Kabuki Syndrome - The Visual Issues

When thinking about good sight, we often think in terms of 20/20 or “seeing clearly”. Most school vision screenings check only eyesight - only at twenty feet, not at reading distance. They rarely tell us whether a child has a clear image at nearpoint or how the eyes work together. The only information they provide is whether a child can see the blackboard. Many vision problems thus go undetected giving parents a false sense of security.

Eyesight vs. Vision

Eyesight and vision are not synonymous. Eyesight is the sharpness of the image seen by the eye. Vision is the ability to focus on and comprehend that which is seen. Vision is learned. Giving meaning to what is seen begins at birth. In the developmental hierarchy, infants move without purpose, while their eyes learn how to work as a team and to sustain focus. Toddlers then use movement to drive vision, such as shaking a rattle for its sound before looking at it. In the final stage, children can gain much meaning about their world merely by looking at it. For example, when you look at an apple, you do not need to touch it to be able to know how it feels. That is because at some point in your life when you touched an apple, you were able to integrate your visual and tactile sense. This experience gave more meaning to the “apple percept” next time you experienced it.

Vision as the Primary Sense

There are three million nerve fibers entering the human brain from the whole body. Two million of those are coming from the eyes. The visual system is so dominant that in order to really attend to the other senses one needs to close one’s eyes. That is why the orchestral conductor closes his eyes to hear the music, and why we close our eyes to smell the beautifully scented flowers or to feel a kiss. Vision can get in the way of connecting fully to our other senses. But, for the most part, the visual system facilitates, working in the background to bring information to our brain to enable us to plan our next move , as well as contributing to general posture and movement.. When the visual system is not functioning efficiently it gets in the way providing poor quality information to our brains and making us less efficient as human beings.

We hear a great deal about individual learning styles. "My child is a kinesthetic learner," a mother told me. She meant that her child is still using touch and movement to get information about the world. From a developmental standpoint, this learning style is more primitive than getting information visually. Well-functioning individuals store all types of sensory images and can visualize and retrieve them upon demand. They no longer need to touch and move to experience their world. Vision directs their thinking, organization, listening and actions.

A Simple Model

At the simplest level, the visual system can be divided into two parts. The first (the hardware) relates to I) The ability of the eye to sustain focus up close and make a smooth shift in focus from near to far. II) The ability to team the two eyes up together so that they achieve comfortable single vision and III) the ability to move the eyes easily when following a moving object ( pursuits) and moving one’s eyes across a page (saccades). The second part relates to the brains ability to process the information ( the software).

Eye-teaming, eye-tracking and eye-focusing are all fine-motor tasks. If fine motor skills are poor which they often are for the KS patient, then the visual skills are likely to be deficient. What is also important to recognize is that extra energy invested to overcome visual efficiency problems diminishes the available energy for processing the incoming visual information. Therefore either of the following two scenarios may be common for the KS patient.

The child who is slightly farsighted and is trying to read may just get tired and loose interest quickly. This is because as a result of poor muscle tone, she finds focusing on the page overwhelming. This child may have been told at a routine eye test that glasses are not required. She may have been told that she has 20/20 vision. However, KS kids need extra help when focusing up close. This can be attained through the use of specially prescribed reading glasses. Reading and writing with the text placed on a 20? sloped surface rather than a flat one will enhance your child’s abilities. It will also make copying from the board far less taxing.

Another child might find that she reads well but understands little. This may be related to the fact that she puts so much effort into getting her eyes to team up, focus and track across the page that she can’t fully comprehend what she is reading simultaneously. Developmental or Behavioral Optometrists are particularly sensitive to these issues and can help your children.

Problems with eye-teaming and general eye control can lead to a child finding it difficult to maintain eye contact with someone talking to him from up-close. The effort required in looking up close at e.g. a speech therapist may result in the child not adequately being able to control the fine-motor aspects of speech at the same time as controlling the fine-motor aspects of vision.

Vision Lays the Foundation for Language & Relationships

Vision plays a major role in language and social-emotional development. Children with language delays, attention deficits, pervasive developmental disorders and autism all have inefficient visual systems. If a toddler is not speaking or relating to others, a vision evaluation is essential. A developmental optometrist can prescribe therapeutic and pleasurable activities to be done at home, during floor time, occupational and language therapy, or at day care. Combining the visual system with touch, movement, audition and social experiences benefits all areas.

What is Vision Therapy?

Vision therapy can be described as physical therapy for the visual system which includes the brain and eyes. Through a series of progressive therapeutic procedures (eye exercises), patients develop or recover normal visual skills. Vision therapy is remarkably successful in rehabilitating all types of binocular vision impairments including amblyopiai (lazy eye), strabismusi, esotropiai, exotropiai, hyperphoria, or loss of binocular fusioni due to hyperopia (farsightedness), myopiai (nearsightedness) or astigmatismi in one eye. In regards to the development or recovery of binocular vision, vision therapy is much more successful than surgery or glasses alone.

Who Can Benefit From Vision Therapy?

Patients of all ages can benefit from vision therapy. The nature of the therapy program varies with the condition treated. For example, a three year-old child with amblyopia, or "lazy eye", might have the better eye patched for a short period of time. An eight year old with strabismus "crossed eye", may require therapy for a period of a year to gain BOTH cosmetic and visual benefits (the two eyes will appear straight AND will be used as a binocular team for normal vision).

Vision therapy can improve visual skills such as stereopsis, binocular coordination, binocular fusion, eye teaming skills, convergence, visual acuity, focusing skills, stereoscopic vision, depth perception, eye tracking, fixation skills, visual form discrimination, visual memory, hyperopia, and visual motor integration (balance, body coordination, hand-eye coordination).

Is Vision Therapy New?

Although Vision Therapy is currently an Optometric specialty, it is actually an outgrowth of orthoptics. Orthoptics, which literally means "straightening of the eyes", was introduced to this country by physicians in the late 1800's. As physicians became more focused on eyeglasses, medication , and surgery, the benefits of orthoptics were taught to fewer and fewer practitioners. However, optometrists in the mid 1900's took the best that orthoptics had to offer, and pioneered the development of vision therapy.

What's Involved In A Vision Therapy Program?

Patients typically come to the office twice weekly for 30 - 45 minutes each visit. In addition, homework is given to be done at home as reinforcement of what is learned during the office therapy sessions. Commitment to the therapy program, and maintaining a schedule of weekly visits, is important in the success of the program.

Can't my child just do the therapy at home?

Vision therapy programs are individualized for the patient, and careful guidance and frequent monitoring is required for success. When attempted by patients without guidance, poor visual habits may actually be reinforced. In addition, in-office vision therapy programs make use of specialty computer programs, regulated medical devices (such as lenses and prisms) and other tools which are not available for use in the home. PLEASE NOTE: Vision therapy is NOT the Bates Method. The Bates Method was invented by W.H. Bates, an ophthalmologist who wrote Perfect Sight Without Glasses (New York, 1920). The eye procedures (eye exercises) employed in Vision Therapy are different from those of the Bates Method. Vision therapy involves a medically supervised program of therapeutic procedures (eye exercises). The techniques and technologies of vision therapy have been reviewed and developed throughout this century by doctors of optometry. In some cases, regulated medical devices (such as lenses and prisms) are used.


To think correctly about your child's visual system one must think about his ability to team his eyes up, to move them with fluency and accuracy across a page and to sustain focus ( for reading) and change focus ( copying from the board). Having these skills will affect your child's development and his ability to utilize and respond fully to his immediate surroundings. Either glasses and / or vision therapy prescribed by a Developmental or Behavioral Optometrist would benefit your child. A list of such Optometrists may be found at www.covd.org .

About the Author: Robert Lederman is a Behavioral Optometrist at the Vision Center in Efrat, Israel

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