Today I am delighted to connect with Dr. Bryce Appelbaum! He is a pioneer in neuro-optometry and is passionate about unlocking life’s potential through vision. He is an owner and managing doctor at Appelbaum Vision and practices in the Bethesda and Annapolis, Maryland areas.
Our brain uses 48-50% of its physiology just for us to be able to see, and there is a very complex interrelationship between the eyes and the brain.
In this episode, Dr. Appelbaum and I dive into his background in neuro-optometry and discuss how his family influenced his career trajectory. We get into eye physiology and the differences between vision and sight and explain how eye problems are also brain problems specific to rewiring our brain and processing. We discuss the impact of nutrition on eye health, foods to support vision and eye health, and how electronics impact myopia. We also talk about ways to address screen limits and visual hygiene, traumatic brain injuries, and more.
“There are more areas of our brain dedicated to processing vision than all the other senses combined.”
– Dr. Bryce Appelbaum
IN THIS EPISODE YOU WILL LEARN:
- Dr. Appelbaum explains how his passion for eye and vision health began in the first grade and how he helps people turn their visual weaknesses into strengths.
- Some of the basics of eye physiology.
- The interrelationship between our eyes and our brains.
- Why are more vision problems emerging now than ever before- particularly in the younger generations?
- What is the difference between eyesight and vision?
- How do our eyes feed information to the rest of our body?
- Doing vision therapy versus getting stronger prescription lenses as we age.
- How vision problems can lead to or be misdiagnosed as ADD, ADHD, or dyslexia.
- How does electronic use impact eye health?
- How to practice 20-20-20 for visual hygiene.
- Dr. Appelbaum shares some recommendations for managing screen time.
- The interrelationship between nutrition, metabolic health, and eye health.
- Some dietary guidelines for the brain injury population.
- Dr. Appelbaum dives into depth perception.
Dr. Appelbaum is on a mission to change the way the world views vision. He believes there is more to vision than just 20/20 eyesight and has developed programs to retrain the brain to revise the eyes.
Dr. Appelbaum has been featured on the front page of USA Today, in the New York Times Magazine, Bethesda Magazine, and as the cover story of OT Advance. He was the 2022 recipient of The Future of Health Award at the Mindshare Leadership Summit and has shared the stage with Dr. Joe Dispenza, Marie Forleo, and JJ Virgin.
Dr. Appelbaum is a pioneer in neuro-optometry passionate about unlocking life’s potential through vision. His expertise includes reorganizing the visual brain post-concussion to return to learning and return to life, remediating visual developmental delays interfering with reading and learning, and enhancing visual skills to elevate sports performance.
Dr. Appelbaum has worked with hundreds of professional athletes, numerous professional and collegiate sports teams, and countless amateur athletes to transform raw talent into honed performance through vision. These athletes include – NFL, NBA, MLB, NHL, MLS, and NWSL players -professional golfers, volleyball, and tennis players, race car drivers -Olympic fencers, gymnasts, swimmers, archers, and shooters.
Dr. Appelbaum also helps teams consider who to draft or sign as a free agent based on assessing a player’s visual potential and identifying how far off they may be from operating at that ceiling.
He is the owner and managing doctor at Appelbaum Vision, PC, a private practice specializing in Vision Therapy and Rehabilitation with offices in Bethesda and Annapolis, Maryland.
Dr. Appelbaum is a board-certified Fellow of the College of Optometrists in Vision Development and an Adjunct Clinical Professor at the Southern College of Optometry. He is certified in Corneal Refractive Therapy/Orthokeratology, a specialty contact lens approach to slowing down near-sightedness and improving eyesight as an alternative to refractive surgery.
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Go to the College of Optometrists in Vision Development website to find a doctor board-certified in vision therapy close to where you live.
Cynthia Thurl tow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
Today, I had the honor of connecting with Dr. Bryce Appelbaum, who is a pioneer in neuro-optometry and is passionate about unlocking life’s potential through vision. He is an owner and managing doctor at Appelbaum Vision and practices in the Bethesda and Annapolis, Maryland area. Today, we dove deep into his background in neuro-optometry and the influence of his family, differences between vision and sight, eye physiology including the need to connect to sunlight and the role in enhancing our chronobiology, the impact of understanding that eye problems are also brain problems, specific to rewiring our brain and processing, the impact of nutrition and its impact on eye health, what foods are beneficial to support vision and eye health, the impact of electronics and myopia, which has increasing prevalence and severity, ways to address screen limits and visual hygiene, traumatic brain injuries, and so much more. I hope you will enjoy this conversation as much as I did recording it.
Good morning, Bryce. So good to connect with you.
Bryce Appelbaum: Thank you so much for having me. Great to see you.
Cynthia Thurlow: Yeah. I loved learning about your background and your parents were obviously in healthcare and how that probably very likely influenced your decision to go into optometry school and become a vision specialist. But let’s talk about your background and what genuinely influenced you to have a passion for eye and vision health.
Bryce Appelbaum: I’m really where I am today because of the work that I do. I have a pretty cool story that really starts in probably first grade and on the soccer field, I remember this fall afternoon at Carderock Springs Elementary School where we’re playing the Purple People Eaters, and there was this moment I can remember honestly as clearly as if it was yesterday, I’m the lone defender, there are these three attackers coming at me on a breakaway, and it’s just me, the goal behind me, and I completely freeze. It’s like my legs are stuck in quicksand and they just blow past me, they score. The feeling I had at the time was just afraid, helpless, like I was lost in space, I let my teammates down, and at the time I had these visual developmental delays, which means I had trouble focusing my eyes, and I had poor depth perception.
My eyes didn’t work well together as a team causing me to really freeze in moments where it would be more common to have sprung into action. That night, the dinner table, I had a complete breakdown of my parents, tears pouring out and I shared how I didn’t know where to be on the field or what to do and how in the classroom I couldn’t see what the teacher is writing on the board and having often asked my friends what does that say? Or pretend to sharpen my pencil up at the board to just kind of get a peek at what she was writing. Because of my vision, I had this confidence that hadn’t developed and I often felt like a turtle kind of retreating into my shell in so many aspects of life. Like you shared, fortunately, I was born to the perfect parents. My mother is an occupational therapist, my father developmental optometrist. It really wasn’t until this breakdown that they really put all the pieces together. From that point forward, my dad went all in, dedicated his career to helping me with his subspecialty of developmental optometry.
Over the next several years, I did consistent vision therapy, sensory integration-based occupational therapy every week. And I struggled learning to read. I was a reluctant reader. I would try and fly through other subjects like math to kind of makeup for my deficiencies in reading. It honestly wasn’t until about fourth grade or so where everything came together, my eyes, my brain, my body started working as this cohesive team. My confidence emerged, I became a stud athlete, I started to actually enjoy reading, developing personal communication skills was something that was natural and I look at it as I turn my disability into a strength where I could kind of get an advantage in life based off of vision.
Obviously continued with therapies and over time have transitioned from a patient to a clinician, but have been studying this work for decades. I’m now dedicated to the evolution of vision therapy and how to make it more accessible and innovations and technological applications. On the other side of this, we can accomplish in a matter of months what was done for me in years. So, we can help people who’ve had their heads buried in screens and phones and other tech devices, who are experiencing all these symptoms like headaches and eye strain and fatigue and environmentally created nearsightedness where we can help people become screen fit so they can get their life back and turn weaknesses visually into strength and superpowers. I feel like I have this obligation. I’m here so that others don’t have to really struggle the way that I did.
Cynthia Thurlow: Well, I really love hearing people’s pain to purposes stories. Certainly, your parents are the perfect example to have a child that was struggling with some of these visual and developmental delays to be the perfect types of parents that would understand exactly the therapies and strategies that were needed to get you to a point of greater comfort and greater confidence. Now, before we start talking about vision and sight and things like that, I thought it might be helpful to kind of review some basics about eye physiology and one thing to really emphasize with listeners is that our eyes are one aspect or one outlook of our brain. It’s important to understand this close interrelationship. They’re not just two separate entities. They are tied together and as a former ER nurse, I was saying to you before we started recording that we took eye health very seriously because it would more often than not give us clues into what was going on with the brain. So, let’s unpack the interrelationship between our eyes and our brains and how they work together so that we can actually see, so actually that physical manifestation of vision.
Bryce Appelbaum: Most people don’t realize we need more than our eyes to see, right? I mean, our eyes are connected to something. There’re more areas of our brain dedicated to processing vision than all of the other senses combined. Obviously, I’m biased, but vision is our dominant sensory system. It should be what’s guiding and leading and kind of creating organization from our world and evolutionarily vision was intended to help us navigate our three-dimensional environment and our world. From how eyes and brain work well together standpoint, we’re all born without the functional visual skills in place. Through our life experiences, we develop the ability to converge our eyes and tract our eyes and focus and process information and really understand the world around us. That’s something that’s either developed and learned well or not learned as well as it could be and that’s when some intervention is needed.
I would say more so than ever, we’re noticing problems in the whole world, but specifically the younger generations because kids are being introduced to technology and screens earlier than ever before and often being asked to read it earlier in earlier ages and very often not visually ready for those demands and that’s when vision problems emerge. My subspecialty and we can talk about that is looks at vision way differently than eyesight. Eyesight is simply the ability to see whether that’s letters on the letter chart or street signs or what the teacher writes on the board in the classroom. Eyesight is what people have glasses for. Eyesight, though, is really just a symptom. It’s a symptom of how the brain is functioning and using the eyes together as a team. And that’s where vision comes in. Vision is brain. Vision is what’s pervasive throughout our entire brain and how our brain understands how to derive meaning and direct the appropriate action.
Vision problems are brain problems, and there’s fixes for brain problems that are created from our environment, from our visual stress, from developing these maladaptations, from life where we don’t have the foundation to meet the demands. And so, we adapt or we avoid. But the majority of vision problems that are functional in nature are treatable, avoidable. And yet the world doesn’t know that. That’s why I’m on a rooftop singing all of this, shouting all of this because it needs to get out there more.
Cynthia Thurlow: No, I couldn’t agree more. It was interesting as I was preparing for a discussion and you just alluded to this. The brain uses 40% to 50% of its physiology just for sites, so just for the action of being able to see and understand the complex interrelationship between our eyes and our brains. One thing I talk quite a bit about is the value of getting sunlight exposure in the morning and maybe you can speak a little bit to this, like what’s actually going on in our eyes, how that information is feeding information to the rest of our body. Because I think that circadian biology is something that I’m really fascinated by and trying to reinforce with people that not only is that just good to connect with the earth but it also has some very deep physiologic processes that go on as our bodies are receiving light through our retinas into our brain reminding our bodies what it needs to be doing.
Bryce Appelbaum: I’m glad you brought this up. The retina is the inner layer of the eye and it’s the layer that has all the photoreceptors that allow us to see small things, react to periphery, to kind of process signals from our world. We have these specialized cells in our retina that only respond to light and they’re responsible for releasing melatonin. Melatonin, I’m sure the audience knows, is what regulates sleep. And so especially regulating circadian rhythms sunlight is hugely beneficial, but the blue light that comes, blue light has gotten a bad rap these days. Blue light is not bad for us. It’s actually critical to life and to vitamin D and a lot of our systemic functions. It promotes alertness and facilitates and influences rhythm and mood, but blue light that’s blasting from screens at our eyes and our brain that’s artificial, for hours and hours and hours that can create disruption in terms of how the retina and the photoreceptors in the eye send these signals of what’s occurring in our life.
It can contribute to, for some people, eye strain and fatigue and light sensitivity, and a lot of trouble with cognition and just the ability to function at a high level, especially with work when we’re staring at screens all day long. There’s not really evidence that blue light harms the eyeball itself at least yet but blue light being blocked that’s artificial or at least shifted in terms of how the brain can then filter and process that information, can be hugely helpful for many people who are like us staring at a screen right now for extended periods of time. So, there’re glasses that protect blue light. There’re lots of different levels of blue light protection and different kind of quality levels. You want one that has the largest spectrum blocked but also getting outside allows us to use our visual system the way that it is intended and allows us to apply our visual skills to space and to facilitate depth and 3D awareness, which we’re not born with where our brain develops cells in the back of our brain in the occipital lobe that are not there when we’re born, that only come from two-eyed life experiences and learning and that critical period for vision development although many eye doctors would say after age eight, you blow out the candles and poof all of a sudden that can’t be trained or taught. I graduated optometry school in 2009 and that’s what I was taught. That’s completely false. It’s been disproven. We have the research and literature to support that. I have patients right now, 97, 92 and 89 in office space vision therapy with me developing depth perception for the first time.
So, we can talk about what’s involved to develop depth perception and what’s needed and how to do that. But our brain has so much neuroplasticity. With the right facilitation of ingredients for our body and life experiences and right intention for what we do and how we do it, we can allow our brains to really influence life in a positive way. Especially our visual system to get that optimal clarity that is needed for sports, for reading, for learning, for driving, for all the important things in life that are so visually dependent.
Cynthia Thurlow: Well, I love the positive reframe because I think there has been and let me be clear I went to school in the 1990s and early 2000s and what I was taught then, which was minimal, even though I was at a big ophthalmology-centered trauma place, is very different than what you’re sharing now, which makes so much sense. All of us as clinicians should be evolving, shifting, and changing our perspectives as we’re learning better and better information, better research, and to hear that there are people in their 80s and 90s that are still neuroplastic, meaning that they’re able to make new neural connections in the brain, they’re able to facilitate change. As I always say, “What wires together fires together.” So, understanding you can still be training your brain even as an older adult is certainly really validating.
I want to touch one thing because I went down the nerdy rabbit hole about the role of melanopsin ganglion cells found in our retinas promote eye health and going back to what you’re talking about before and they are very intricately related between the sleep-wake cycles dopamine levels which I’m sure we’ll probably talk about as it pertains to screens, also pain, metabolism, mood, and wakefulness. Now, one thing that I know we will talk about today, maybe not yet, is the interrelationship between metabolic health and vision or sight, I think that it’s important for us to understand that it’s not just a function of getting older that all of a sudden your vision starts to change. It is heavily influenced by lifestyle choices and nutrition as well.
Bryce Appelbaum: So much to comment on there. What you said at the end about getting older. Our brains don’t have to function differently as we get older. We can still have mental clarity and we can still learn new things. Any brain can be taught new tricks depending on how old it is that shouldn’t limit the ability for the brain to learn. In the vision world, most people say at around your 40s, early to mid-40s, you start pulling things farther away and your arms aren’t long enough that now all of a sudden, you can’t see things up close. Anatomically, the focusing muscle, the internal muscle inside of the eyes that’s responsible for making things clear, keeping them clear, does become more rigid and less flexible as we age. Just like any muscle in our body, if we stop using it, we lose voluntary control over it.
The simple solution is up close becomes hard. Let me grab some over-the-counter readers and magnify things and then I don’t have to struggle as much. For some people and in some cases that’s warranted. But so often in the visual world, when we look through a lens, we adapt to that lens, that becomes our new normal. We then need something stronger or different to maintain that same clarity. We go down this vicious cycle where the prescription is rapidly changing. From a near perspective, if we could focus things at, let’s say, 16 inches, and then all of a sudden it starts to recede to 20 inches. If we then magnify it so the brain doesn’t have to work, our brain literally forgets how to use those systems from a just normal prescription standpoint. As we grow and as our bodies change, our prescriptions can change.
But we shouldn’t be getting new glasses every year at the eye doctor and faraway shouldn’t be getting blurry and blurrier and you shouldn’t be needing a stronger and stronger lens unless there is something functionally driving that. I’m a big believer that any prescription should be the weakest lens possible, that is the most balance between each eye, that gives the greatest improvement. If we relate this to blood pressure, let’s say if 100-mg pill gets your blood pressure to a target level and so does a 10, in my opinion you go for the 10, but you bring up ophthalmology and optometry and the kind of disconnect that’s there. Ophthalmology in general are surgeons and they’re trained heavily on the intervention of eye disease and on structure.
I’d say optometry in general are trained more on function and development. If surgery is needed or you need a unique diagnosis based off of the photoreceptors that are missing or absent, like you mentioned before, absolutely ophthalmologists are the go-to there. But if we’re talking about performance in life and how our eyes can work together as a team, and how we can use the inside and outside muscles of our eyes in synergy. I think optometry is definitely the subset of doctors to see there. And specifically, those that practice vision therapy who are board certified in vision development and rehabilitation, who know that at any age there should be a level in which our eyes are functioning together as a team. The inside and outside muscles of our eyes need to be in synergy for us to be able to maintain clarity in a single image for extended periods of time, especially if we’re high-level athletes, or if we’re reading forever, if we’re on screens for a long time.
No two people see the same, no two people should see the same. If somebody gets a pair of glasses, tries them on and it doesn’t seem right or it creates a symptom, in my opinion, it’s not right. You need to go back to the doctor. What’s better one or two that is done in eye exams that creates so much anxiety for so many people, those are just measurements. What do you then do with those measurements in terms of predicting the right balance for life? What can we do then to make it so that our visual system is guiding and leading rather than creating symptoms or making life more challenging than it should be?
Cynthia Thurlow: Well, I love that you are able to provide some objectivity about different types of eye health professionals, which I think is so important. Now, if someone is coming to you for vision therapy, and I love that you call it PT for the brain because that’s really what it is, is the average person is this a lengthy process that they’re working with you? Is this something that goes on for months or is it something that goes on for years? I’m asking out of just genuine curiosity because this is a new concept, but it’s one that I think for many of us, I think we would rather do physical therapy for our brains than be getting stronger and stronger prescription lenses or contacts or things like that that we have to utilize, or that we choose to utilize. Let me reframe that, choose to utilize as our vision is changing and we’re getting older.
Bryce Appelbaum: I just want to clarify one thing you shared. It is physical therapy for the brain, but I would say it’s physical therapy through the eyes for the brain, with the intention of rewiring the software in the brain to change how somebody’s taking in the world around them and processing visual information. In my practice at least, I work and treat with essentially four main populations. Number one, kids with visual developmental delays impacting reading, learning, and academics. Number two, people with head injury or concussions where the visual system is massively disrupted based off of what we talked about initially, having there be so much of the brain dedicated to processing vision, and two-thirds of the neurons entering our brain actually originate from our eyes. It’s impossible, in my opinion, to have a head injury and not have vision being impacted is just a matter of at what level.
Number three, eye turns or lazy eyes as an alternative to surgery. Often eye turns, let’s say, are not problems with eye muscle length or strength. They have to do with coordination and the brain not learning how to use the eyes together as a team. It’s a very high correlation with kids who skip over crawling or walk early who then develop lazy eyes or eye turns because they don’t have the motor foundation to support the visual learning that’s coming and that’s so crucial to life. And then the fourth area, athletes. I work with a lot of professional athletes, a lot of nonprofessional Weekend Warrior athletes, kids, adults, anybody’s visual skills and abilities can be improved. It’s a matter of whether improving them does anything to improve life.
You mentioned about a timeline. My model is office-based therapy, is ideal in every scenario and we put a big emphasis on home reinforcement where new learning takes place in office, we give you ways to practice those skills at home and the more you practice, the faster you establish muscle memory and the faster things become habitual and automatic and unconscious. But that’s not something that is available to everybody and it’s not available to even as close as many people as it should be. We do have online programs that people do where it’s not the gold standard, but it can improve symptoms dramatically for certain people and certain populations.
We do see a lot of people who fly in from out of state or out of country for intensive programs or bootcamps. Although this sounds crazy, we’ve worked with somebody to develop depth perception in a week, but they were doing, let’s say, 2 hours a day six days a week of therapy. Timeline, I think, really depends on how much opportunity the brain has for learning. In general, the more learning that takes place with the least amount of time between the learning, the faster we get to where we need to be.
I see a lot of varying levels of visual dysfunction. We see lots of stroke victims and brain-injured individuals who, in general, need more treatment time than others. We also work with kids who are reluctant readers or avoiding reading because they don’t have the visual foundation in place to support those demands. They’re skipping words and skipping lines and losing their place and getting really frustrated with school and having to listen for what the teacher shares with their ears rather than with their eyes because they don’t have this coordination of the different muscle systems with the brain’s ability to process that information.
In that population of the kids, a lot of kids who are misdiagnosed with ADD or ADHD or dyslexia when, as you know better than almost anybody, our medical world is so quick to slap labels on behaviors when at least in these cases, ADD, ADHD, dyslexia, in my opinion, cannot be diagnosed or are inaccurate diagnoses unless functional vision problems have been ruled out. So much of visual dysfunction, specifically something called convergence insufficiency, the difficulty to use the eyes together as a team that occurs with all near tasks, has a very high correlation with inattention and difficulty focusing the eyes. If it’s hard to focus the eyes, it’s going to be that much harder to focus the mind, compared to if that was not the case.
It’s not uncommon that we see somebody who is a really smart child or individual who’s doing great in so many areas of life, but any deskwork or sustained near concentration tasks is just not functioning the way it should. They’re avoiding it and they’re now getting headaches and eye strain and words are moving or they’re seeing double, or they’re not remembering what they’re reading. For a child who’s not able to articulate that or for a parent or somebody who doesn’t know that this even is a thing, there are so many misdiagnoses and missed opportunities in healthcare when all of us eye doctors are trained. We just got to focus heavily on the pursuit of seeing those tiny letters at the distance and making sure our eyes are healthy, which absolutely are important. But what about what the brain does with the information the eye sends it and how the brain processes that information and then how the brain tells the rest of the body how to react and how to move and how to function and how to respond to the world around us? So, vision problems are everywhere. Once you start hearing about them and knowing what’s possible, I mean, I’m sure a lot of people listening are probably thinking of people they know or themselves who are struggling unnecessarily in life because of hidden or misdiagnosed vision problems.
Cynthia Thurlow: It makes a great deal of sense in one area in particular the impact of screen time, the impact of blue light, the impact of iPhones and tablets and computers and kids now can stream 24/7 unfettered in a lot of instances, especially we’re three years into the pandemic or out of the pandemic or however we want to reframe that. From your perspective, what have been some of the net impacts you’ve seen with regard to electronic use and eye health?
Bryce Appelbaum: Cynthia when you and I were kids, our parents had to drag us in from being outside all the time, especially in the summertime. It’s, “No, I don’t want to come inside, I want to play, I want to climb in the trees, I want to play ball with my friends.” Now so many parents are having to drag their kids outside because they’re buried in a tablet or on a video game and in this dark environment where they’re not engaging with real people or three-dimensional space, they’re engaging with a screen. We now are seeing the impacts of what COVID has had on life in so many areas, but specifically the visual system. Myopia or distance blur or nearsightedness is at a ridiculously steep incline in terms of prevalence and severity, the magnitude of myopia and myopia is where near vision is relatively clear relative to the distance, but it’s not simply just about blurred vision.
This is when we’re starting to notice with our children that they’re squinting or covering an eye or faraway is getting blurry. That’s the slow, gradual process that’s already in place and it’s already been happening. The world that is up close, if that’s presenting stress to our visual system and we don’t have the tools in place to meet those demands, again, we adapt or we avoid. Myopia is at such an increase right now. It’s estimated that by 2050, 50% of the population will be nearsighted. We now have stats now that two individuals who are going to have a child, if neither one of them is nearsighted, there’s a one in four chance their child will be nearsighted based off of the environment. If one of them is nearsighted, there’s a one in three chance that their child will be and if both of them are, there is a one in two chance.
Myopia or prescription, definitely there’s a genetic component, but the environmental component is so much more powerful and influences life negatively at such a greater degree. There’s been a study that has come out now that said during the COVID lockdown even children had a six to eight times increase in myopia. There was a study with Dutch teenagers that said that there’s an increase in the level of myopia correlated with using screens for more than 20 minutes. Although this isn’t really a whole lot new from what we’re experiencing in life, everything needs to be done in moderation. I always preach 20, 20, 20. Which means on a screen, taking a break at least every 20 minutes and looking at something at least 20 feet away for at least 20 minutes. The more visual breaks we take, the less likely we’re going to adapt to that environment. The focusing muscles we’re talking about, there are these internal muscles inside of our eyes and they’re sphincter muscles, so they’re circular and they get constricted or they have to work when we’re looking at something up close.
Right now, staring at a screen, your focusing system is engaged and so the muscle is constricted and even observing somebody, the pupil is smaller. If everyone were to squeeze their hand real fast right now, after about 5 seconds, your hand starts to hurt. If you were to let go and squeeze and let go and squeeze and do it back and forth, you can maintain that tension for an extended period of time. I think that’s a great analogy for what our focusing system is having to do on a screen, where it’s literally locking in to that distance and having to make something clear. If we’re not able to then maintain flexibility and look away and look out a window or look through the screen, then that’s going to cause tension on the system and force this adaptation to occur.
There’s so much that we all can do just from a visual hygiene standpoint with screens or with ergonomics and how to set all that up. I’m happy to go into that if you think there would be interest. But I’m so glad that most learning for kids now is not virtual and it’s not online, at least in most places, because man we have problems with that from so many perspectives, but specifically from a vision perspective.
Cynthia Thurlow: No, I can just imagine and it’s interesting. My kids, at the time we’re in Northern Virginia, so from March 2020 to March 2021, they were home on Zoom probably like most of their peers, even though they’re good students, they were bored, they’d have their gaming computers up, they would be looking at Zoom, half paying attention. Let me be clear, I did not support this, but running a business and all of us working from home it was impossible to supervise every single thing.
But they were both middle schoolers at that point in time, so old enough to be independent for parts of the day. So, for parents that are listening, realistically, I would imagine most teenagers, as an example, are spending, you know they come home from school, they’re doing homework online, they’re on screens. How realistic is it to ask and I’m just being a total realist when I say this, even as an adult like to do 20, 20, 20 I think that’s fantastic, but I would imagine encouraging your kids to get off electronics, to give their brain and their eyes a break, is a bit of a challenge.
I think if my kids were younger, maybe I would be able to have more direct control over those kinds of things. But what are some of the recommendations because I would imagine if you’re working with athletes, you’re working with teenagers, young adults, what kind of accommodations are you making for them in particular?
Bryce Appelbaum: Well, it depends if you want your kids to think that you’re really annoying and they have trouble with you, [Cynthia laughs] because if that’s the case, there’s a lot we can do. Just real quick, I always like to give screen time limits for kids in particular. Under 18 months or so, we should be limiting screen as much as possible, except for engaging with a loved one on FaceTime who’s not local because you want them to be interacting. If we’re 18 months to two years old, I would say 30 minutes max and again high-quality engagement as the only option. When we then get to about two to five years old, not more than an hour a day and six and above, not more than 2 hours. American Academy of Pediatrics has 2 hours as max. I think from a realistic standpoint, especially for you with teenage kids or older kids who have minds of their own are going to do what they want and probably the opposite of whatever their mom says. I think setting a timer on their phone, on the screen, and there’s apps that can do that literally just says every 20 minutes, just look away or get up and grab a snack or go to the bathroom. Really limiting screens in terms of balancing that with at least as much time as we’re on a screen, with outdoor play, with ball sports, engaging with each other. If there is a choice to be able to interact in three-dimensional space or not always choose three-dimensional space.
How we set up our screens? I think there are habits that we can put in place to be more mindful. The line of sight of the screen straight ahead should be about 15 degrees lower than eye level and you want to set the top of the screen to where eye level is you’re looking down a little bit. We don’t want to be closer to the screen and what’s called the Harmon Distance, which is if you were to put your fist against your face, the distance between the middle knuckle and the elbow is really the closest distance that’s from an optometrist a long time ago named Dr. Harmon, that’s the closest we should be going. In terms of kind of the right distance, I think if you were to lean back and put your arm all the way straight, the distance from where your arm would be totally straight from kind of the middle finger on the screen towards you, so it’s around 16 to 30 inches for most people.
We could do a lot with brightness and contrast. I always say start as low as you can and then slowly increase. Ideally, it’s around 40% to 65% for most people, but then the right performance lenses I think is hugely important. We talked about blue light and blue light, in general, is great, but we want to block this artificial blue light that’s blasted from our screen, specifically blue light and low plus magnification, so over-the-counter readers that seem way too weak. Obviously seeing an eye doctor and finding that right prescription of balanced-performance lenses is absolutely what we should all be doing. But a little bit of magnification can go a long way in terms of giving the brain a better opportunity for the eyes to work together as a team, decreasing some of the visual stress associated with near, so that our result in response to that stress is different. And it can often act almost like a spot if we’re lifting weights where it’s ensuring that you’re still doing the work, but that the right form and habits are in place there.
Although screens are everywhere and they’re not going anywhere, this is our new normal now. With the right visual foundation in place, with the right setup optically, with the right glasses in front, we can actually thrive in this environment. But it’s almost like one of the biggest kept secrets now. Definitely eye care, but especially medical care where if we’re more intentional with what we’re doing, we can make it so that we can handle those demands, even though it’s better to be outside and engaging with print and one another face to face.
Cynthia Thurlow: Now, that was an incredible synopsis of recommendations that I think listeners will absolutely find really invaluable. Let’s pivot and talk a little bit about the role of nutrition and eye health. I come from a traditional allopathic background and so, yeah, the things we worried about in cardiology was if you have diabetes bad enough that it impacts your retina, you get retinopathy, but there’s so much more to eye health than that. Let’s talk about metabolic health as it pertains to how healthy our eyes and our vision can be.
Bryce Appelbaum: I love this. Especially for the concussion population and those who are brain injured, one of the most common triggers of symptoms can be sensitivities to food. Inflammation is the root cause of so many problems that in many cases are avoidable. Having the right ingredients for your body in terms of what we provide ourselves food wise, supplement wise, nutrition wise literally gives our body the instructions and the directions on how to function and what to do. I’m a big proponent of limiting as much inflammatory foods as possible in general, but specifically for the brain injury population, gluten free, dairy free, high fats, getting your body into ketosis, allowing for autophagy to occur, intermittent fasting, which you are the queen of, I would love to hear your thoughts on your experiences with people who’ve had some brain injury, but the foundation needs to be in place for learning, especially to take off.
We have a very strict protocol, a very strict concussion cocktail that I recommend in terms of supplements for all the patients we work with. Certain diets that are really helpful, but brain fog and visual snow and dizziness and nausea and vertigo and all of these symptoms that are so common with head injury can’t often be completely eliminated with vision therapy and other treatments needed, unless we’re addressing this from a nutrition and supplement standpoint. I think that’s crucial to just longevity to decrease inflammatory reactions that occur. You brought up the retina and there’s a lot of people who say age-related macular degeneration, let’s say, almost should be looked at as type 3 diabetes.
The retina, the macula, the sweet spot of our eyes that allow us to see crystal clear, the center of the bullseye can become damaged with life, with UV exposure, with toxins, with a genetic predisposition, if you’re a smoking individual or ex-smoking individual, so a lot we can control, a lot we can’t control, but so much can be a choice in terms of systemic disease if we have the right team around us guiding us in terms of the right choices and the things to avoid.
Cynthia Thurlow: That’s really helpful. Do you find that there are and again, we’re speaking in generalization, so it’s not specific to any one type of disorder? When you’re talking about nutrition, obviously, anti-inflammatory diet, probably brightly pigmented fruits and vegetables, lots of the omnivore kind of process without all the processed foods. Are there specific ingredients or specific vitamins or minerals that are based on research that are particularly beneficial for eye health? I always think about healthy fats and fat-soluble vitamins and things like that. But based on the research, what are the heavy hitters, the ones that you think are most impactful?
Bryce Appelbaum: Absolutely. This is in no particular order of what’s the best, green leafy vegetables are fantastic in terms of providing zeaxanthin and lutein, which are carotenoids, they help the retina, they’re protective from harmful UV light. They’re wonderful. That’s also in really colorful fruits, vitamins A, C, and E, great antioxidants. Eggs have lutein. There’s a lot of research on lutein, specifically in the yolk, that’s great for macular health, and choline, which is great for cognition, fats, which you mentioned. I am a huge proponent of omega-3s and the right obviously sourced omega-3s and the right balance of DHA and EPA. But from two specific standpoints as that relates to vision, number one our tear films, the layers in front of our eyes are comprised of three different layers. The outer layer, the mucin layer, if you load up on omega-3s, you can actually get that layer to be more protective so that your own tears don’t evaporate as quickly as they would otherwise. They can help with blink rate, they can help with dry eye, they can help kind of set the right balance between watering the grass and the right fertilizer because your own body is then producing more robust tears, and that mucin layer is really enhanced.
But then also from a head injury standpoint, omega-3s are what our brain is essentially created from. I’m not going to give recommendations on dosages, but I think that is something that is great for so many aspects of life and health, but specifically for eye-brain integration and brain health. CoQ10 is amazing, promotes brain health. Carrots, although many people think carrots are the best vegetable out there for the eyes, they do have beta-carotene, which is helpful. In World War II, there was a propaganda. a marketing ploy that made the world think that carrots were like the superfood for the eyes. I would say if we’re choosing green leafy vegetables or antioxidant-rich fruits, I would choose those over carrots, but carrots are also very helpful. Nuts and specifically nuts that have the right type of fats in them. When we reference omega-3s, I think it’s definitely the cold-water fish that are important. So, the salmon, sardines, anchovies, mackerel, halibut. Everyone always asks when I’m recommending omega-3s to somebody, “Oh, I eat a lot of fish.” We’ve got to have higher quality, higher dosages, and more for our body to be bioavailable rather than just dietary. Nuts, sunflower seeds, almonds, those are rich in vitamin E, which is really helpful. Broccoli has choline, zinc, iron, that’s great. I think a lot of what is preached in certain diets that certain people who know better recommend I think is great for the eyes and for the brain.
Cynthia Thurlow: No, that’s really practical and very healthy advice. I got a lot of questions about psychedelics and their impact on vision and the integration between our eyes and our brains. Do you feel comfortable speaking to that? It was just like I had multiple people asking the same questions, so I thought, okay, there’s clearly some interest here and this is not my area of expertise.
Bryce Appelbaum: I’ve been asked a ton about this as well lately, [Cynthia laughs] and I’m going to give an answer that gets us to understand what’s occurring neurologically and then what’s influenced from other exogenous substances. When we are under stress in general, the autonomic nervous system acts like a seesaw between the fight or flight systems. From a vision standpoint, our pupils wide in and we get this tunnel vision under stress where we’re kind of primed to react to what’s around us. That’s intimately related to two different visual processing systems in our brains. One that responds to central focal visual input and one that responds to peripheral ambient input. In a normal healthy brain in the absence of stress, we’re able to see what’s in front of us and what’s around us simultaneously to be able to know where we are located in space, where other things are in relation to us, and to respond appropriately.
But like I mentioned, under stress, when the sympathetic nervous system gets activated, we get this tunnel vision effect where it’s almost like we’re looking to paper towel holders. When that happens, very often you feel lost in space, periphery collapses, depth perception gets limited. If you can understand the reason for that reaction based off of the autonomic imbalance, whether it’s from a head injury or just too much stress in life, we can actually retrain the brain to use those two systems in a healthy synergy, to actively activate periphery, to actively lock in centrally, to be able to have a healthy relationship between both of these. So that, at least from a vision standpoint, we’re able to maintain the functional skills that are needed for the stress-induced environment.
Now, very often, so much of our brain is not even being tapped into and especially from a vision standpoint. Certain substances or supplements can activate certain areas of the brain where at least we know from a training standpoint, we can improve and establish for people who never developed the ability to think in mental pictorial images. The ability to integrate input from multiple sensory systems, the ability to see things from other perspectives, the ability to see a figure as well as ground at the same time to be able to selectively lock in back and forth, to be able to discriminate, to be able to establish memory in sequence or in real time. I think from a from a standpoint of allowing different areas of the brain to communicate more effectively with one another and for different centers to establish neuronal connections that were either not there or we’re now tapping into them or we’re building more robust networks. So much can be done to train the brain from the use of the visual system.
I would say that’s our bread and butter in vision therapy and neurorehabilitation where we’re literally establishing connections that are either severed or weren’t there to begin with or we’re just not tapping into. Even from a head injury standpoint, I’m a big believer that the vision problems that occur from a functional standpoint after a head injury, they don’t go away on their own, you just learn how to bypass them and how to compensate. Unless you’re forcing yourself to tap into those systems in that processing by arranging the conditions appropriately with, let’s say, a vision therapy setup where we’re integrating cognition and balance and movement and vestibular input and all the systems that rely on vision in life, to really raise the level of demand so that we can engage in higher level thinking and use what we have so our eyes, brain, and body can be working more nicely together as a team.
Cynthia Thurlow: I think that’s a really nice explanation. I think that nowadays there has been a resurgence or a degree of popularity for some of these psychedelic medications and I’ve never experienced any of them my own. In talking to clinicians who’ve done Ayahuasca and some of these other modalities, what they’ve been able to do in terms of brain retraining has been pretty incredible. Now, I want to be respectful of your time, but one other question that I got was talking about depth perception. Is this something that people are and I know, as we’ve had this conversation, is this something that when people start struggling with depth perception, whether it’s at night, they have poor vision at night, and this has been the way they’ve been their entire lives. Is this something that we can work on through vision therapy or is this a fixed issue for them?
Bryce Appelbaum: Thank you for bringing this up. I cannot wait to enlighten people in terms of what we now know from clinical practice, from research, from let’s just say medicine, from the current century versus what we knew in the past. There’re two specific vision problems that I’d like to talk about that influence depth perception and then we’ll get into depth perception. The two vision problems, number one, strabismus, which is the medical term for an eye turn and number two, amblyopia, which is the medical term for a lazy eye.
We now have research and literature to support what my profession has known for a very long time that a lazy eye, for instance, the inability for one eye to see small letters. There are certain reasons why that occurs, but that is a two-eyed problem manifesting one side. Unless it’s addressed from a two-eye basis, the progressing improvement that can come from, let’s say, patching, is often minimal.
The old-school methodology was that there’s a good eye and that there’s a bad eye. The good eye we got to cover up and we got to force the bad eye to then have to function. Put aside the emotional toll that can take on a child or the frustration that comes with that or the difficulty to just be in a hallway or function in a classroom standpoint. If we’re looking at it as a lazy eye because of faulty vision development and the eyes not working well together as a team, when you’re covering up an eye, you’re actually preventing the eyes from working altogether as a team. Very often we’ll then see fragile eye coordination manifests after that. Then all of a sudden, there’s an eye turn because the brain literally is not able to use both eyes together.
The most advanced treatment is office-based vision therapy now, where we’re literally teaching the brain how to engage that eye in the presence of the other eye, whether that’s with lenses or filters or prism or virtual reality where we can literally make it. So, the brain has to, let’s say, use detail under two eye conditions with that eye that isn’t seeing as well, but maybe relying on the eye that’s open for more periphery to kind of create the glue to occur.
The eye turn I mentioned strabismus, the medical term for an eye that’s pointing in a different place, very, very often has nothing to do with the eye muscle strength or length. It has to do with coordination and the brain’s ability to use the eyes together as a team, which again is a learned process. All of us who have children early on in life, notice eyes are pointing all over the place. For me, that was terrifying because I see my kids learning how to take in the world and use their eyes. That was very scary even knowing what I know for all three of my kids.
The medical model would suggest, well, if one eye is in or out or up or down, we need to shorten or lengthen one of the extraocular muscles so that it’s easier for the eyes to point to the same place. But again, strabismus and eye turn in 90 plus percentage of the cases has to do with the brain not having learned how to use the eyes together. That’s a symptom of the problem if you can address the underlying problem, which is maybe it has to do with focus and eye conversion synergy, maybe it has to do with a visual midline that shifted. Maybe it has to do with a motor system that’s not developed the way it should be. Very often with an infant who’s developing an eye turn. We can just have the parents bring, come into the room from a different position, position the crib in a room differently, or knock all the furniture down out of a room and having somebody literally try and explore how to use their body in space and have vision guide movement. So much can be influenced in a positive way.
Back to depth perception, depth perception or 3D awareness is something we’re not born with. It requires two-eyed learning. It requires a sweet spot of both eyes to be pointing in the same place for long enough that these new cortical cells in our occipital lobe actually develop and then we tap into those and once they’re there you can often lose the ability to tap into that system, but they’re there and then we have to figure out how to get back to that system. But faulty depth perception or 3D awareness not being what we want it to be. That can show up for a child who can’t catch a ball or somebody who’s hesitant going up and down stairs or terrified to go off a high dive because they don’t know how much space exists there or anxiety driving or on a bridge when you actually can kind of see the periphery and all the water below you, it almost locks you into that central vision there.
The autonomic imbalance that can occur under visual stress, where we go between central and peripheral processing that impacts depth perception. Head injuries impact depth perception. To me that is why we have two eyes to be able to see in depth. That’s why our species is so evolved and why we can do so many more things than other species. We all deserve to see in 3D. We all deserve to have our eyes working together as a team. But so many of us aren’t able to tap into that higher level of visual processing based off of how we’ve adapted to our visual world. There is neuroplasticity at any age, any brain can be taught how to see in depth. If there are two eyes, you need two eyes. But there’re different levels of depth as well. There’s a depth that allows you to really see the pockets of space that exist between leaves or a snowfall that’s really fine tuned.
But then there’s also depth perception that lets how to slow down your car as you’re on a highway and you see something really far away. And so, depth perception can be enhanced, it can be trained and a lot of the athletes we work with who have solid depth perception, we’re teaching them how to react more quickly to visual information or how to slow down the ball, or how to heighten that peripheral awareness so they can really lock in centrally and be in the zone that we all hear about. We actually know what that looks like visually and we know how to get somebody to that place and have control over that system.
So, vision is our dominant sensory system. It’s one that significantly influences life. Again, I’m biased, but depth is something that we all take for granted often until we lose it or something many people are desperately trying to seek out. And finding a doctor board certified in vision therapy is the first step to go. There’s a website called covd.org, which is a website that an organization that board certifies doctors internationally in this type of work with vision therapy. If you check on– go to the website, you can type in an address and it’ll show within a radius of where you’re located. All the doctors that are within 25, 50, 100 miles, whatever the radius is. You definitely want to see somebody who has the letters F-C-O-V-D after their name, which means they’re a Fellow of the College of Optometry in Vision Development, and they’re board certified in Vision Therapy. I would argue the level of care is very different for those that are versus not. If you’re questioning whether there’s depth perception improvements that could be possible, I would say just questioning that probably is a good sign that there is. Don’t let doctors tell you that this can’t be trained or treated or you’re over a certain age because that’s just blatantly not accurate.
Cynthia Thurlow: Well, Dr. Bryce, it has been a pleasure connecting with you today. Please let listeners know how to connect with you, how to hear more about your vision therapy program, which we will put some affiliate links below, but how can people work with you, work with your team?
Bryce Appelbaum: So, my practice is in Bethesda and Annapolis, Maryland. So right outside Washington DC. Practice is appelbaumvision.com on Instagram, I’m @drbryceappelbaum. I have a program that has been out for a few months now getting unbelievable attention called Screen Fit, which is an online vision training program. It’s a wellness program to train and rehabilitate the visual skills and abilities necessary to support the high visual demands of screen usage. It’s designed to relieve a lot of the visual stress from technology that comes.
It takes tired, strained, blurry eyes and helps you develop a clear and more comfortable vision. So that’s screenfit.com. Also, I have concussionclear.com, which is a great website that’s informative just on how head injuries and vision influence one another and ways to work with us, either virtually flying in for intensive programs or even just online programs to help move the ball in a better direction.
Cynthia Thurlow: Wonderful. Well, it’s been such a pleasure connecting with you. I know this will be the first of many conversations.
Bryce Appelbaum: Thank you so much for having me and love what you’re doing and love what you preach to the world and how you’re changing the world from an intermittent fasting standpoint.
Cynthia Thurlow: Thank you.
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