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Article

The Van Orden Star: A Window into Personal Space

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.

WEIGHTING THE SCALES IN THE SEARCH FOR BALANCE

Harvard physiologist Walter B. Cannon proposed that all humans seek a position of homeostastis with their environment, a "steady state." Our bodies operate on a system of coordinates and axes of rotation (Fig. 1).

When a body displays postural skews, it is responding to a misreading of spatial cues by the visual vergence system. Suppose we vi­sualize the Van Orden Star pattern as an ex-

Correspondence regarding this article should be addressed to Melvin Kaplan, OD, 150 White Plains Road #410, Tarrytown, NY 10591.

Volume 33 / Spring 2002

Melvin Kaplan, OD Celeste M. Lydon, OD

tension of the patient's perception of axes and planes in external space, as illustrated in Fig. 2.

If the patient's Star drawing shows apices above or below primary gaze, or the target midline, he has demonstrated errors in ver­gence (Fig. 3).

Execution of this pattern, while straight­forward and simple, requires the individual to rapidly and accurately interpret what he sees, generate motor response, and maintain atten­tion throughout. The appearance of his star pattern is fundamentally a predictor of the pa­tient's spatial behavior. It reveals the way he responds to internal and external constraints. It depicts his particular version of homeosta­SIS.

INSTRUMENTATION OF THE VAN ORDEN STAR

The keys to using any test are:

l. Understand the demands of the test.

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2. Keeping instructions consistent. 3. Making sure the available facts fit the

model of interpretation.

The instrument of choice is the Correct-Eye­Scope with the transilluminated back. The Scope has an adjustable shaft with a Brewster stereoscope attached. The shaft marks dictate the visual distance to which the subject will att~nd. The standard design of the target, as desIgned by Van Orden, is a white translucent paper with two columns of figures, such as a star and a cross. Columns are composed of eleven figures placed 140 mm apart, for far point testing (Fig. 4).

I use the standard Van Orden Star pat­tern, but in addition created a modification for near, so I might see the patient's response to near point demands. If the distance star pat­tern represents a conflict between the visual and kinesthetic senses, but near point activity usually creates the greatest stress, the adap­tive response illustrated by the patient's star

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pattern would most likely be exacerbated at near. place

The second segment is easily done by ad­ colum justing the shaft to the near point setting. A ure 01 new test sheet is given with the same columns to be of figures now 95 mm apart (Fig. 5). pear 1

Figure 6 is the star pattern of a 6-year-old succe boy with learning-to-read difficulties. The dis­ comp) tance star pattern was relatively as expected. The near pattern, however, displayed disorga­nization indicative of vergence dysfunction, a DIFF symptom, as we know, of reading difficulty. DIFF

INSTRUCTIONS TO THE PATIENT In nent

Direct the patient to sit in front of the in­ the' strument and look through the eyepiece. Ask Quid

, him, "How many columns of figures do you recogsee?" If the answer is two, ask, "Can you see varia both columns at the same time, or do they ap­ the s pear one at a time?" If the answer is the cent former, direct the patient to take two same­ Dona s~ze pencils, one in each hand. Guide the pa­ oum' bent to hold the pencils so as to write with into f them simultaneously. Ask him to place a pen­cil point on the center cross of each column­ 1. Tr right pencil on the right cross, left on the left. 2. Tl Now ask, "Can you see both pencil points at re the same time?" If yes, have him draw simul­ 3. A taneous lines , one toward the other, until the fu pencil points look as if they're touching. Next, 4. A

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Instructions to the Patient Fig. 6.

place the left pencil on the top figure of the left column and the right pencil on the bottom fig­ure of the right. As before, the two pencils are to be brought toward each other until they ap­pear to touch. The procedure is repeated with successive figures until the star pattern is complete.

DIFFERENT PATTERNS, DIFFERENT INTERPRETATIONS

In the optometric literature, several emi­nent authors have offered interpretations of the Van Orden Star, including MacDonald,2 Quick,:3 ByalV and of course, Van Orden. 1 All recognized some frequently seen pattern variations. Van Orden recognized the value of the star for illustrating the balance between central and peripheral visual function. Mac­Donald's model has had the greatest influence on my thinking. He divided patients' patterns into four major classifications:

1. The tight peripheral-central relationship 2. The loosely organized peripheral-central

relationship 3. A mismatch between visual central visual

function 4. A visual kinesthetic mismatch.

MacDonald as well as Van Orden both ad­here to the model that an individual's percep­tion of space influences his sensory system, and thus would influence that individual's drawing of the star. A model is never right or wrong, it is based on the facts available at the time. Building on clinical experience, I was able to expand the model beyond the central­peripheral concept to include temporal and spatial factors, as well. The human organism is, after all, a spatial action system. Other or-

Volume 33 / Spring 2002

ganisms may depend more on other sensory modes, but in man, the visual sense dominates our sensory intake.

Human behavior is molded and condi­tioned by temporal and environmental con­straints; these in turn, affect all aspects ofhu­man performance. We seek a homeostasis with our environment. The Van Orden Star reflects the state of balance we have struck, be it ideal or distorted. Any distortions ofthe api­ces of the star reflect that individual's coming to terms with his personal space, his attempt to achieve balance.

Environmental constraints affect percep­tual constancy and intersensory localization. Watch someone hitting a ball. 1fhe sometimes hits and sometimes misses, under similar con­ditions, there is a lack of perceptual constancy and intersensory localization. Temporal con­straints manifest in postural shifts away from the vertical. For example, idiopathic scoliosis in teenagers is associated with a visual per­ceptual dysfunction according to Dr. Richard Herman, Orthopedic Surgeon, Good Samari­tan Hospital in Phoenix, Arizona. When we observe shifts in posture, we can suspect they are functional, not structural. Many ofus have observed this in traumatic brain injury pa­tients. Some shuffle their feet, moving at a snail's pace, others walk on their toes, rushing along to maintain balance.

The following figures represent the most frequently seen star patterns. You will see many variations, but these are representative of common presentations.

Figure 7 represents an optimal balance be­tween temporal and spatial elements. The in­tegrity of the illustration's planes and axes in­dicate a maximum balance in personal space.

Figure 8 denotes constraints, in MacDon­ald's terms, of the peripheral-central relation­

23

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ship. My interpretation suggests that this pat­tern results when central demands supersede peripheral demands, and the individual se­lects a space location closer to him. The visible space world is rotated about the horizontal axis, bringing the saggital plane closer, and directing the apices above the line. This type of individual will display behaviors associated with tunnel vision.

Figure 9 also represents constraints in the peripheral-central relationship. In this rela­tionship, peripheral demands supersede focal. The visible space world is again rotated about the horizontal axes, but here the saggital plane appears further away and apices appear above the line. This pattern is usually associ­ated with individuals who have increased near point activity and visual stress.

Figure 10 displays constraints in the pe­ripheral-central relationship that are mani­fested by disorganization ofthe visual system. The apices are poorly formed. Either they do not form an apex, as seen on the left side, or they form a fan shape, as seen on the right. These patients usually present a peripheral bias with no perceptual constancy. There may be an emotional component to this patient's visuo-spatial distortion.

In a study composed of 60 emotionally dis­turbed patients at the Westchester Medical Center and 60 control subjects, we compared far point Van Orden Star patterns. There ~as

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phrenic patients and the control subjects. USI]Typically, the schizophrenic subjects showed a ENlcrossing, fan-like presentation on the right

side, and no apex formation on the left (p = ( .003) (Fig. 11). Compare this to a typical far Star point drawing from the control group (Fig. 12). iors.

Figure 13 shows constraints in the periph­ dam eral-central relationship, which shows up as mole disorientation in the apices. These constraints are functional warps , and they can be seen in physical performance as well as in a pencil and paper manifestation. For instance, when envl the patient is walking a foot may toe-in rather able than point straight ahead. The star pattern apices may be clearly formed, but they differ · ·,,~

,,~in linear length. The pattern is rotated about the vertical axis, a projection ofhis body image • v that is rotated around the mid-body axis. The subject's perception of his space world makes gouthe frontal plane closer on the larger apex side the than on the shorter apex side. giv

Figure 14 represents constraints in the pe­ "wb ripheral-central relationship that implies dis­orientation and disorganization. The star has whi poorly formed apices. There is no apex on the bel< left, and the right side forms a fan. There are COOl many variations of this rendition, with apices rel~ being unequal along the frontal plane, or po­ we sitioning above or below the midline. These ate star patterns are usually produced by indi­viduals with concomitant visual and emo­ fail tional issues.

a significant difference between the SChlZO­

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USING THE VAN ORDEN STAR TO ENHANCE YOUR ANALYSIS

Clinical interpretation of the Van Orden Star can be a tool to recognize spatial behav­iors. The spatially coordinated pattern is, fun­damentally, a projection of the way behavior is molded and conditioned by temporal and en­vironmental constraints. We know that visual thinking operates on a "what" and "where" system. For an individual to interact with his environment, three questions must be answer­able:

• Where am I? • Where is it? • What is it?

The temporal "where" system is homolo­gous with the spatial ambient, or if you prefer, the peripheral system; the star pattern can give useful insight about the patient's "where."

According to my model, a star pattern in which both apices are well formed but meet below the line depicts a problem of binocular coordination. This level of dysfunction has a relatively mild effect on the patient's sense of well being. The pattern is commonly associ­ated with near point stress.

When the drawings end above the line but fail to meet in a definite apex, there is a more severe spatial organization problem. This pat­

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Volume 33 / Spring 2002

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tern signals a temporal-spatial mismatch, and the individual's behavior will indicate a greater degree of stress.

As problems with the "where" system in­crease in severity, the digressions of pattern execution will increase. The key is that there is a mismatch in the magnitude of frontal plane design between the right and left fields. This represents an individual who has prob­lems organizing hislher space world, and at the same time is unable to orient himlherself in personal space. It is not uncommon for these people to relate instances of panic be­havior.

The concept of retinal rivalry has given way to a concept of cortical rivalry, with a di­vision between the different aspects of the spa­tial system. The neurobiologist Pettigrew came up with a tantalizing theory of where this is all happening in the brain.

"In monkey studies during the late 1990's, only higher-cognitive areas-parts of the brain that process patterns and not raw sensory date­consistently fired in sync with changes in the animals' perception. That discovery buttressed a new theory: that the brain constructs con­flicting representations of the scene, and that representations compete somehow for atten­tion and consciousness."

Now we can accept the fact that vision is not in the eye, but rather in the brain. When viewing the Van Orden Star, we see a representation of

Fig. 14.

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projected visual behaviors. The question that remains is, what do we do about it?

LENS APPLICATION AND THE STAR PATTERN

For the past 25 years I have been a cham­pion of yoked prisms, which I call ambient lenses for the modification of human behavior. I have been prescribing them for individuals with learning differences, emotional difficul­ties, and autistic spectrum disorders. In addi­tion, they have been very instrumental in re­habilitating traumatic brain injury cases.

In much of the literature on prism, it is the focal aspect of the lenses that is emphasized. Prism is prescribed to displace the image on the retina and align the foveae, producing single binocular vision. When an image enters a prism, it is compressed toward the prism base and expanded toward the apex. Ifprisms are applied in a yoked configuration with bin­ocular prisms oriented in the same direction, they induce spatial reorganization about the axes and planes of space. There is then a com­parable shift in organization and orientation of the body, as directed by the incoming light.

Patients coming into my office are tested with the Van Orden Star and with Keystone skills before coming into the examination room. These two tests give invaluable insight into the visual behavior of the patient. Often I can predict what findings will follow in the analytical, which in turn will confirm the pre­liminary findings.

The Van Orden Star supplies information as to the selective field, its organization, and orientation. Behaviors can then be analyzed, and the type of lens needed for relearning se­lected.

Case in point, a 35-year-old adult male worked mainly at near point. He displayed the following information on the Keystone: Exo posture near and far on the lateral muscle bal­ance test, full fusion at far on the fusion test, but only 50% at near. The Van Orden Star had well-formed apices that met below the hori­zontal plane. As a result, I could predict that he was having trouble sustaining attention at work, had to reread to understand, and had problems maintaining his place when reading. The analytical showed poor positive fusional reserves at near, and high break and recovery of negative fusional reserves at near. All these

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strailindicated an application of yoked pnsm, qUIZZbase up. placeHere is the implied pearl: When apices are rightformed above the line, base down prism is in­withdicated. If apices are below the horizontal line,

Abase up is called for. strokThis interpretation of visual behavior from horizthe Star pattern, and the method of lens ap­Inoreplication, goes beyond the balance of central­A dr: peripheral function expressed by Van Orden, port.or the tightlloose organization described by his gMacDonald. I do not think it contradicts, but baserather is an expansion of their thinking. DiffePrescribing of yoked prism, for me, started levelwith a course of study at the Gesell Institute cretEconducted by Dick Appel and John Streff. perf(Streff introduced us to the work of Bruce Wolff

1\who had been using large-magnitude yoked desc:prisms to alter behavior in his training room.

I began using low-magnitude therapeutic lens "PI prescriptions about 1972 and have written ar­ ani ticles describing their use with learning­ thE difference children. thE

Byall presented Figure 15 and said, "This eq is (a common) pattern, and it indicates that en,

the person is a 'straight-eyed squinter'." (For tel thlall you non-dinosaurs, "squint" was the term

commonly used from strabismus.) He would VIE

ouprescribe plus for the following reason: he felt bathat the frontal plane of the patient was pos­

tured too close, and was causing stress. Plus PEl would allow the patient to posture further CID back in space, and gain relief. As I indicated LEI earlier, to me this pattern reveals internal IN (constraints that would interfere with spatial orientation, and the patient would physically

haviexhibit a midline problem. tienTo cite another case: A 13-year-old girl yok(from Massachusetts turned her foot in as she tionwalked. She was having reading problems and dowthat was the reason for her coming to my of­thelfice. Her Van Orden Star was similar to that of horiFigure 13, but in her case the right apex was

well formed but of greater magnitude than the SpOl

pro~left apex. I asked her mom, a nurse, "Would andyou like to see your daughter's feet point

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straight when she walks?" Her mother, with a quizzical look of disbelief, said, "Of course." I placed a pair of glasses on the gir l with 2 base­right yoked prisms. When she started to walk with the glasses on, her toes pointed straight.

A similar case was that of a 75-year-old stroke victim with unequal apices along the horizontal axis. His Van Orden pattern was more involved. His apices were disorganized. A dragging of his right foot marked his trans­port. With the use of yoked base-right prisms, his gait improved, as well as his balance. Both bases reported improvement when reading. Different degrees of constraint cause different levels of behavior difficulties. However, dis­crete lens application can raise any level of performance.

MacDonald's model oflens application was described by him thus:

"Prescribing lenses should be used to restore and maintain a balance of energies throughout the system. A plus lens will be used to flatten the input energy gradient, and reduce the en­ergy input, into the system by spreading the energy over a greater area. A minus lens will tend to steepen the gradient and concentrate the energy ... input into the system. As we view the system in operation, we should ask ourselves what effect the lens will have on the balance of the system."

PEARL: BASE UPIDOWN FOR CHANGES IN ORGANIZATION; BASE LEFTIRIGHT FOR CHANGES IN ORIENTATION

Yoked prisms are just one more tool we have to change that energy gradient in the pa­tient's personal space. Prescribing base-up yoked prism rotates the visual level of atten­tion to a lower, closer field ofview. Yoked base­down prism rotates that level higher and fur­ther away. Both involve a rotation about the horizontal axis in space. There is a corre­sponding effect on the vergence system, im­proving spatial organization, sense of timing, and awareness of depth.

Yoked base-right prism rotates the energy input about the vertical axis, moving attention toward the left field of view, while base-left moves it to the right. Laterally directed yoked prism affects the orientation of the body, and will influence the individual's posture, trans­port, and version eye movements.

Volume 33 / Spring 2002

CONCLUSIONS

Each of us has a personal way of viewing our environment. A tall person has a different view of his space world than a short person. This can influence hislher posture and behav­ior. Our actions and reactions to our environ­ment are orchestrated by temporaVspecial constraints.

When we perform an optometric examina­tion' we are measuring an individual's adap­tive response to his particular constraints. Wouldn't it be exciting to have a diagnostic tool that would give us insight into the per­sonal space that governs our patient's perfor­mance? The Van Orden star isjust such a tool, and it can deliver the information quickly and accurately. The revealed patterns of visual be­havior are reflections of behavioral patterns the patient has adopted. The paradigm pre­sented gives an outline for the presentation, the interpretation, and the prescribing lenses from the Van Orden Star.

REFERENCES

1. va Star Patterns, Mast Development Co., Keystone View Division, 2212 E. 12th Street, Davenport, IA 52803, or Circle Publishing Co., P.O. Box 13073, St. Louis, MO 63110.

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17. Kaplan M. Visual Training , Series No . 1-12. Santa Ana, California: Optometric Extension Program, 1987-88.

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19. Lesser SK. Questions and Answers, Vol. 2, No.2. Duncan, Oklahoma: Optometric Extension Program, 1952:3-4.

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in high functioning people with autism. J Autism Deu Dis· orders. 1993;23:1-13.

28. Wandell B. Foundat.ion of Vision, Sinauer Assoc. Inc., 1995.

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