Article The Van Orden Star: A Window                                               Melvin Kaplan, ODinto Personal Space   ...
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.. ..                           ,., """ ,-,                  Instructions to the Patient                                  ...
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projected visual behaviors. The question that       indicated an application of yoked pnsm,remains is, what do we do about...
straight when she walks?" Her mother, with a CONCLUSIONSquizzical look of disbelief, said, "Of course." I                 ...
13. 	 Harris P. The behavioral use of prisms. Vision Therapy Too l       ing, Series 2, No . 12, Optometric Extension Prog...
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The Van Orden Star: A Window into Personal Space


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The analysis of spatial behavior is, fundamentally, a description of the way behavior is conditioned by internal and external constraints. Skews of spatial orientation are brought about by visual adaptation to these two constraints. The Van Orden Star probes the way we perceive, and mentally represent, the world around us. The Star can give insight into how we put this knowledge to work, and into action. 1
In every day life, we see coping patterns people have adopted in response to what they see and feel. There may be a turned foot, or a curved back; there may be heightened or lessened attention to a task. Coping patterns sometimes generate labels: dyslexic, autistic, emotionally disturbed, brain injured.
Perceptual far-or near-point activities involve different levels of constraints. How an individual responds to these constraints is manifested in the way he modifies his drawing of the Van Orden Star patterns......

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The Van Orden Star: A Window into Personal Space

  1. 1. Article The Van Orden Star: A Window Melvin Kaplan, ODinto Personal Space Celeste M. Lydon, OD The analysis of spatial behavior is, funda­ tension of the patients perception of axes andmentally, a description of the way behavior is planes in external space, as illustrated inconditioned by internal and external con­ Fig. 2.straints. Skews of spatial orientation are If the patients Star drawing shows apicesbrought about by visual adaptation to these above or below primary gaze, or the targettwo constraints. The Van Orden Star probes midline, he has demonstrated errors in ver­the way we perceive, and mentally represent, gence (Fig. 3).the world around us. The Star can give insight Execution of this pattern, while straight­into how we put this knowledge to work, and forward and simple, requires the individual tointo action. 1 rapidly and accurately interpret what he sees, In every day life, we see coping patterns generate motor response, and maintain atten­people have adopted in response to what they tion throughout. The appearance of his starsee and feel. There may be a turned foot, or a pattern is fundamentally a predictor of the pa­curved back; there may be heightened or less­ tients spatial behavior. It reveals the way heened attention to a task. Coping patterns responds to internal and external constraints.sometimes generate labels: dyslexic, autistic, It depicts his particular version of homeosta­emotionally disturbed, brain injured. SIS. Perceptual far- or near-point activities in­volve different levels of constraints. How an INSTRUMENTATION OF THE VANindividual responds to these constraints is ORDEN STARmanifested in the way he modifies his drawing The keys to using any test are:of the Van Orden Star patterns. l. Understand the demands of the test.WEIGHTING THE SCALES IN THE Mid-bodY orICllIIaSEARCH FOR BALANCE Harvard physiologist Walter B. Cannonproposed that all humans seek a position ofhomeostastis with their environment, a"steady state." Our bodies operate on a systemof coordinates and axes of rotation (Fig. 1). When a body displays postural skews, it isresponding to a misreading of spatial cuesby the visual vergence system. Suppose we vi­sualize the Van Orden Star pattern as an ex- Correspondence regarding this article shouldbe addressed to Melvin Kaplan, OD, 150 WhitePlains Road #410, Tarrytown, NY 10591. Fig. 1.Volume 33 / Spring 2002 21
  2. 2. ,..,. rei.,. Tfli_, • • • • • • • • • 110 ~~ • + ) + • " • • • ". JI.• • • • • • • Fig. 4. pattern would most likely be exacerbated at near. The second segment is easily done by ad­ justing the shaft to the near point setting. A new test sheet is given with the same columns of figures now 95 mm apart (Fig. 5). Figure 6 is the star pattern of a 6-year-old boy with learning-to-read difficulties. The dis­ Fig. 2. tance star pattern was relatively as expected. The near pattern, however, displayed disorga ­2. Keeping instructions consistent. nization indicative of vergence dysfunction, a3. Making sure the available facts fit the symptom, as we know, of reading difficulty. model of interpretation.The instrument of choice is the Correct-Eye­ INSTRUCTIONS TO THE PATIENTScope with the transilluminated back. TheScope has an adjustable shaft with a Brewster Direct the patient to sit in front of the in­stereoscope attached. The shaft marks dictate strument and look through the eyepiece. Askthe visual distance to which the subject will , him, "How many columns of figures do youatt~nd. The standard design of the target, as see?" If the answer is two, ask, "Can you seedesIgned by Van Orden, is a white translucent both columns at the same time, or do they ap­paper with two columns of figures, such as a pear one at a time?" If the answer is thestar and a cross. Columns are composed of former, direct the patient to take two same­eleven figures placed 140 mm apart, for far s~ze pencils, one in each hand. Guide the pa ­point testing (Fig. 4). bent to hold the pencils so as to write with I use the standard Van Orden Star pat ­ them simultaneously. Ask him to place a pen­tern, but in addition created a modification for cil point on the center cross of each column­near, so I might see the patients response to right pencil on the right cross, left on the left.near point demands. If the distance star pat ­ Now ask, "Can you see both pencil points attern represents a conflict between the visual the same time?" If yes, have him draw simul­and kinesthetic senses, but near point activity taneous lines , one toward the other, until theusually creates the greatest stress, the adap­ pencil points look as if theyre touching. Next,tive response illustrated by the patients star • A A • • • • • • • 15M14 •B~~~r-----------------~~~~.B + " > + • • • • • • A • • • • Fig. 3. Fig. 5.22 Journal of Optometric Vision Development
  3. 3. .. .. ,., """ ,-, Instructions to the Patient Fig. the left pencil on the top figure of the left ganisms may depend more on other sensorycolumn and the right pencil on the bottom fig­ modes, but in man, the visual sense dominatesure of the right. As before, the two pencils are our sensory be brought toward each other until they ap­ Human behavior is molded and condi­pear to touch. The procedure is repeated with tioned by temporal and environmental con­successive figures until the star pattern is straints; these in turn, affect all aspects ofhu ­complete. man performance. We seek a homeostasis with our environment. The Van Orden Star reflects the state of balance we have struck, be DIFFERENT PATTERNS, it ideal or distorted. Any distortions ofthe api ­ DIFFERENT INTERPRETATIONS ces of the star reflect that individuals coming to terms with his personal space, his attempt In the optometric literature, several emi­ to achieve balance. nent authors have offered interpretations of Environmental constraints affect percep ­ the Van Orden Star, including MacDonald,2 tual constancy and intersensory localization. Quick,:3 ByalV and of course, Van Orden. 1 All Watch someone hitting a ball. 1fhe sometimes recognized some frequently seen pattern hits and sometimes misses, under similar con­ variations. Van Orden recognized the value of ditions, there is a lack of perceptual constancy the star for illustrating the balance between and intersensory localization. Temporal con­ central and peripheral visual function. Mac ­ straints manifest in postural shifts away from Donalds model has had the greatest influence the vertical. For example, idiopathic scoliosison my thinking. He divided patients patterns in teenagers is associated with a visual per­into four major classifications: ceptual dysfunction according to Dr. Richard Herman, Orthopedic Surgeon, Good Samari­ 1. The tight peripheral-central relationship tan Hospital in Phoenix, Arizona. When we2. The loosely organized peripheral-central observe shifts in posture, we can suspect they relationship are functional, not structural. Many of us have3. A mismatch between visual central visual observed this in traumatic brain injury pa ­ function tients. Some shuffle their feet, moving at a4. A visual kinesthetic mismatch. snails pace, others walk on their toes, rushing MacDonald as well as Van Orden both ad­ along to maintain to the model that an individuals percep­ The following figures represent the mosttion of space influences his sensory system, frequently seen star patterns. You will seeand thus would influence that individuals many variations, but these are representativedrawing of the star. A model is never right or of common presentations.wrong, it is based on the facts available at the Figure 7 represents an optimal balance be­time. Building on clinical experience, I was tween temporal and spatial elements. The in­able to expand the model beyond the central ­ tegrity of the illustrations planes and axes in­peripheral concept to include temporal and dicate a maximum balance in personal space.spatial factors, as well. The human organism Figure 8 denotes constraints, in MacDon­is, after all, a spatial action system. Other or- alds terms, of the peripheral-central relation ­Volume 33 / Spring 2002 23
  4. 4. A A A i­ • .. .. A A Fig. 7. Fig. 9.ship. My interpretation suggests that this pat ­ phrenic patients and the control subjects.tern results when central demands supersede Typically, the schizophrenic subjects showed aperipheral demands, and the individual se­ crossing, fan-like presentation on the right lects a space location closer to him. The visible side, and no apex formation on the left (p =space world is rotated about the horizontal .003) (Fig. 11). Compare this to a typical faraxis, bringing the saggital plane closer, and point drawing from the control group (Fig. 12).directing the apices above the line. This type Figure 13 shows constraints in the periph­of individual will display behaviors associated eral-central relationship, which shows up aswith tunnel vision. disorientation in the apices. These constraints Figure 9 also represents constraints in the are functional warps , and they can be seen inperipheral-central relationship. In this rela­ physical performance as well as in a penciltionship, peripheral demands supersede focal. and paper manifestation. For instance, whenThe visible space world is again rotated about the patient is walking a foot may toe-in ratherthe horizontal axes, but here the saggital than point straight ahead. The star patternplane appears further away and apices appear apices may be clearly formed, but they differabove the line. This pattern is usually associ­ in linear length. The pattern is rotated aboutated with individuals who have increased near the vertical axis, a projection of his body imagepoint activity and visual stress. that is rotated around the mid-body axis. The Figure 10 displays constraints in the pe­ subjects perception of his space world makesripheral-central relationship that are mani­ the frontal plane closer on the larger apex sidefested by disorganization ofthe visual system. than on the shorter apex side.The apices are poorly formed. Either they do Figure 14 represents constraints in the pe ­not form an apex, as seen on the left side, or ripheral-central relationship that implies dis ­they form a fan shape, as seen on the right. orientation and disorganization. The star hasThese patients usually present a peripheral poorly formed apices. There is no apex on thebias with no perceptual constancy. There may left, and the right side forms a fan. There arebe an emotional component to this patients many variations of this rendition, with apicesvisuo-spatial distortion. being unequal along the frontal plane, or po­ In a study composed of 60 emotionally dis­ sitioning above or below the midline. Theseturbed patients at the Westchester Medical star patterns are usually produced by indi­Center and 60 control subjects, we compared viduals with concomitant visual and emo ­far point Van Orden Star patterns. There ~as tional issues.a significant difference between the SChlZO­ A +. + ..--~-.:: + ~--+-·BB +::::::;:L;4?~----------"1~~~ .:=::::+== .. ~ ----1r-= + A A A Fig. 8. Fig. 10.24 Journal of Optometric Vision Development
  5. 5. A + + A A Fig. 13. Fig. 11. tern signals a temporal-spatial mismatch, andUSING THE VAN ORDEN STAR TO the individuals behavior will indicate aENHANCE YOUR ANALYSIS greater degree of stress. As problems with the "where" system in­ Clinical interpretation of the Van Orden crease in severity, the digressions of patternStar can be a tool to recognize spatial behav­ execution will increase. The key is that ther eiors. The spatially coordinated pattern is, fun­ is a mismatch in the magnitude of frontaldamentally, a projection of the way behavior is plane design between the right and left fields.molded and conditioned by temporal and en­ This represents an individual who has prob­vironmental constraints. We know that visual lems organizing hislher space world, and atthinking operates on a "what" and "where" the same time is unable to orient himlherselfsystem. For an individual to interact with his in personal space. It is not uncommon forenvironment, three questions must be answer­ these people to relate instances of panic be­able: havior. The concept of retinal rivalry has given• Where am I?• Where is it? way to a concept of cortical rivalry, with a di­ vision between the different aspects of the spa­• What is it? tial system. The neurobiologist Pettigrew The temporal "where" system is homolo­ came up with a tantalizing theory of wheregous with the spatial ambient, or if you prefer, this is all happening in the brain.the peripheral system; the star pattern cangive useful insight about the patients "In monkey studies during the late 1990s, only"where." higher-cognitive areas-parts of the br ain that process patterns and not raw sensory date­ According to my model, a star pattern in consistently fired in sync with changes in t hewhich both apices are well formed but meet animals perception. That discovery buttressedbelow the line depicts a problem of binocular a new theory: that the brain constructs con­coordination. This level of dysfunction has a flicting representations of the scene, and thatrelatively mild effect on the patients sense of representations compete somehow for atten­well being. The pattern is commonly associ­ tion and consciousness."ated with near point stress. When the drawings end above the line but Now we can accept the fact that vision is not infail to meet in a definite apex, there is a more the eye, but rather in the brain. When viewingsevere spatial organization problem. This pat­ the Van Orden Star, we see a representation of ~ • Fig. 12. Fig. 14.Volume 33 / Spring 2002 25
  6. 6. projected visual behaviors. The question that indicated an application of yoked pnsm,remains is, what do we do about it? base up. Here is the implied pearl: When apices areLENS APPLICATION AND THE formed above the line, base down prism is in­STAR PATTERN dicated. If apices are below the horizontal line, For the past 25 years I have been a cham­ base up is called for.pion of yoked prisms, which I call ambient This interpretation of visual behavior fromlenses for the modification of human behavior. the Star pattern, and the method of lens ap­I have been prescribing them for individuals plication, goes beyond the balance of central­with learning differences, emotional difficul­ peripheral function expressed by Van Orden,ties, and autistic spectrum disorders. In addi­ or the tightlloose organization described bytion, they have been very instrumental in re­ MacDonald. I do not think it contradicts, buthabilitating traumatic brain injury cases. rather is an expansion of their thinking. In much of the literature on prism, it is the Prescribing of yoked prism, for me, startedfocal aspect of the lenses that is emphasized. with a course of study at the Gesell InstitutePrism is prescribed to displace the image on conducted by Dick Appel and John Streff.the retina and align the foveae, producing Streff introduced us to the work of Bruce Wolffsingle binocular vision. When an image enters who had been using large-magnitude yokeda prism, it is compressed toward the prism prisms to alter behavior in his training room.base and expanded toward the apex. If prisms I began using low-magnitude therapeutic lensare applied in a yoked configuration with bin­ prescriptions about 1972 and have written ar­ocular prisms oriented in the same direction, ticles describing their use with learning­they induce spatial reorganization about the difference children.axes and planes of space. There is then a com­ Byall presented Figure 15 and said, "Thisparable shift in organization and orientation is (a common) pattern, and it indicates thatof the body, as directed by the incoming light. the person is a straight-eyed squinter." (For Patients coming into my office are tested all you non-dinosaurs, "squint" was the termwith the Van Orden Star and with Keystone commonly used from strabismus.) He wouldskills before coming into the examination prescribe plus for the following reason: he feltroom. These two tests give invaluable insight that the frontal plane of the patient was pos­into the visual behavior of the patient. Often I tured too close, and was causing stress. Pluscan predict what findings will follow in the would allow the patient to posture furtheranalytical, which in turn will confirm the pre­ back in space, and gain relief. As I indicatedliminary findings. earlier, to me this pattern reveals internal The Van Orden Star supplies information constraints that would interfere with spatialas to the selective field, its organization, and orientation, and the patient would physicallyorientation. Behaviors can then be analyzed, exhibit a midline problem.and the type of lens needed for relearning se­ To cite another case: A 13-year-old girllected. from Massachusetts turned her foot in as she Case in point, a 35-year-old adult male walked. She was having reading problems andworked mainly at near point. He displayed the that was the reason for her coming to my of­following information on the Keystone: Exo fice. Her Van Orden Star was similar to that ofposture near and far on the lateral muscle bal­ Figure 13, but in her case the right apex wasance test, full fusion at far on the fusion test, well formed but of greater magnitude than thebut only 50% at near. The Van Orden Star had left apex. I asked her mom, a nurse, "Wouldwell-formed apices that met below the hori­ you like to see your daughters feet pointzontal plane. As a result, I could predict thathe was having trouble sustaining attention atwork, had to reread to understand, and hadproblems maintaining his place when reading.The analytical showed poor positive fusionalreserves at near, and high break and recoveryof negative fusional reserves at near. All these Fig. 15.26 Journal of Optometric Vision Development
  7. 7. straight when she walks?" Her mother, with a CONCLUSIONSquizzical look of disbelief, said, "Of course." I Each of us has a personal way of viewingplaced a pair of glasses on the gir l with 2 base­ our environment. A tall person has a differentright yoked prisms. When she started to walk view of his space world than a short person.with the glasses on, her toes pointed straight. This can influence hislher posture and behav ­ A similar case was that of a 75-year-old ior. Our actions and reactions to our environ­stroke victim with unequal apices along the ment are orchestrated by temporaVspecialhorizontal axis. His Van Orden pattern was constraints.more involved. His apices were disorganized. When we perform an optometric examina ­A dragging of his right foot marked his trans ­ tion we are measuring an individuals adap ­port. With the use of yoked base-right prisms, tive response to his particular constraints.his gait improved, as well as his balance. Both Wouldnt it be exciting to have a diagnosticbases reported improvement when reading. tool that would give us insight into the per­Different degrees of constraint cause different sonal space that governs our patients perfor­levels of behavior difficulties. However, dis­ mance? The Van Orden star isjust such a tool,crete lens application can raise any level of and it can deliver the information quickly andperformance. accurately. The revealed patterns of visual be­ MacDonalds model oflens application was havior are reflections of behavioral patternsdescribed by him thus: the patient has adopted. The paradigm pre­ "Prescribing lenses should be used to restore sented gives an outline for the presentation, and maintain a balance of energies throughout the interpretation, and the prescribing lenses the system. A plus lens will be used to flatten from the Van Orden Star. the input energy gradient, and reduce the en­ ergy input, into the system by spreading the REFERENCES energy over a greater area. A minus lens will 1. va Star Patterns, Mast Development Co., Keystone View tend to steepen the gradient and concentrate Division, 2212 E. 12th Street, Davenport, IA 52803, or the energy ... input into the system. As we Circle Publishing Co., P.O. Box 13073, St. Louis, MO 63110. view the system in operation, we should ask 2. MacDonald LW. A progTammed approach to visual train ­ ourselves what effect the lens will have on the ing, Visual Training, Series 1, Nos. 2 & 5. Duncan, Okla­ balance of the system." homa: Optometric Extension Program, 1962-63:9, 27. 3. Quick HE. Office procedures for the Van Orden Star, Visual Training at Work, Vol. 2, No.7. Duncan, Oklahoma: Opto­PEARL: BASE UPIDOWN FOR metric Extension ProgTam, 1953:39--42.CHANGES IN ORGANIZATION; BASE 4. Byall RS. Interpretation of the Van Orden Star, VisualLEFTIRIGHT FOR CHANGES Training at Work, Vol. 4, No.8. Duncan, Oklahoma: Opto­ metric Extension Program, 1955:21-28.IN ORIENTATION 5. American Psychiatric Association. Diagno:;tic and Sta.t;sti­ Yoked prisms are just one more tool we cal Manual olMental Disorders (4 th Edition). Washington, DC: American Psychiatric Association, 1994.have to change that energy gradient in the pa ­ 6. Bartley SH. Space perception. In: Principles ol Perception.tients personal space. Prescribing base-up New York: Harper and Brothers, 1958:246-249.yoked prism rotates the visual level of atten­ 7. Berthoz A. Reference frames for the perception and control of movement. In: Paillard J, ed. Brain and Space. Newtion to a lower, closer field of view. Yoked base­ York: Oxford University Press, 1991.down prism rotates that level higher and fur ­ 8. Birnbaum MH. Neural organization for emotional expres ­ther away. Both involve a rotation about the sion. In: Reyment ML, ed. Feelings and Emotion: The Wit­horizontal axis in space. There is a corre ­ tenberg Symposium. Worcester, MA: Clark University Press.sponding effect on the vergence system, im ­ 9. Carmichael JB. More Rotten Apples in the Visual Spaceproving spatial organization, sense of timing, Barrel, Transcript of the St. Louis Conference on Theoret­and awareness of depth. ical Optometry and Visual Training, Caryl Croisant, Box 39 Del Mar, Morro Bay, California, 1963:25. Yoked base-right prism rotates the energy 10. Carmody DP, Domingo ES, Lewkowitz KC. Modifications ofinput about the vertical axis, moving attention Attention and Spatial Orientation in a Child with Motortoward the left field of view, while base-left Disabilities. In review, 2000.moves it to the right. Laterally directed yoked 11. Dolezal H. Living in a World Translormed: Perceptual and Performatory Adaptation to Visual Distortions. New York:prism affects the orientation of the body, and Academic Press, 1982.will influence the individuals posture, trans ­ 12. Forrest E. Stress and Vision, Optometric Extension Pro­port, and version eye movements. gram Foundation, Inc. , 1988.Volume 33 / Spring 2002 27
  8. 8. 13. Harris P. The behavioral use of prisms. Vision Therapy Too l ing, Series 2, No . 12, Optometric Extension Program, ofBehauioral Vision Care: Prisms , Barber A, ed. Santa Ana, 1964:77-8l. California: Optometric Extension P rogram, 1996. 21. Margach C, Carmichael J. Visual Behauior, Series 2, 1968 ­ 14. Horner S . Use of Lenses and Prism8 to Enhance Vi sion i969, Optometric Exte nsion Program. Training, Series I , 1972-1973. Duncan, Oklahoma: Opto­ 22 . Myers J . Using VO Stars in testing and training vergence metric Extension Program, 73533. problems, Vision Ther. 1997;38(4):53-57. 15 . Howard IP. Human and Visual Orientation. New York: 23. Reinke AR. The Clinical Int.erpretation of the Van Orden Wiley, 1982. Star, Transcript of the West Coast Visual Training Confer­ 16. Kaplan M, Edelson DP, Gaydos AM. Postural orientation ence, Caryl Croisant, O.D., Box 39, Del Mar, Morro Bay, modifications in autism in response to ambient lenses. California, 1959:92 . Child Psych and Human Deuel. 1996;27:81-9l. 24. Schrock R. Optometric Training in Action, Series 2, 1969 ­ 1970, Optometric Exte nsion Program. 17. Kaplan M. Visual Training , Series No . 1-12. Santa Ana, 25. Skeffington AM. Clinical Optometry, Series 38, 1970-1971, California: Optometric Extension Program, 1987-88. Optometric Extension Program . 18. K1-askin RA. Lens Power in Action, Series 1, No. 1-12. Dan ­ 26. Slade G. Functional Optometry in R euiew , Series I , 1959 ­ ca n, Oklahoma: Optometric Extension Program, 1978-79. 1960, Optometric Extension Program. 19. Lesser SK. Questions and Answers, Vol. 2, No.2. Duncan, 27. Wainwright-Sharp JA, Bryson SE . Vis ual orienting deficits Oklahoma: Optometric Extension Program, 1952:3-4. in high functioning people with autism. J Autism Deu Dis· 20. MacDona ld LW. Van Orden Star, chalkboard routines, and orders. 1993;23:1-13. the attainment of visu ally directed activity, Vi sual Train ­ 28. Wandell B. Foundat.ion of Vision, Sinauer Assoc. Inc., 1995. 28 J ournal of Optometrjc Vjsion Development