Ray Gottlieb, OD, PhD, FCOVD, FCSO
Dean, College of Syntonic Optometry
raygottlieb@me.com

Bob   was   one   of   developmental/behavioral   optometry’s   great   thinkers  and innovators.  He put together a comprehensive approach to vision training/therapy that he called: MAVE (Motor, Auditory, and Visual Education) and later called Stress- Point Learning.  Pepper served in the US Army in Europe as a water purification specialist going into uncharted areas looking for sources of clean water to prepare the way for our combat soldiers during WW II. After the war he took pre-optometry courses at Oregon State, Stanford and Lewis and Clark Universities, where he met and married Grace who survives him. They were married for 67 years and had two children Barbara and Bradley. After receiving his OD degree from the Pacific College of Optometry in the early 1950’s the couple moved to Lake Oswego, near Portland Oregon where he opened a private practice. For several years he practiced the OEP/Skeffington-based vision training approach.
 
In the early 1960’s his children told him about using a trampoline at school that day. They described an approach offered by Jim Coffell for improving students’ gross motor skills. Pepper was curious and went to their school to observe this training. He noticed that the children were learning to pay attention at a very deep level as they learned to do seat drops, knee drops and other complex motor acts. They had to remember, plan and act as they perfected their motor skills. Pepper’s mind went into high gear. What would happen if information-processing learning tasks were added to this trampoline motor training? Would this improve the attention, memory and goal attainment abilities of normal children? Could it improve reading and learning skills of underachieving children? Could it improve performance of already skilled athletes? That was the start of his unique “Stress-Point Learning approach.
 
He recognized that optometric vision training could be much more than normalizing ocular motility, fixation, suppression, convergence and accommodation. Why not expand our field by working to develop the higher visual/cognitive skills that enable patients to meet   real   life   challenges   with   clear   and organized vision? Pepper’s approach covers a broad range of functions including: the emotional; motivational; perceptual; goal-achievement; neural-organizing; decision-making; error reducing; confidence-building; and self-coaching and social- communication behaviors. Pepper’s stress-point approach increases what is now called executive functioning and working memory abilities such as information processing, comprehension, decision-making, planning, adapting, problem-solving, multitasking and goal-maintenance skills. As these improve, so do the visual perceptual, visual motor and gross motor functioning. Pepper expanded and tested
his ideas for the rest of his life, gaining insights from his patients, family, students at his children’s preschool and from nature. He loved to golf, hunt and fish and found ways to enlarge the range of his thinking from these hobbies. He learned from talking to teachers, psychologists, professional athletes and CEO’s of large companies. In 2015 he called to tell me about new insights gained while looking at a colony of ants working together to accomplish a goal.
 
Pepper’s taught more than a series of training tasks. He also invented a unique set of teaching principles that apply not just to stress-point training and optometric vision therapy but also to the whole range of teaching, therapy, parenting and coaching endeavors. If his work does become mainstream, it would revolutionize education, parenting and rehabilitation therapy.
 
In the 1960’s, ’70’s, ‘80’s and into the 1990’s Pepper conducted dozens of 3- and 5- day workshops for optometrists around the US. He also taught in Italy. He wrote articles and books. His first article: A Model of Vision and Basic Principles, published in  1965  in  The  Oregon  Optometrist, describes his study of children’s behavior during the learning process at the Lake Oswego Preschool where his children had attended years before. Here he gained a new insight, the stress-point principle. “In order for growth and development to occur, the environmental challenge must be within the individual’s operational range. If it is overwhelming – too great a challenge – the individual tries to escape. If it is not challenging enough, the individual does not have to learn or adapt to meet the challenge?” . . . “Matching the stress- point’ is the guiding principle of learning.” It is challenging patients at the stress-point that their otherwise hidden blocks and weaknesses are revealed. This is just one of many Powerful Pepper Principles.
 
In 1967 he wrote his first book: Developmental Vision – A Multi-Sensory Approach to Vision, published by OEPF. “Developmental Optometry has contributed much in the area of vision that may be related to how a child learns. There must be a coordinated effort on the part of all professions to integrate their knowledge. Helping the child to realize his greatest potential should be the ultimate goal.” (From the Preface). I’m not sure whether this book is still available from OEP but Pepper’s second book (with co-author, Mary Jane Nordgren, D.O.): Stress-Point Learning – A Multi-sensory Approach to Processing Information published by OEPF (2006) is available. Both of these books describe the Pepper model of vision, the Pepper Principles and a whole bunch of trampoline-based and other training tasks.
 
Also available through OEPF are two Pepper Training Program manuals (The Diagnosis and Training of the Perceptual Visual Discrimination Skills and Concentration Profile. Also available from OEP is the Concentration Profile Training Kit for testing and training the perception of size, space, form, direction and color described in his manuals and books. These are recent re-publications that were written and originally released in 1970. The concentration profile is a dynamic test that reveals not only a total error score and length of time taken to finish the test, but also the unique pattern of how a patient’s learning and attention behavior changes over time, to show their unique pattern of when in a task most mistakes are most likely to be made, – the beginning, middle or end of the task, i.e. do they have problems starting, staying focused or losing attention just at the end of tasks. It also shows whether the patient is able to control the speed of their responses in order to minimize their errors – do they rush through the test without noticing their errors or be so unsure of their perceptions that they have to double check every answer.
 
In 1987 Pepper wrote Sports Vision Therapy, an article about his work with a top NBA basketball player. It appeared in OEP’s Research Reports and Special Articles, Curriculum II, Volume 59 (9). In an “Editor’s Comments” that introduced the article, the editor wrote, “To our thinking, this article presents behavioral optometry at it’s best.” This article is a must read for those of us into sports therapy.
 
My book, Attention and Memory Training: Stress-Point Learning on the Trampoline. (OEPF, 2005), was originally written for parents and teachers in 1992. It covers many of Pepper’s principles and trampoline sequence reading tasks. I was greatly relieved when Bob called me to say how much he liked the book. I had been fearful that I may have misstated some of his principles or exercises, but he reassured me that he was very pleased. It is written in simpler language than Pepper’s books.
 
Bob called me about eight years ago to tell me that he was waking up every night in a panic, afraid that when he died, his work would die with him. I told him that his work had a great influence on me personally, by improving my own attention and learning skills, and professionally. It was a huge part of my practice. A few months later he called to say that I was the one he wanted to pass his work to. I was the one to bring it into the world. The first thing I did in this effort was to set up an OEP-sponsored Pepper Stress Workshop and Meeting at Pacific College of Optometry, near to where Bob lived. My co-teachers were veterans who, like myself, had taken Pepper’s workshops decades ago and were actively using his approach in their VT. Each of us taught a part of Pepper’s approach. Also attending were optometrists new to Pepper plus several PCO faculty and students. Bob Pepper was there for the whole time. About 30 optometrists attended. The goals for this meeting were to honor Bob for his contributions (see text of plaque honoring him) and to see how we might set up a new organization or team of Pepper teachers to spread his work. Not much came of making a Pepper organization but I was asked by OEP to teach his work as a Regional Clinical Seminar RCS). I have taught RCS Attention and Memory seminars in the U.S. and presented Peppers approach in Spain, France, Italy, Germany, Belgium, Mexico, Hong Kong and at optometry, wellness, occupational/physical therapy, education and music teachers conferences. So the ball is still in play. If you would like to know about upcoming events or join in this effort to bring Pepper’s Stress-Point Learning into the mainstream, please email me.

Reviewed by Desiree Vanderstar (Class of 2017)
Midwestern University, Arizona College of Optometry

The Reason I Jump offers an insiders guide to the autistic experiences of a non-verbal Japanese thirteen year old, Naoki Higashida. It was first published in 2007 and has since been translated into over 24 languages. The novel is presented as a Q & A, with brief short stories in between serving as coffee breaks for the reader. Higashida is able to answer via an alphabet grid constructed specially for him. There is also an introduction/preface and afterword by David Mitchell, shedding a little more light as to how this New York Times Bestseller came to fruition.
 
Mitchell explains that the aim of the novel is to demonstrate that those diagnosed with autism continue to possess intellectual acuity and spiritual curiosity. He also wanted to discredit the thought stream that autistic individuals are “antisocial loners who lack empathy.”
 
I think the novel accomplished all of its goals and more. It becomes evident in his extremely personal answers that Higashida is a deeply thoughtful and spiritual individual.  When asked if he would like to be “normal” (Q24), Higashida says “I’ve learnt that every human being, with or without disabilities, needs to strive to do their best, and by striving for happiness, you will arrive at happiness.” He continues, “as long as we can learn to love ourselves, I’m not sure how much it matters whether we’re normal or autistic.”  His answers are deep, complex and sympathetic, often stating “ please, whatever you do, don’t give up on us. We need your help.” (Q5) Perhaps the greatest lesson to take away form this book was stated by David Mitchell in his forward. He said, “ emotional poverty and an aversion to company are not symptoms of autism but consequences of autism.” As Higashida explains in Question 13, “because things never, ever go right, we end up getting used to being alone, without even noticing its happening” and “whenever I overhear someone remark how much I prefer being on my own, it makes me feel desperately lonely.” His experiences and explanations are not always relatable but are eye opening to minds of individuals who march to the beat of their own drum.
 
I would recommend this book to both health care professionals and the general public because of the importance of the message it is trying to convey. His hardships are not unique and can offer insight into thought processes different than our own. When describing unpleasant flashbacks that lead to emotional meltdowns, Higashida says “please try to understand what we’re going through and stay with us,” which is a recurring statement he makes throughout the interview. To the reader, this is a neon sign that says we need more compassion and understanding in our society.
 
Today, Higashida continues to act as an advocate for autism. He keeps an informative blog and is regularly featured in Japanese magazine The Big issue. He has continued to write several poems, essays and novels and is now twenty-four years old.

NeuroRehabilitation. 2014;34(1):129-46. doi: 10.3233/NRE-131025.
Thiagarajan P, Ciuffreda KJ, Capo-Aponte JE, Ludlam DP, Kapoor N

Review by
Jeremy Hauptman (Class of 2017)
Midwestern University, Arizona College of Optometry

Individuals who suffer from traumatic brain injury (TBI) can endure life-changing consequences that make activities of daily living more difficult or even impossible to complete. TBIs are due to a diffuse axonal injury that causes axons to stretch, twist, and tear resulting in damage of white matter. The damage causes reduction in strength, number, and organization of neuronal synapse, resulting in decreased synchrony and firing rate of axons.  Patients suffered from this damage through slower responses and have to exert more effect for simple tasks compromising complex tasks such as reading. Reading is a complex task that requires precise coordination between aspects of the oculomotor system including accommodation, versions (saccades) and vergences. In addition to the precise coordination required, one must concurrently have the ability to accurately comprehend the reading material.  Earlier research suggests that the majority of individuals with TBI have deficient oculomotor abilities.

This study evaluates the effect of oculomotor-based vision rehabilitation in individuals with TBIs. The goal is to answer the following questions: (1) Can oculomotor training (OMT) improve reading rate in this population? (2) What oculomotor parameters correlated with the improved reading rate and related factors?

Twelve subjects were recruited from the Raymond J. Greenswald Vision Rehabilitation Center at the State University of New York, State College of Optometry, Optometric Center of New York, New York City. These patients were between the ages of 23 to 33, suffered from TBI greater than 1 year prior, exhibited at least one symptom (skipping lines while reading, blur), had one clinical sign (receded near point of convergence) of non-strabismic oculomotor dysfunction, and had stable systemic health. Exclusion criteria included persons greater than 40 years old, best correct visual acuity, poorer than 20/30 in either eye, constant strabismus, and amblyopia or ocular diseases in either eye.  Subjects underwent laboratory (Arrington eye movement recording system, versional parameters, saccadic latency, saccadic ratio, etc) and clinical (near point of convergence, near point of accommodation (push up), reading eye movements (Visagraph) parameters, near vision-related symptoms survey using the Convergence Insufficiency Symptom Survey scale and subjective visual attention using the Visual Search and Attention Test before and after OMT and sham training. The twelve subjects completed the study in 15 weeks.  Subjects underwent both OMT and ST each for 6 weeks, 2 sessions a week. All three oculomotor subsystems (version/vergence/accommodation) were randomly ordered across sessions. Completing the 15 weeks, there was 3 one-week measurement periods: one week before phase 1 treatment, one week following phase 1 treatment, and one week following phase 2 treatment. 

Each treatment lasted 45 minutes (15 minutes/oculomotor subsystem) with 15 minutes of rest for a total of 9 hours of training over 6 weeks.  Versions were trained with the computerized oculomotor rehabilitation software; horizontal vergence training incorporated both amplitude and facility training for both response and speed. Step vergence amplitude training was completed with base-in/base-out prism. Accommodative training incorporated accommodative amplitude training for 10 minutes and binocular step accommodative facility for 5 minutes. Sham training was void of any disparity simulation or blur simulation, the primary drivers of the respective systems. 

Following the oculomotor training, over 80% of the abnormal parameters significantly improved. Saccadic eye movements, amplitudes of vergence and accommodation and reading rate all improved. There was a 25% increase in reading rate.  Reading rate, fixations/100 words, and grade level efficiency improved significantly. Changes in reading rate with oculomotor training was correlated to 2 key clinical parameters: the increase of binocular accommodative amplitudes to normal level and the increase ability of near point of convergence even though it fell short of normal level. Also, following oculomotor training, there was 2 significant changes in the non-oculomotor components reducing patients near symptoms and increased visual attention. No parameters changed with sham treatment. 

In conclusion, oculomotor-based vision rehabilitation reveals the ability of neuroplasticity to help rebuild or relearn reading skills individuals lost due to the TBI. This neuroplasticity can help improve oculomotor components, reading rate and the ease which one can comprehend the desired material.

Neurorehabil Neural Repair. 2014 Jun;28(5):462-71.
doi: 10.1177/1545968313516870
Schaadt AK, Schmidt L, Reinhart S, Adams M, et al.

Review by
Jeremy Hauptman (Class of 2017)
Midwestern University, Arizona College of Optometry

The quality of life of patients who have suffered from traumatic brain injury (TBI) and stroke resulting in brain lesions, can significantly impact a person’s daily visual, mobile, cognitive, and social functions. In examining the visual consequences of these brain lesions, patients commonly complain of blurred vision, diplopia, and reduced binocular depth perception. This study evaluates the treatment options to improve convergent fusional amplitude and stereoacuity in patients who have suffered from a stroke or TBI. Although studies on this patient population are minimal, there have been effective studies shown in the treatment of amblyopia and other neurological issues. Through effective rehabilitation strategies, these treatment options are aimed at improving the convergent fusional amplitude and stereoacuity in and relieving signs and symptoms.

Perceiving the world as we do requires both a cognitive sensory and motor component that actively keeps two images as single. The sensory component ensures the merging of disparate monocular images to be fused stereoscopic representations. This process occurs in the visual cortex with contour-based stereocues being processed by V1 and refined analysis of disparity information by the extrastriate areas (V2-V8). The role of the motor component is to align the eyes appropriately through the vergence (convergence/divergence) system to keep an image single. The motor component occurs in the midbrain oculomotor areas and frontal eye fields. A disruption in these areas secondary to strokes and TBI’s can help explain the signs and symptoms patients’ experiences.

Twenty patients (11 patients with unilateral or bilateral brain damage resulting from stroke/ 9 patients with traumatic brain injuries) with significant problems with binocular vision were recruited from the Neuropsychological Outpatient Department of Saarland University. Patients with permanent diplopia or blurred vision and those with diseases of the anterior visual pathway were excluded.
All patients underwent baseline ability testing for fusional convergence, stereoacuity, near/far visual acuity, accommodation, and subjective binocular reading time until diplopia emerged at 6 different time points. Each patient underwent 3 baseline sessions (pre-therapy, a post-therapy assessment after 6 weeks of treatment, and a 3 and 6 month follow up). After the third baseline session (pre-therapy), patients completed fusion/stereotraining for 60 minutes twice per week (average sessions completed: 13.92) within a 4 to 8 week period. Patients received a novel fusion and dichoptic training using the following 3 different devices to slowly increase fusional and disparity angle:

1. Prism to practice horizontal convergent fusion. Amplitudes were increased when patient achieved fusion for greater than 2 minutes without diplopia.
2. Dichoptic device to displace 2 different images to each eye with increasing horizontal disparity.
3. Cheiroscope to laterally separate the image of left eye by mirror and see if the patient had ability to retrace picture on a blank sheet that was seen by the right eye.

The study hypothesized fusional amplitudes and stereopsis improved selectively during treatment but not during treatment free intervals (baseline/follow-up). Assessments were completed on each patient’s oculomotor, orthoptic, and neurophysiological ability through visual acuities at distance and near, saccades/pursuits, strabismus and gaze palsies.  Binocular visual fields were mapped using dynamic perimetry with Tubingen bowl perimeter and visual neglect was tested through 5 tests: horizontal line bisection, number cancellation, drawing clock face from memory, figure copying, and indented reading test. The study assessed horizontal, convergent motor fusion using prism and Bagolini lenses were worn to determine a patient’s ability to fuse two monocular images. Stereoacuity was measured with the Titmus test and later with the TNO test. Finally, subjective reading duration was defined by time (in minutes) until blurred vision/diplopia emerged while reading simple texts.  
    
Analyzing the groups of patients (TBI and stroke), both groups improved in all these variables as well as a slight increase near visual acuity. No significant changes were observed during the pre-therapy and follow-up periods, ruling out spontaneous recovery and demonstrating long-term stability of binocular treatment effects. The stroke patients showed higher training benefit than TBI in convergent motor fusion. This difference in outcome may be attributed to the differences in the damage mechanism with stroke versus TBI. TBI is a more extensive shearing injury versus an isolated cortical area injury. The shearing injury may involve more extensive damage to the brainstem, part of brain that is critical in motor fusion. The TBI showed higher training benefit than strokes in subjective reading duration. Exploring the differences in outcomes of the two groups in subjective reading duration, epidemiologically between the two groups may play a factor; stroke patients are appropriately 20 years older than the TBI patients. This suggests that changes in cognitive and sensory abilities may also play factor. Lesion chronicity was not significantly correlated with average improvement of motor fusion, stereoacuity, or subjective reading duration in either sample

In conclusion, this study indicates under the ideal treatment conditions, one’s brain has the plasticity to relearn binocular fusion and stereovision. Exploring treatment options such as the ones used in this study can help provide leading edge rehabilitation strategies to treat binocular vision deficits resulting from permanent visual cortical damage.

Handa T, Ishikawa H, Shoji N, et al. J AAPOS. Dec;19(6):552-4.

http://www.sciencedirect.com/science/article/pii/S1091853115005650
Article reviewed by Sari Schwartz, OD 2017-New England College of Optometry
 
The purpose of this preliminary study is to investigate the effectiveness of using a modified iPad for the treatment of hyperopic anisometropic amblyopia. Amblyopia causes more vision loss in the population less than forty-five years of age than all other ocular problems combined, excluding refractive error. This common and detectable abnormality of spatial vision can be treated, potentially allowing for more equal quality images to be received by each eye and then further processed by the brain.    
Seven male and female subjects, aged three to seven years old, were selected to participate in this study. Each participant had some degree of hyperopic anisometropic amblyopia and <10Δ exophoria at distance and near to ensure no strabismic component to their amblyopia. The subjects were first managed with full refractive correction and then underwent different treatment modalities for their amblyopia. The first treatment group consisted of three subjects using Occlu-pad training for one hour every day, while the two subjects in the second treatment group performed the same Occlu-pad training in addition to three hours of daily occlusion therapy. To serve as a control, the final group’s two subjects performed occlusion therapy only, with no use of the Occlu-pad.

The Occlu-pad training works by displaying different images to the subject’s eyes. This can be achieved by placing a circular polarizing filter over the amblyopic eye and a light reduction filter over the patient’s normal eye, and removing the polarizing film layer from the liquid crystal display of the iPad. Since the polarizing filter of the glasses matches the screen output and the light reduction filter does not, the amblyopic eye can view the task at hand while the non-amblyopic eye only views the white screen background. With Occlu-pad use, patients were instructed to train by either actively playing web games or passively watching videos for one hour a day for a total of four weeks. Occlusion-treated patients were instructed to patch their dominant eye for three hours a day. All groups were limited to no more than two months treatment.

Out of the five patients that underwent Occlu-pad training with or without occlusion, all had a notable improvement in visual acuity in their amblyopic eye. The two patients that underwent strictly occlusion therapy had little or no increase in visual acuity in their amblyopic eye. The greatest improvement was seen in the first month of training and the worse the starting acuity, the better the achieved ending acuity.
This study shows that there are several advantages to treating anisometropic amblyopia using a modified iPad. First, the Occlu-pad can accurately track compliance by automatically logging dates and hours of playtime on the device. This feature allows study results to be better compared between subjects. Existing treatment options are not always well-understood or successful due to poor compliance and an inability to reliably track time spent under occlusion. Another advantage of the Occlu-pad is that it allows amblyopia training to be done in the comfort of a patient’s home on a device that is familiar to the millennial generation. Training with a portable and user-friendly device allows treatment to be initiated and completed at the convenience of the patient. Lastly, the Occlu-pad is a binocular training device that allows amblyopic patients to use both eyes while being treated. This allows patients to train in a setting that better represents how they function in their daily lives.

Many factors must be considered when analyzing the results of this study. First, subjects in the study totaled only seven. In order to draw a stronger conclusion and extrapolate results to more hyperopic anisometropic amblyopes, it is important for future research to include a larger study cohort. Secondly, using different web games and videos leads to variability in treatment. Playing web games requires the patient to actively respond to the task, which potentially improves hand-eye coordination. However, merely watching a video is a passive form of training that theoretically serves less benefit. Although this variability may maintain the interest of the subjects throughout the treatment period, it creates a distinction between actively and passively treated patients. Additionally, future studies should aim to select subjects with more similar refractive errors, and treat all subjects for the same amount of time. In this study, the amount of anisometropia ranged from +2.5D to +6D, and the training time varied from 240 to 960 minutes. This inconsistency makes establishing guidelines for the amount of training time for different severities of anisometropic amblyopia very difficult. Finally, no definitive activities we were outlined for the patients undergoing three hours of occlusion treatment. By assigning subjects an activity while they are patching, stricter control and therefore more accurate strategies can be established for treating patients with hyperopic anisometropic amblyopia.

Significant improvement in visual acuity of the amblyopic eye with use of full optical correction, occlu-pad training, and/or occlusion treatment demonstrates that hyperopic anisometropic amblyopia is treatable. By devising a scheme for different signals to be received by each eye, modified iPad activities can improve our amblyopic patients’ vision and lives. Overall, this is an excellent preliminary study exploring the efficacy of such iPad training activities for amblyopia, but using more subjects and tighter control of the activities performed during treatment will increase the validity of future studies.

By Ernest Loewenstein, OD

Dr. Patrick Pirotte was the Behavioral Scholar in Residence at the New England College of Optometry in March of 2016.  The College annually invites a distinguished behavioral optometrist to spend several days on campus during. The Scholar meets with students, faculty and administration, gives lectures to students in their classes and participates in a symposium that is open to the general optometry community. This annual program is jointly sponsored by the Rosborough Behavioral Optometry Studies Endowment Fund and the college. Dr. Pirotte’s visit was partly funded by COVD as a component of their Tour de Optometry program. Dr. Pirotte is a graduate of the University of Kansas at Wichita and the Southern California College of Optometry. He is a Fellow of COVD.
 
Dr. Pirotte’s lectures were based in the subject of neuroplasticity and its application to vision rehabilitation, both in vision related learning problems and in the treatment of patients with traumatic brain injury. In the course of the lectures Dr. Pirotte cited his own experience as a disabled learner who had to drop out of college, and his rehabilitation by a behavioral optometrist who made it possible for him to achieve educationally. It was that experience which set him on the path to practice behavioral optometry. During the period that he was out of college Dr. Pirotte studied music and became an accomplished jazz pianist.
 
As a part of Dr. Pirotte’s lectures he emphasized the proliferation of research papers in recent years that provide scientific underpinning to the principles and practices of behavioral optometry that have long been a part of the protocols that were established by the pioneers beginning in the 1950’s. He cited as one example a research paper from the Mayo clinic asserting the importance of saccadic eye movements in reading. In a dramatic example drawn from his own practice Dr. Pirotte showed a video of the improvement in posture and gait achieved immediately with the application of yoked prisms for a young man who had sustained a severe concussion in a fall on the ice during a hockey game.
 
As part of the program Dr. Pirotte presented a lecture on vision and learning for the general optometric community as well as the faculty and students of the College. Following the lecture Dr. Pirotte participated in a symposium on the future of optometric practice and the economics of a behavioral optometry. He was joined in this session by Dr. Bud O’Leary, who has a private practice in Reading Massachusetts and Dr. Richard Laudon of the New England College of Optometry. Dr. Laudon was an organizer of Dr. Perrot’s visit as well as of this symposium.