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......

1. Article
The Van Orden Star: A Window Melvin Kaplan, OD
into Personal Space Celeste M. Lydon, OD
The analysis of spatial behavior is, funda­ tension of the patient's perception of axes and
mentally, a description of the way behavior is planes in external space, as illustrated in
conditioned by internal and external con­ Fig. 2.
straints. Skews of spatial orientation are If the patient's Star drawing shows apices
brought about by visual adaptation to these above or below primary gaze, or the target
two constraints. The Van Orden Star probes midline, he has demonstrated errors in ver­
the way we perceive, and mentally represent, gence (Fig. 3).
the world around us. The Star can give insight Execution of this pattern, while straight­
into how we put this knowledge to work, and forward and simple, requires the individual to
into action. 1 rapidly and accurately interpret what he sees,
In every day life, we see coping patterns generate motor response, and maintain atten­
people have adopted in response to what they tion throughout. The appearance of his star
see and feel. There may be a turned foot, or a pattern is fundamentally a predictor of the pa­
curved back; there may be heightened or less­ tient's spatial behavior. It reveals the way he
ened attention to a task. Coping patterns responds to internal and external constraints.
sometimes generate labels: dyslexic, autistic, It depicts his particular version of homeosta­
emotionally disturbed, brain injured. SIS.
Perceptual far- or near-point activities in­
volve different levels of constraints. How an
INSTRUMENTATION OF THE VAN
individual responds to these constraints is
ORDEN STAR
manifested 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
orICllIIa
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 vi­
sualize 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. Fig. 1.
Volume 33 / Spring 2002 21

2. ,..,. rei.,. Tfl'i_,
• •
• •
• •
• •
• 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, a
3. 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 PATIENT
Scope with the transilluminated back. The
Scope has an adjustable shaft with a Brewster Direct the patient to sit in front of the in­
stereoscope attached. The shaft marks dictate strument and look through the eyepiece. Ask
the visual distance to which the subject will , him, "How many columns of figures do you
att~nd. The standard design of the target, as
see?" If the answer is two, ask, "Can you see
desIgned by Van Orden, is a white translucent both columns at the same time, or do they ap­
paper with two columns of figures, such as a pear one at a time?" If the answer is the
star and a cross. Columns are composed of former, direct the patient to take two same­
eleven 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 pen­
tern, but in addition created a modification for cil point on the center cross of each column­
near, so I might see the patient's 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 at
tern represents a conflict between the visual the same time?" If yes, have him draw simul­
and kinesthetic senses, but near point activity taneous lines , one toward the other, until the
usually creates the greatest stress, the adap­ pencil points look as if they're touching. Next,
tive response illustrated by the patient's star
•
A A • •
• •
• •
• 15'M14 •
B~~~r-----------------~~~~.B + " > +
• •
• •
• •
A • •
• •
Fig. 3. Fig. 5.
22 Journal of Optometric Vision Development

3. .. ..
,., """' ,-',
Instructions to the Patient
Fig. 6.
place the left pencil on the top figure of the left
ganisms may depend more on other sensory
column and the right pencil on the bottom fig­ modes, but in man, the visual sense dominates
ure of the right. As before, the two pencils are our sensory intake.
to be brought toward each other until they ap­ Human behavior is molded and condi­
pear to touch. The procedure is repeated with tioned by temporal and environmental con­
successive 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 individual's 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
Donald's model has had the greatest influence the vertical. For example, idiopathic scoliosis
on my thinking. He divided patients' patterns in teenagers is associated with a visual per­
into 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 we
2. The loosely organized peripheral-central
observe shifts in posture, we can suspect they
relationship
are functional, not structural. Many of us have
3. A mismatch between visual central visual
observed this in traumatic brain injury pa ­
function
tients. Some shuffle their feet, moving at a
4. A visual kinesthetic mismatch.
snail's pace, others walk on their toes, rushing
MacDonald as well as Van Orden both ad­ along to maintain balance.
here to the model that an individual's percep­ The following figures represent the most
tion of space influences his sensory system, frequently seen star patterns. You will see
and thus would influence that individual's many variations, but these are representative
drawing 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 be­
time. Building on clinical experience, I was tween temporal and spatial elements. The in­
able to expand the model beyond the central ­ tegrity of the illustration's planes and axes in­
peripheral concept to include temporal and dicate a maximum balance in personal space.
spatial factors, as well. The human organism Figure 8 denotes constraints, in MacDon­
is, after all, a spatial action system. Other or- ald's terms, of the peripheral-central relation ­
Volume 33 / Spring 2002 23

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 a
peripheral 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 far
axis, 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 periph­
of individual will display behaviors associated
eral-central relationship, which shows up as
with tunnel vision.
disorientation in the apices. These constraints
Figure 9 also represents constraints in the
are functional warps , and they can be seen in
peripheral-central relationship. In this rela­
physical performance as well as in a pencil
tionship, peripheral demands supersede focal.
and paper manifestation. For instance, when
The visible space world is again rotated about
the patient is walking a foot may toe-in rather
the horizontal axes, but here the saggital
than point straight ahead. The star pattern
plane appears further away and apices appear
apices may be clearly formed, but they differ
above the line. This pattern is usually associ­
in linear length. The pattern is rotated about
ated with individuals who have increased near
the vertical axis, a projection of his body image
point activity and visual stress.
that is rotated around the mid-body axis. The
Figure 10 displays constraints in the pe­
subject's perception of his space world makes
ripheral-central relationship that are mani­
the frontal plane closer on the larger apex side
fested 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 has
These patients usually present a peripheral
poorly formed apices. There is no apex on the
bias with no perceptual constancy. There may
left, and the right side forms a fan. There are
be an emotional component to this patient's
many variations of this rendition, with apices
visuo-spatial distortion.
being unequal along the frontal plane, or po­
In a study composed of 60 emotionally dis­
sitioning above or below the midline. These
turbed patients at the Westchester Medical
star patterns are usually produced by indi­
Center 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
+. +
..--~-.::
+
~--+-·B
B +'::::::;:L;4?~----------"1~~~ .:=::::+==
.. ~ ----1r-=
+
A A A
Fig. 8. Fig. 10.
24 Journal of Optometric Vision Development

5. A
+
+
A A
Fig. 13.
Fig. 11.
tern signals a temporal-spatial mismatch, and
USING THE VAN ORDEN STAR TO the individual's behavior will indicate a
ENHANCE 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 pattern
Star can be a tool to recognize spatial behav­ execution will increase. The key is that ther e
iors. The spatially coordinated pattern is, fun­ is a mismatch in the magnitude of frontal
damentally, 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 prob­
vironmental constraints. We know that visual lems organizing hislher space world, and at
thinking operates on a "what" and "where" the same time is unable to orient himlherself
system. For an individual to interact with his in personal space. It is not uncommon for
environment, three questions must be answer­ these people to relate instances of panic be­
able: 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 where
gous with the spatial ambient, or if you prefer, this is all happening in the brain.
the peripheral system; the star pattern can
give useful insight about the patient's "In monkey studies during the late 1990's, 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 he
which both apices are well formed but meet
animals' perception. That discovery buttressed
below the line depicts a problem of binocular a new theory: that the brain constructs con­
coordination. This level of dysfunction has a flicting representations of the scene, and that
relatively mild effect on the patient's sense of representations compete somehow for atten­
well 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 in
fail to meet in a definite apex, there is a more the eye, but rather in the brain. When viewing
severe spatial organization problem. This pat­ the Van Orden Star, we see a representation of
~
•
Fig. 12. Fig. 14.
Volume 33 / Spring 2002 25

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 are
LENS APPLICATION AND THE formed above the line, base down prism is in­
STAR 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 from
lenses for the modification of human behavior. the Star pattern, and the method of lens ap­
I have been prescribing them for individuals plication, goes beyond the balance of central­
with learning differences, emotional difficul­ peripheral function expressed by Van Orden,
ties, and autistic spectrum disorders. In addi­ or the tightlloose organization described by
tion, they have been very instrumental in re­ MacDonald. I do not think it contradicts, but
habilitating 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, started
focal aspect of the lenses that is emphasized. with a course of study at the Gesell Institute
Prism 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 Wolff
single binocular vision. When an image enters who had been using large-magnitude yoked
a 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 lens
are applied in a yoked configuration with bin­ prescriptions about 1972 and have written ar­
ocular prisms oriented in the same direction, ticles describing their use with learning­
they induce spatial reorganization about the difference children.
axes and planes of space. There is then a com­ Byall presented Figure 15 and said, "This
parable shift in organization and orientation is (a common) pattern, and it indicates that
of 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 term
with the Van Orden Star and with Keystone commonly used from strabismus.) He would
skills before coming into the examination prescribe plus for the following reason: he felt
room. These two tests give invaluable insight that the frontal plane of the patient was pos­
into the visual behavior of the patient. Often I tured too close, and was causing stress. Plus
can predict what findings will follow in the would allow the patient to posture further
analytical, which in turn will confirm the pre­ back in space, and gain relief. As I indicated
liminary findings. earlier, to me this pattern reveals internal
The Van Orden Star supplies information constraints that would interfere with spatial
as to the selective field, its organization, and orientation, and the patient would physically
orientation. 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 girl
lected. from Massachusetts turned her foot in as she
Case in point, a 35-year-old adult male walked. She was having reading problems and
worked mainly at near point. He displayed the that was the reason for her coming to my of­
following information on the Keystone: Exo fice. Her Van Orden Star was similar to that of
posture near and far on the lateral muscle bal­ Figure 13, but in her case the right apex was
ance test, full fusion at far on the fusion test, well formed but of greater magnitude than the
but only 50% at near. The Van Orden Star had left apex. I asked her mom, a nurse, "Would
well-formed apices that met below the hori­ you like to see your daughter's feet point
zontal 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 Fig. 15.
26 Journal of Optometric Vision Development

7. straight when she walks?" Her mother, with a CONCLUSIONS
quizzical look of disbelief, said, "Of course." I
Each of us has a personal way of viewing
placed a pair of glasses on the gir l with 2 base­
our environment. A tall person has a different
right 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 environ­
stroke victim with unequal apices along the
ment are orchestrated by temporaVspecial
horizontal 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 individual's 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
Wouldn't it be exciting to have a diagnostic
bases reported improvement when reading.
tool that would give us insight into the per­
Different degrees of constraint cause different
sonal space that governs our patient's perfor­
levels 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 and
performance.
accurately. The revealed patterns of visual be­
MacDonald's model oflens application was
havior are reflections of behavioral patterns
described 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
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