Reviewed by Paul Harris
Better late than never. This excellent book came across my desk a few years ago and though I read it very soon after I got it, I’m just now getting the opportunity to write up my review of the book. Mel Kaplan has been a master clinician for a long while and has established a very positive reputation working with many different populations of patients with special needs. In this book Dr. Kaplan shares with the reader not only his philosophy in the diagnosis and treatment of the visual disorders of patients on the autism spectrum but he clearly shares the nuts and bolts of his clinical protocols, more clearly than in any of his writings to date. This book is a “must-have” and “must-read” for all behavioral optometrists who work with special needs populations.
Dr. Kaplan has been a strong proponent of many problems being in what Colwyn Trevarthan first called the “ambient” vision.
“These problems stem from deficits in the ambient vision processes involved in peripheral vision. Autistic and other disabled children often have perfectly normal focal vision-the central vision that allows us to identify objects when we look straight at them. In other words, they have no problem with the ‘What is it?’ function. The problem lies instead with ambient vision, which involves the entire field of vision and tells us about the location of objects in space-the ‘Where is it?’ function.”
“Ambient vision, also referred to as peripheral vision, encompasses the entire visual field. It is a lower-resolution system that operates largely on a non-conscious level, and allows us to rapidly identify where we are and what is happening in our environment.”
Dr. Kaplan’s philosophy of prescribing yoked prisms comes from his insights into their effects on ambient vision. Though I do not use the term “ambient” vision, the actions of the prisms he describes align very nicely with my own philosophy of the spatial transformations which yoked prisms afford our patients.
“Conventional eye care professionals often use prisms in one lens, in order to compensate for ocular muscle imbalances. The purpose of ambient prism lenses, however, is not to compensate for a mechanical defect, but rather to actually alter perception in ways that cause patients to reorganize their visual processes. Prismatic visual field appears compressed at the base (flat edge) and expanded on the apex (thin edge). Near objects are reduced while distant ones are amplified.”
“When we addressed his impaired depth perception with ambient prism lenses and vision therapy, he was able to move more easily in three-dimensional space, and could successfully learn this skill and related ones.”
Here he discusses the usual duration of the positive effects of the yoked prisms.
“Although the children received no therapy, they exhibited a significant decrease in behavior problems over the first two months in response to the glasses alone. These benefits began to fade slightly at four months.”
As a teacher at Southern College of Optometry of the vision development part of our Pediatrics course it is nice to see Kaplan restate things that are the cornerstones of optometric practice which were codified at the Gesell Institute many years ago.
“By the age of 5, according to the Gesell Battery of Child Development, children should be able to sustain balance on one foot for the count of ten while looking at themselves in a mirror. The results of this and the mirror task offer the clinician insight into whether the patient is field-dependent (attends to space) or field-independent (attends to self).”
“The normal age at which children become able to move their eyes while holding their head still is five years.”
We have this general understanding that earlier is not always better particularly with walking and reading. Here Kaplan discusses a piece of child development usually not discussed at all.
“While most new parents are proud when their baby strongly grasps a finger and won’t let go, releasing is a more advanced stage and one that is crucial both for exploration and for development of the visual system.”
According to Greg Kitchener among others, “The primary purpose of the visual process is the direction of movement.” Kaplan echoes this in the following two statements:
“Human beings are ‘spatial action units’ and movement is the basis of awareness.”
“To be effective, vision therapy must break old patterns, and stimulate a patient to move, feel, and think.”
In this last quote Kaplan shares his thoughts on vision therapy:
“Vision therapy moves through three logical stages, each building on the previous one. These stages are awareness, attention, and automaticity. Awareness is, in effect, a neural ‘awakening’. Attention: At this stage, patients become more capable of allocating and focusing energy. Automaticity: Patients become able to perform tasks while paying little active attention. It is crucial for training to be long term, so that patients can move from awareness to attention to automaticity.”
I highly recommend this book not only to behavioral optometrists but it should be quite insightful for those who are part of the multidisciplinary team that treats children with special needs.