denise: So, yeah, I wish that that was something that patients were able to see more quickly. I feel like a lot of times they're going to their ophthalmologist and they're still patching, and they're not necessarily doing the research to know that there's another way.

Thomas: Yeah, trying to educate them and also educate others in the field. I mean, there are publications now within the ophthalmology field, which is showing it as well. So, I think that, you know, ophthalmology will be coming on board more with it because they've been researching it too. But, yeah, it's. There's a lot of. Even traditional optometrists, we're very much in the old school thinking that patching is the regimen. And some haven't looked at some of the newer research showing that, you know, things like even two hours of patching is equivalent to, you know, six hours or 12 hours or so. So, they may, you know, so hopefully, you know, word will spread more about some of the different options that are available these days.

Denise: Right? Yeah. So can you tell us a little bit about what separates people who succeed in vision therapy from the ones that struggle or. Or just don't have a good outcome?

Thomas: Well, first of all, it would be kind of the complexity of their individual case, you know, like how many things might be combined within their case, you know, so, and how those are managed. And, you know, what the optometrist will tend to do to set the visual system in a way that it can move towards the direction that they need to. So as a vision therapist, you know, we're following what our optometrist is prescribing for the program to do and implementing that. And then the optometrist, when they do their intake examination, would see what kind of optical supports would be appropriate for the person to be able to move forward. So, then we can use those optical supports in our vision therapy program with the patient to try to find that level where they can engage with the activity that we're doing. Then, in terms of. My most successful patients are the ones that actually do their work, you know, that, you know, when you assign them, you know, their home reinforcement, you know, they're. They're on it, you know, they're doing it and coming in and giving you additional feedback about what they're noticing, what they're experiencing. And I look at it when I'm working with my patients, when I do my first visit, visit with them. As I say, you know, we're going to be working together as a team, you know, to work on trying to make your vision better. And so, my role as the vision therapist is to implement the appropriate activities at the appropriate time. And I kind of need your feedback to know, like, where are we in terms of challenge level? So, when we're learning something, you know, there's three levels of learning that we can deal with. And so, I give you an activity that's too easy. Your brain isn't going to learn anything new because you already know how to do that. It can use existing pathways. If I give you anything that's too hard or frustrating, you're not going to learn anything from that because you're just working so hard. There's no new learning that can take place. So I usually tell my patients, we've got to be working in medium, you know, so if we're in medium, that's a good place where you have to apply yourself a little bit, and that's where you start to Discover, like, what you do with your vision, you know, so when where setting up some of the tools we're using. If I set up a visual experience where maybe you're seeing two images and then you do something that brings them together and it looks 3D, you know, my question is going to be, what did you do? You know, and you might be, I'm not sure what I did. And it's like, you know, my job is to help you build that awareness of what you did to fix that problem. Or if I set up a situation where something looks a little bit blurry and you do something that makes it look clear again, what was that thing you did, you know, that made that clear up? Because that's where you start getting the transition from what you're learning in the activity into real world, you know, so that way, if you were experiencing double vision in your real life or something that wasn't looking as clear as you want it to, you can do your thing and try to make it look more clear. Or like when we're training eye movements, if, for example, we're doing the activity called the Martian ball, where the person's following the ball that's hanging from a string, you know, and you feel your eye move a little bit glitchy, and then you make your eye move smoothly, and I say, hey, your eyes looking really smooth right now. What are you doing to make your eye look smooth? You know, that might be something you need to do while you're reading to help your eyes hang on to that sentence. So that way they're not skipping, you know your place from your reading. So, I try as much as I can to make that connection into the real-world experience. Because then you'll have people that do sort of bonus therapy, you know, so if they're out in their world, then they're looking at things, they're kind of doing what they've been doing on their therapy activities to make things look more clear, make things look more three dimensional, or hold their eyes, you know, make more accurate eye movements or whatever it is. So that way, you know, they're actually implementing what they've learned from vision therapy in the real world. So, I find that those are the patients that are most successful because they actually start transitioning the skills into real life.

Denise: Right. Okay, that's awesome. Do you think that people understand how much work it actually takes all of the time, or do you think that sometimes there's an unrealistic expectation in there?

Thomas: I think sometimes there are some individuals who think magical thinking, like we're going to wave the magic wand and everything's going to get better. They think that, you know, we're going to be looking at a computer program or something that that's going to fix their eyes and things like that and not realizing that, you know, it's really on them to kind of figure out, like, what they're doing. You know, part of what we do as a vision therapists is we're setting up conditions in a way to help guide them to use their vision in a way that they're habitually not using their visual system. So, they're developing a new habit of how to use their visual system. And if we do that appropriately, they'll kind of learn what they need to do in order to make that new thing happen with the visual system. Whatever skill it might be that we're working on, if it's a eye body or eye hand coordination thing, or an eye movement thing, or focusing or eye teaming or even visual perceptual skills, you know, where they've got to look at something, remember it, and then reproduce it, those kinds of things. You know, we need to find that appropriate demand level where they kind of have an aha moment of, oh, this is what I'm supposed to do. But a lot of times people sort of expect you to, you know, kind of give them the magic tool or the, you know, like, if I do this procedure, this is going to make my eyes better. I heard from a friend of mine that I should work with this particular, you know, tool or something, and that's gonna, you know, make my vision better. And it's like, well, you know, a tool is a tool, you know, and not all the tools are appropriate for every person. Different people gravitate to different experiences that we have in vision therapy. I know when we were talking before the podcast, you were mentioning the Brock String, and I'll have some patients who absolutely love the Brock String. And can they say, I can see, but my eyes are doing. I can tell where I'm looking at other people that absolutely dread the Brock String. And just so you need to make sure you have something that the person is going to be able to engage with. So that way they're getting an understanding of what's going on. So that's why we have a lot of different procedures in vision therapy, a lot of different tools, because, you know, that particular tool that we're using may not be speaking to that person, or they may not be able to engage in it, or maybe it's not providing them the appropriate Feedback of what they need to do with their visual system. But if we use something else, they go, oh, now I know what you want me to do. So, it's like being able to hone in on that so that way they can have that aha moment and discover, oh, this is what I'm supposed to do with my visual system.

Denise: Yes. Awesome. Is there anything that slows people down or they end up giving up because they maybe reached a plateau and weren't able to get over that?

Thomas: You know, I. Depending on the complexity of what a person's dealing with, you know, if we anticipate that the program is going to be kind of lengthy, sometimes talking about that up front, you know, say, this is going to require some time. In the office I work in, in Dr. Popilski's office, we do groups of 11 sessions and do a progress evaluation after every 11. So, we can do a check in and see, like, you know, are you feeling like you're approaching your goals? Let's take a look at your measure. Where do you feel you are right now? Because sometimes people do need little breaks or little vacations in the process to live life or do what they need to do and then come back into vision therapy another time. And I think sometimes, you know, when we've stimulated some of these neural pathways for them, you know, and they're starting to use what they're learning in the real world, you know, there's that time away from vision therapy where some of those skills can coalesce and kind of get more integrated. And then when they come back into vision therapy now, we can do, like, another block of time there. Usually if I see someone who's like, on an uphill movement, you know, so you see their skills are continuing to progress, it's usually not advisable to take a break during that because they're on that uphill kind of movement. When you have someone who's sort of in a plateau situation, that might be an okay time to say, hey, why don't we go ahead and take a little pause for some time, give you a chance to kind of get out there in real life and do some things you want to do and then have you come back in, you know, check and see where things are, and then, you know, see if it's time to go ahead and start another round of vision therapy. And a lot of it's going to depend on the person's goals and what their symptoms are. You know, a lot of times, some people will feel that once their symptoms have disappeared that you know that they can be done, and that could be a good indicator. But sometimes we want to try to have their visual markers be at certain places, so we know that the system is going to be stable. The other thing, too, is like taking a look at how much effort are you having to use to make your vision do what it needs to do. You know, if you're having to, you know, work really hard to focus your eyes and do what they need to do, you know, it's great you've got that ability. But we want to try to get you to a place where you can do it at ease, you know, where you can do it in a relaxed way. Because in real life, it's going to be difficult for you to come up with that amount of energy to use your vision that way for a long period of time. So, we want to try to have it be at ease. And so, you know, that's one of the conversations, you know, having with the patients, like, how do you feel you're doing? You know, and a lot of times they know, they say, I know I'm a lot better. I know I'm kind of. Of thinking my way through this a little bit. I'd like to do a little more therapy to polish up my skills a little bit. It's like, okay, fine, you know, let's go ahead and we'll. We'll take you, you know, to that place. So.

Denise: Yeah, I like that. So, what I'm hearing you say is that everyone's different. Right. And you're going to take them where they are and help them reach their goal based on what their expectations are and making it so their visual system really works for them?

Thomas: That's the goal.

Denise: Yeah, yeah, yeah. And do you ever, in those pausing times, like, refer them to another kind of a practitioner or determine that maybe they need some other kind of therapy that's going to support their visual system in a different way?

Thomas: Sure, Like, a multidisciplinary approach is, like, really helpful. So, some patients may need, you know, things like craniosacral therapy or central auditory processing therapy, or, you know, other things that are out there. And a lot of times, too, especially if we're working with individuals who are, you know, involved in multiple therapies simultaneously, it can make bit difficult for them a lot of times to fit in because each one of those therapies may be assigning them home exercises to do, you know, and so they're trying to think, like, how do we fit all of these in? And, you know, we still have to get to and from work, to and from school, we have to get homework, we have to eat, we have to sleep. You know, we have to do all those things, you know, like, there's only so many hours in the day. So, it's like, sometimes determine, like, what is the priority that kind of needs to take place first. So that way, you know, my feeling is, you, you want to get the best you can out of each therapy that you may be doing, you know, so sometimes, you know, it's like you don't want to just go through the motions of what's going on, because, again, like, you're trying to build these neural pathways in the brain. And so, if you're just kind of going through the motions, you may not be getting all you can out of that experience, you know, where when you're really present and engaged, you know, you start to notice things. Like, what was your experience like when you went through vision therapy and were learning, like, how to use your visual system in a new way? Did you find yourself having to, like, tune into, like, what you were doing, how you were using your visual system?

Denise: Yeah, I think that I had been trying to tune into that for a while because I looked at natural vision improvement things prior to finding vision therapy. I don't think that I analyzed it at a very deep level because that's not my personality type, but it was kind of more, how do I feel? How does my eyesight feel at this moment? And why is it that I can't do what I feel like I'm supposed to be doing? You know, I, I, I'm teaching my brain all these things, but initially it was not coming together at all because my eye would not point in the right direction. And so, it was this kind of constant frustration. I'd go home and do the exercises and think that something had shifted and go back and still not be able to do whatever it was, you know, for the longest time until after the surgery. I don't know if that answered the question.

Thomas: No, but I mean, that's one of the things, you know, thinking about how difficult that is to think, like, you're trying to engage your eye to align into the proper position and then trying to, like, how do I make this do what it needs to do? And that kind of thing. And that's something that we have to be mindful of when we're working with our patients. You know, it's like that internal awareness about, how am I controlling what I need to do. One of our forefathers in behavioral optometry, Dr. Skeffington came up with model of vision that has four interlacing circles that are overlapped. And he felt that vision answers for primary questions for us. And the first one is kind of like, you know, where am I in space? And that circle kind of encapsulates like, do I understand how my body parts work? Do I understand where I am in space? And how critical that is, like, for, you know, someone trying to engage their alignment, you know, to feel like, how am I going to make my eye move into the position that it needs to move in? My feeling is in. Vision therapy is trying to help foster a patient's awareness of what they're doing with their vision is important because it's going to help them, you know, as they go through the process.

Denise: Right? Yeah. And along the way, as you have been working in vision therapy, you started training a lot of other vision therapists, Right? How did that all come about?

Thomas: So, first, sort of starting within the clinic I was in when we would hire new people as the practice was growing and we were needing more vision therapists, having them come in and starting to work with that. But then after the Vision Therapist Toolkit book came out, we were invited to present that, our book and our how we were teaching about the tools at the California Regional Vision Therapist Forum in San Diego. And that was back in 2004, I believe. And then from that, that led to other teaching opportunities down the road, where it was in 2013 that I taught for COVD at the time, the VT101 course. And then that led to a Dr. Charlie Ho from the Philippines attended one of the VT101s I was teaching in 2014 in San Diego. And he asked me, would you be able to teach this course to, you know, us in the Philippines? And so, then I wound up going to the Philippines and teaching there and then developing further courses for them so that they could have more topics, you know, besides just the VT 101. And then that led to other courses. And so, it's now grown to where we're teaching in the Philippines and Malaysia, and it's just been very exciting.

Denise: Nice. When you observe the therapists that you're training, what tells you whether they're going to be able to get good outcomes or not?

Thomas: Well, in terms of, like, you know, qualities of a good vision therapist, I think one is curiosity, you know, trying to take a look at, here's the person I'm working with, and here's the condition that they have. And then how has this kind of evolved so that way, then it can kind of help inform your approach about, you know, how you might work with them. I think the power to observe is very important because we have to. When we're working with our patients, we have to observe, like, their total being, you know, to kind of see, like, what's going on so we can notice, like, how much effort are they putting into doing the thing we're asking them to do. So, we can determine where are we on that learning scale. Are we at frustration zone? Are we kind of in easy, or are we in the medium area? So, if we are kind of in that frustration zone, we need to dial back the demand level, so that way they're not going to, you know, have a meltdown or something like that. And then being able to think quickly on your feet is, I think, very important as well, because, you know, if something's not working, you've got to be able to make a change to it, and you've got to be thinking about, okay, what is falling apart here? You know? So, like, I. I just finished a second book that I've written for OEPF is publishing it, and it talks about how to use Dr. Skeffington's model and Dr. Getman's model to analyze your VIS therapy to see, like, if a person is having challenges in the activity you're working with, how can you apply those models to see, okay, what aspect of the activity is not working so, you know, how to modify it to try to get it into a place that's more developmentally appropriate for that person, or even to determine is that activity even a developmentally appropriate activity to be doing with them at that moment? You know, should there be something that comes prior to that that then helps them kind of get prepared? And that's why earlier, when talking about, you know, patients and how they're all different, it's difficult sometimes to have a step one, step two, step three approach towards different conditions because different people are coming to the situation with different life experiences. So, some people might be very attuned into what they're doing with their eyes. They might be able to feel, like, how they're moving them and how they're changing them where other people don't feel anything going on up there, and they're not sure, like, oh, you know, did my eyes move? They may not even notice that that happens. And so sometimes we have to change the activities we're working on to help prepare them for activities we want to do down the road. So I think a vision therapist needs to be able to think quickly, to be able to realize, okay, if this is not working, here's what I need to do to change it to go to something else that's going to be more appropriate or give that patient more appropriate feedback about how they are using their visual system. You know, so I may need to use a different tool. A lot of therapists can learn activities and learn how to use the tools, but I think one of the key things for a vision therapist is learning when is it appropriate to use a particular tool or activity that you're doing and kind of the how they're kind of presenting it or implementing it, where it kind of helps the patient understand kind of like what's going on, what's expected of them in that procedure and that kind of thing. And I think that, you know, therapists need to have good compassion for their patients, you know, understand that some of these people are working very hard just to do what they do, you know, and so when they are having a challenge on an activity, we have to consider the fact that this person may be using all the energy they have just to give the output that's coming out right now. And it's like, okay, we have to change something in a little bit here. And I kind of think that having personal experience, like, you know, some people don't have a visual issue, so they're not sure. You know, I've had parents before who, you know, when they're having their child go through therapy, the parent may never have had a visual issue at all. So, they don't understand what it feels like or is like to have a visual problem and have that manifest. And also, I think for vision therapists, like, it's important for them to have some personal experience with the activities, like not just having read the instructions on here's how you do this procedure, but that they're actually. They've done it themselves. They know what it feels like on them. So that way, then it's going to help make them a better coach to their patient. They can say, you know, when I was learning this activity, this is what I had to do to try to make it work. Maybe you could try the same thing. And maybe their suggestion may not help that person, but it might be a springboard that that person says, hey, if I try this, would this help me? You know, and so it might. Again, that collaborative environment where you can work together towards the outcome you want to have.

Denise: Yeah. When you're training them, do you ever do those activities where you put a certain kind of lens in front of them? So that it mimics what the patient might be seeing if hasn't experienced that.

Thomas: Yeah. In fact, during one of the courses that I've taught for strabismus and amblyopia, we will use prisms to kind of set up a situation. Say, you know, just have the person experience, like, what a double vision experience might be like. And I'll just have them sit in that for a little bit and just say, like, what is your visual system trying to do right now? What are you actually experiencing? You know, without them actively doing anything, just observing the experience itself. And so then they get to, you know, notice that, hey, sometimes the image over here went away, sometimes only part of the image went away, sometimes it moves somewhere else and for them to be able to understand why a person may have developed suppression as a coping mechanism to avoid visual confusion and things like that, so that you understand that when you have someone who maybe isn't letting go of that solution. Because we have to realize a lot of the patients that we're working with have come up with solutions to a visual issue. You know, a lot of times if they do have strabismus and they're suppressing, that's their solution to avoiding double vision. It's just like if I move that image far enough out of the way, I can pay attention to a primary image and ignore the other image. And that way then I'm not confused by what I'm seeing. And then when we're trying to undo that through therapy, sometimes as the images start getting closer to each other, but they're not completely fused yet. You know, it is messy looking, and that can be a very difficult process. And you wonder why someone might be experiencing a lot of suppression during that situation. And it's because, well, now we're coming back into sort of a situation of visual confusion. This is where the optometrist may need to be seeing them more frequently and making adjustments to their prescription to help promote better fusion. So, if they're being able to grow towards using binocularity better and things like that. So, you know, it's a team effort all the way around between the optometrist, the therapist and the patient, kind of working together and communicating well with each other, right?

Denise: Well, yeah. And then my doctor was always worried that he was going to create double vision for me, and I started to experience a little bit of it at a certain distance, and that started to become a little bit scary. It's like, oh, no, I gotta be able to work through that and get that to fuse right at that distance, you know, and that's still the distance that I struggle with, about, you know, fifty to a hundred feet, focusing on like a speaker at the podium kind of a thing.

Thomas: And that's where like the initial intake and the evaluation the doctor does to kind of see, like, what are the conditions that are present here? Because, you know, within strabismus there are other components to strabismus that the doctor is checking for as well, to kind of see what the prognosis is going to be for, for the case, you know, so, you know, they're looking at things about not just what direction the strabismus is, if it's inward or outward or vertically or things like that, but then also. So, is it constant or intermittent? You know, so if you have someone who has intermittent strabismus, it's going to be easier, you know, because they've got some binocularity in space somewhere. So, you can start in a little different spot in your training than for someone who has constant strabismus where their brain is really not used to using that eye whatsoever. And you got to kind of help the brain be aware that, hey, there's another visual channel that, you know, is present here that we could use. Then they also need to check with things like, is the angle of deviation the same in all angles of gaze? Where if there's variation in there, it makes it a little more challenging because the person may not be sure how to control their alignment when they're looking in different positions of gaze. And so sometimes we have to start therapy in the angle of gaze that they have the best alignment and then massage our way over into those other angles of gaze. So that way they can start developing that coordination between the two eyes a little bit better. And then they also need to check things like the presence of things like anomalous correspondence and things like that. Because if you have situations with anomalous correspondence, that's a situation where within the visual system, when we're looking at something binocularly, ideally the, the fovea of each eye is pointing at the object we want to see. So that way we're getting a clear image landing on the fovea of both retinas. For someone who has anomalous correspondence, they may be aligning one of the eyes in such a way that a non-foveal point is pairing together with the fovea of the other eye. It avoids the issue of double Vision, because now they are using a non-foveal point with the other eye. So, they see a single target of what they're looking at, but it's not really as precisely aligned as they should. And so, then the doctor has to determine, like, what path they want to follow in dealing with, you know, that situation. So, I don't know if you had had anomalous correspondence yourself, but, you know, with anomalous correspondence, that's one of the. The concerns we may have about creating a condition called intractable diplopia. You know, where the person is, you know, not being able to fuse two images together. So, the doctors will kind of decide, like, which pathway is best to use in treating that condition. You know, if you have someone who has normal correspondence, then usually you don't have to worry too much about creating kind of a permanent form of double vision because they're being able to pair fovea to fovea of each eye. So, the doctor will kind of inform the therapist as to, you know, how they're going to approach and require the therapist to give a lot of feedback when they're doing some of the different activities. So that way we can see if the procedures we're using are appropriate for the patient at that time, you know, so that way, you know, we may start with larger targets, targets with not a lot of detail to them, so that the brain is getting used to kind of pairing both eyes together to put kind of the conglomerate kind of overall picture together. And then as we see their vis system can tolerate that starting to move to finer targets, you know, as their system can tolerate.

Denise: So that changes where their eye is pointing. When you do those bigger targets, it gets the eye that's not pointing the right way to do what it's supposed to. Is that what you're telling me?

Thomas: When we're using larger targets, then that's gonna be covering a larger area of the retina. So, you may get, you know, kind of a more global sort of fusion. So, you're getting both to generally point in the same direction than where you're looking at really, really small kind of targets and asking them to have very precise alignment where the visual system may not be prepared to do something like that at that time.

Denise: Okay, so that's one of the avenues that you would go in if you were doing one of those two options.

Thomas: So, the doctors that I tend to work with usually will work with the person in their point of anomalous correspond and try to get what fusion we can get there and binocularity There. So that way we don't disrupt their sensory habit. But there is a school of thought of disrupting the anomalous correspondence and trying to establish normal correspondence and then working from there. So, there's two different schools of thought as to how to approach anomalous correspondence.

Denise: Okay. So, I'm taking it that they make that approach because they've had success in dealing with it, in doing it that way, rather than the way that your doctors are doing it.

Thomas:  for the people that use the disruptive approach. Yeah, there are people that are very comfortable in doing that method of working with patients and working that way. But generally, the doctors I've worked with will tend to work in a path of kind of working with what system the person has right now at that time and building the binocularities that they have. Have.

Denise: Okay. And so, as they build it, then it becomes more corresponding, because it depends.

Thomas: Like, some people can do wonderfully with anomalous correspondence and get depth perception and better alignment, cosmetic alignment with their eyes and things like that, and they're more functional that way. You'll have some individuals who may start to show more normal correspondence as they go through that, because the brain kind of goes like, oh, this is what we're supposed to do, you know, so just again, depending on the individual and some of the different techniques, you know, that we're working, you know, along our way there. 

Denise: Okay, so I would say that those were the more complex cases when you're dealing with that kind of a situation, correct?

Thomas: Yeah, it's definitely more complex when you're dealing with those situations and they require more care and following and things like that.

Denise: So, do you see any correspondence between how old someone is and the complexity of their case, or is it just all over the place?

Thomas: It really is kind of all over the place, I think, like. Like when we're working with, you know, toddlers and, you know, small kids and things like that. It's, you know, it's. You're not able to necessarily coach them in the same way that you would an adult who's going through, you know, and, like, their level of internal awareness of, like, you know, how to access their eyes and make their eyes focus and things is more challenging. So, you have to sort of set up situations where their visual system is sort of doing what you need it to sort of stimulate their system to, you know, be operating the way that you'd like it to. So, we might be doing more activities with, like, you know, red and green flashlights or red and green glasses and lights and, you know, light prites and different things like that. So, so when we're presenting them targets, we know they're seeing it or they're not. It's very clear-cut feedback that everyone knows. You know, are we using both eyes or is one eye on vacation? You know, what do we need to do Where I have patients that kind of run the spectrum. A lot of my patients I've been working with recently have been in their 70s and 80s, you know, individuals who've had strokes or other brain traumas and they can have very complex cases as well. A lot of it has to kind of do with their internal kind of motivation and wanting to work on, you know, what they're working with. And so a lot of them, when they understand what they're contending with and we can kind of talk about what their goals are and see, you know, are their goals realistic for what their condition has, you know, so we can sort of, you know, discuss are some of these functional things that they'd like to do going to be able to be accessible to them in the future? You know, it kind of helps us when we're having that clear communication up front. Now we know where we're working towards. So that way, you know, we're working together towards something that is maybe a possibility for them to do versus if there are certain functions that they want to be able to do again that really may not be safe for them to do or things like that. The doctor may have to have those conversations with them and say, okay, those goals, I'm not sure if those are something that we'll be able to do again. But you know, we'll keep them on the radar so we can see as we're moving forward. So that way, you know, we can all be in harmony with one another as we're moving forward.

Denise: Yeah. Do you ever have people come in that you say there's really nothing we can do to help you?

Thomas: You.

Denise: Does that ever happen?

Thomas: Well, you know, again, like all the patients that we work with see the doctor first and so the doctor does the exam, you know, so we have to make sure that we have a healthy visual system, that it's intact, that there's no physical obstructions or things that would be preventing the visual system from working and then just depending upon, you know, what they're dealing with, because they may have some pathological sort of things that are going on that are causing distortions to their vision that vision therapy may not be able to handle and do anything with. I had a lady who she was dealing with natural degeneration, and, you know, she was concentrating a lot on the things she couldn't see in a. Vision therapy is not going to cure macular degeneration or anything. But we were working on some activities to work on her peripheral awareness. And when we did that, she had this mental shift in her mind. She says, you know, I've been concentrating what I can't see. I haven't been thinking about what I can see, you know, and just having that for her was like, a huge shift because she had just been concentrating on, like, the kind of black hole that she noticed in her vision, but she didn't realize that she still had access to a large area of her visual field. And so that was a really helpful thing. So, I think depending on the person and what they're dealing with, you know, everyone, I think, can take away something from vision therapy that they feel is helpful to them. But again, I think, like, when you're working towards clear goals, it makes it a lot easier than, you know, if you just. I want to see better. Well, you know, what does see better mean to you? You know, or. I want to read better. Okay, what does read better mean to you? Is it. Do want to be more comfortable? Do you want to skip your place less? Like, what's. What does read better really mean? You know that kind of a thing or whatever goal it is, you know, so we can kind of be more specific on what those are.

Denise: Yeah, well, and it sounds like you want to make sure that you're on the same page as far as what the success and vision therapy look like at the end of the day. Right?

Thomas: Yeah, because, you know, at the end, you know, when. Like, when. When they come in for their first session, I'll, you know, ask them, you know, why they're there. Do they understand why they're there for vision therapy? And do they notice things happening in their vision that are bothering them? And even though they filled out a history form, I like to kind of hear them kind of tell me what's kind of like, foremost in their minds, and then I make notes of that. So, if they say, like, you know, I can read for five minutes, and my eyes are tired or I have a headache. Okay. So, you know, wouldn't one of your goals be to read longer than five minutes? Okay, let's jot that down. Okay. When you're losing your place, are you losing your place on every page or is it every few pages or, you know, what have you. When you're copying from the board, are you copying letter by letter or you remember a string of information, you know, so we get kind of specific. So that way, like I mentioned, after every 11 sessions, and I can go back and say, okay, so how's reading going? Can you read longer than five minutes without getting tired? You know, and then, oh, I read 20 minutes the other day. Oh, great. So, you are reading more than five minutes. Great. You know, so if we have kind of like, specific kind of goals like that, it makes it easy then to go back and, like, check and see, you know, like, are these improving? You know, and then. And also, during those times, check in. Are there new goals that you have? You know, I had a gentleman I was working with who had suffered a concussion from a surfing accident, and his job required him to be on zoom meetings all the time, and he just could not look at screens. And if screens would nauseate him, you know, he was just a mess. And so, for vision therapy, his goal was, I need to be able to look at screens. I was like, okay. And so, he went through the program, and he was doing very well. We were to a point where I was like, you know, you could graduate from vision therapy if you'd like to. You know, we're at a point where your binocularity is excellent and all this stuff. And he says, well, I think I have some new goals. I was like, okay, what are your new goals? And he was like, well, I'd like to get back to mountain bike riding. I'd like to go back to doing surfing. I'd like to, you know. So, his goals changed now that he had achieved his initial goal. Now he had new goals that he wanted to do. So, it's like, okay, said, well, you know, we'll treat you as a sports vision athlete now, and, you know, we'll kind of treat you that way. So, we were incorporating a lot more balance techniques and a lot more quick reactions. And he wanted to do this one technique he saw there's things called longboarding and surfing and where people. People like, crisscross walk from one end of the surfboard to the front of the surfboard and back. So, he wanted to be able to do that kind of stuff. I says, well, I don't really know anything about surfing or doing that, but we'll do some balance and do some things like this, and we'll try to get that integrated in. And so, we were doing that. And so, he started doing his mountain bike riding again and getting out and doing surfing and was having a really good time. And, you know, that was great. And he, you know, graduated vision therapy like a month ago. And it was like really a great experience for him. So, you know, I think that being in touch with your patient and knowing what their goals are and what they'd like to achieve, and I think that once a person's in therapy for a little bit, they get more of an idea of what some of their goals may be. See, I've had adult patients who were coming in primarily because their eyes get tired working on computers. And then as they kind of see some of the stuff we do, then they might say, hey, can you help me with my visual memory? And it's like, well, what are you experiencing? And you know, they might share. Well, you know, know nowadays we don't have to memorize people's phone numbers or things, but they, I'd look at a number, and you know, I can only remember a few digits before, you know, I have to do that. Okay, sure. You know, we could work on visual memory skills if that's something that's important for you at this point here. Because again, like I said, you know, we're working together as a team to try to help bring their vision where they would like it to be. And so, if that is something that is important to them, that then let's work on it and make it easier. I had one lady who was going through, and her goal was when she was cooking that she did not knock her spices off of her spice rack. She had a pull-out spice rack. Every time she would try to reach for the spices, she would knock them off, they would fall off the spice rack and onto the floor because her depth perception was really off. So, I said, okay, well, when we're going to be doing some of our activities, I'm going to be asking you a lot of where questions about where things are to the point that you're just going to be like, I hate these questions. Yeah. You know, you want to know exactly where that spice rack is from you so you're not knocking things over. So, I've got to get you to be able to look more critically at like how far away things are. So again, it kind of varies from person to person, what their goals are and what we're going to be working on.

Denise: Yeah. And it sounds like success can be different for every person because every person's goals are going to be so different. Different, right, yeah. So, do you think about vision and vision therapy a lot differently now than you did when you started out?

Thomas: Yeah, definitely. I had mentioned this in the second book that I wrote when I started, you know, and going through therapy as a patient. And since I had challenges with. With my binocularity and feeling, you know, fatigue from reading and working in computers and things like that, I really sort of had that mindset of, like, vision therapy being, like eye exercises and like, physical training and you're going to the gym and you're getting your eyes stronger. And that all made sense to me, you know, that, okay, this is what we're doing. But, you know, I have some patients who would improve, and they'd have wonderful convergence and divergence ranges, and they could clear, you know, various powers of lenses and everything, but they were still feeling symptoms. You know, it was like, you know, it didn't make sense to me, like, why are you still feeling symptoms if you've got these strong eyes? So, you know, as you would attend more education and learn more in the field, you know, there were a lot of presenters who would talk about the importance of the patient noticing, like, where the object is in space relative to them and things like that. And then that kind of started to hit home a little bit more as kind of, you know, realizing that that spatial processing is so important because that's going to help the brain know how much convergence to do, how much focusing to do. So, it's one thing to have the strongest eyes that you can have, but you're not going to engage that full strength all the time. Your brain has to understand what's just another enough focusing or convergence to do or holding my eyes on a line or whatever it happens to be. And so, it caused my model of vision to evolve. And then when I learned about Dr. Skethington's model and Dr. Gatman's model, you know, that kind of helped organize therapy that, you know, therapy isn't like this haphazard, like, oh, let's try this activity, let's try that. You know, an activity might be great for working on convergence, but there may be some prerequisite that a person has to understand what to do with their eyes before that activity is appropriate to do. You know, so again, learning how to sequence the procedures so that you're giving the person an appropriate demand level at the right time. So, when their models came in, again, that evolved and helped my visual system understand. And then when we started working with patients doing Syntonics and seeing so many patients that have benefited from the help from syntonic, and that also kind of expanded my model even more. So, it's evolved quite a bit from when I first started and thinking I'm just making a person have strong eye muscles, you know, so yeah.

Denise: Awesome. Where do you see vision therapy going in the future?

Thomas: Wow. I think with all of the different developments that are happening in terms of like FMRI studies and, and all these other ways that they can map the brain and all of that. And I think with the work that we do in vision and how vision permeates so much of the brain, vision's involved in so many different processes and the integration within all the other senses. I just think that vision therapy will have a tremendous opportunity to grow because more professions, I think, will start seeing the interaction that we have. I know that when Susan Berry spoke at the COVID meeting back in 2006, she had made the comment that like some of the work that we're doing just with like depth perception, you know, the areas of the brain that we're being able to reach with, doing three dimensional work really intrigued me to try to think like, wow, some of the different places that we're getting to. So, I don't know if we really know the full depth of what we're going to be able to do, but it's just very exciting to be a part of it and see it go into the future. Future.

Denise: Awesome. So, what, what advice would you give to someone who's just starting their vision therapy journey right now?

Thomas: As a patient or a therapist or either?

Denise: Well, you have both perspectives, right?

Thomas: No worries. For someone who's starting their journey as becoming a vision therapist, I would suggest go through vision therapy as a patient yourself first, so you get personal experience. There are, are a ton of incredible books that you can access to read and learn all that you can about the visual system. You can go to the OEPF website and there are many, many great books on there where you can learn a lot about the visual system, the process, and educate yourself that way and then attend conferences when you can. There are, are great educational opportunities. The OEPF organization offers a clinical curriculum of courses that can help establish your foundation in the field of vision therapy. So great way to get your feet wet and get started in the process as someone who's a patient. And you're getting started. I'll tell patients, especially if they're going to be in a long journey, is kind of journaling, you know, like, where am I right now? You know, what are some of the things that are challenges that you may be experiencing visually? Because as you go through the journey, some things are going to get better and vision therapy is very subtle. So, some things Will just, you know, issues you had previously made drop away. There are still some challenges that you have that you recognize, and you wonder, am I ever going to get better? But then if you look back at your early journal kind of experience, you might realize, oh, that used to be hard for me, but now it's not. Oh, that used to be hard for me, but now it's not. And you can kind of see, like, how far you've come, you know, to the point where you are now. And that can kind of help fuel you and motivate you about where you need to go. There may still be those challenges ahead in the future, but you can see the rear-view mirror, like, all the things that were so difficult before or they're not there, you know. And I think, like, for parents that are having kids go through vision therapy, it can be tricky to have that intrinsic motivation for kids. Sometimes I do have kids who they know that they're struggling with, you know, different visual aspects to things. And a lot of times when the doctor has done the exam and found a reason for it, and it kind of lifts a weight off the child that they realize, okay, they're not dumb, they're not stupid. You know, there's actually a visual problem here that's at work, and we can work on this to improve it. A lot of time they're like, on it, you know, and I'll have the parents say they were coming to me saying, we need to do my vision therapy now and say that we have to do it. And so that's really great. But a lot of times you'll have kids that don't perceive that they have an issue. You know, they think they're fine. And so doing vision therapy can be more challenging in those situations because they don't have that motivation, they don't have that desire because they feel. Feel like they're okay, you know, that they're. That they're doing fine. And then they're wondering, why do I have to do this thing, you know, that makes my eyes tired or gives me a headache or, you know, makes my eyes blurry or whatever it is, you know, and. And so being able to have those conversations and sit down and develop goals for them, like, if there are things they notice, like, you know, do they have trouble catching balls or hitting balls or, you know, doing cornhole or. Or riding a bike or various things. And like, could their visual system be a part of that? And maybe being able to help communicate to them appropriate goals for their age that can kind of help Them get better. Because it's very difficult to make someone do something. Like I tell my patients, you know, when we meet, I said, we're going to be, you know, a team. And so, we have to have a captain. And do you know who the captain of our team is? You know, a lot of times you're like, is it me? And I go, yeah, you're the only person who can make these do anything. I don't have a magic wand or anything that can make them do anything, you know, but you're the only person that can do that. And so, you know, we're going to be working together. I'm going to be a helper; your parents are going to be helpers. And we're going to work on this together to see if we can get team, you better visual skills to help you with not getting tired when you read or losing your place or whatever it is, you know, that they're having difficulties doing. Doing. So, I kind of think, you know, being able to develop that is important.

Denise: Yeah. I love all of your advice. It's going to be so great for people to hear that.

Thomas: Oh, well, thank you. Thanks.

Denise: Yeah.

Thomas: Well, when you've worked with a number of people, and I think I've learned a lot from my patients as well as I have from professionals, because, you know, working with people with different conditions and having them kind of tell me what they needed in order to either make an activity successful or make therapy manageable for them to be able to do, you know, that kind of thing has been helpful. And again, you'll have some patients who have a very difficult time trying to fit any home exercises in whatsoever. And it's like, okay, well, we'll have to have a conversation about that and see. But it might make therapy take a little longer, but if you're okay with that, we'll work at your pace and see what you can do. I kind of want to be able to help someone and not have someone who feels like they just have to give up because they can't, you know, commit to doing five exercises four days a week or whatever. You know, it might be in their particular case, you know, if they're only able to do one really good activity that week, great. And do that. And, you know, it's better to do something than to do nothing. So, if we can do something to promote your system to go where it needs to go, go, then let's work our way to that way.

Denise: Awesome. Great. Do you have any final words that you'd like to leave us with today.

Thomas: Oh, well, I just thank you for doing this to help make vision therapy more visible to people. Because, you know, even though, like, I've been doing this, I started training as a vision therapist in 1987, and the OEP foundation started in 1928. And so, it's going to be celebrating its 100th anniversary in two years. And it's just amazing how many people will come to me and say, oh, is vision therapy new? Is this something new? And it's like, no, it's been around for a long time, but a lot of people don't know about it. So, I just thank you for helping to spread the word that vision therapy exists out there because there's a lot of people that can be helped by vision therapy, and it's just nice to know that, you know, there's people spreading the word about it. So, thank you so much.

Denise: Well, thank you. I appreciate that. Thanks for listening to the Healing Our Sight podcast today. I'd love to connect with you. You can leave a comment by clicking the link in the show notes. I love receiving your messages. You're also invited to join the Healing Our Sight Facebook Group. Let me know what resonated with you and how I can better serve you.