Abstract
Vision is often reduced to the ability to see clearly, but clinical care shows that vision is far more than acuity alone. Skeffington’s Four Circles of Vision offers a functional model for understanding vision as the integration of posture and spatial awareness, binocular coordination, identification, and speech-auditory/language processing. This framework helps explain why a purely mechanical, bottom-up view of vision does not fully address the needs of patients with ADHD, traumatic brain injury, developmental delays, or sensory and emotional challenges. By viewing vision as a dynamic process involving the eyes, body, and brain, clinicians can better understand symptoms and more effectively support visual performance in everyday life.
Why Vision Is More Than 20/20
I used to think vision was simply about seeing clearly. Now I say vision is more than 20/20. But what does that really mean?
When I was working toward my fellowship and becoming board certified in vision development, vision therapy, and vision rehabilitation, I was challenged with a question that really made me stop and think: What is your model of vision? That question forced me to dig deeper and truly define what I meant when I said, “vision is more than 20/20.”
Today, when I explain this to patients and their parents, I describe vision as a dynamic, whole-body process that influences how we move, learn, and interact with our environment. One of my favourite ways to say it is this: we must learn how to coordinate both sides of our body before we can truly learn how to coordinate our eyes!
From a Mechanical Model to a Functional Model of Vision
Early in my training, I understood vision through a structured, mechanical model. At the foundation was a well-balanced refractive correction, followed by accommodative, vergence, and oculomotor skills, and finally visual perceptual abilities at the very top. The idea was straightforward: build from the bottom up, and the system should function properly.
Figure 1 – Traditional Hierarchical Model of Vision: a bottom-up framework placing eye health as the foundation for higher-level visual processing.
While this approach works for some individuals, I quickly found that it did not adequately explain or resolve the symptoms of patients with ADHD, traumatic brain injury, developmental delays, or sensory and emotional challenges. Think of the child who can’t sit still for the Quoit vectogram or muster enough arm strength to hold up a Brock String. It became clear that vision could not be fully understood as a simple hierarchy of splinter skills.
What Is Skeffington’s Four Circles of Vision?
Through further education in behavioural and functional optometry, I was introduced to a model that helped bridge this gap: Skeffington’s Four Circles of Vision, developed in 1963 by Dr. Arthur Skeffington, who is known to many as the father of behavioural optometry. This model emphasizes that vision is not just about the eyes, but rather the integration of multiple systems working together simultaneously. It reframes vision as a coordinated interaction between the body, the eyes, and the brain. The four systems are anti-gravity, centering, identification, and speech-auditory/language.
Figure 2 – Skeffington’s Four Circles of Vision: vision emerges from the integration of anti-gravity, centering, identification, and speech-auditory/language systems.
Anti-Gravity: Spatial Awareness and Visual Stability
The first system is the anti-gravity system, which answers the question, “Where am I in space?” Before the eyes can fixate accurately, the brain must establish spatial orientation through posture, balance, and body awareness, integrating visual, proprioceptive, and vestibular input.
This develops early as infants learn to lift their heads, roll, crawl, and explore, using their body as the reference point for vision. When this system is inefficient or didn’t develop properly as an infant, patients may struggle with balance, spatial awareness, and visual stability.
Centering: Binocular Vision, Eye Teaming, and Depth Perception
Once the brain knows where the body is in space, the next step is locating objects. This is the role of the centering system, answering, “Where is it?” It relies on binocular vision, allowing both eyes to work together for accurate eye teaming and depth perception.
When this system is inefficient, patients may experience double vision, poor depth perception, or difficulty maintaining focus.
Identification: Visual Recognition, Focusing, and Interpretation
The third system, identification, answers the question, “What is it?” It involves sustaining visual clarity, active focusing (accommodation), and the brain’s ability to recognize and interpret what is seen.
This allows us to distinguish letters like b, d, p, and q and the skill of identifying similarities versus differences. This is often the circle that is most challenging in patients with letter reversals or early reading difficulties.
Speech-Auditory/Language: Meaning, Cognition, and Response
The final system is what I believe connects vision to understanding and action. The speech-auditory/language system answers, “What does it mean, and what do I do with it?” It integrates visual input with language and cognition, allowing us to interpret, respond, and interact with our environment.
Whether it’s reading comprehension, following directions, or describing what we see, this system gives vision its purpose. As I often tell patients, “What good is vision if we can’t share it with someone else?”
How the Four Circles of Vision Work Together
When all four systems work together, vision emerges at their intersection. The exciting part for us as optometrists is that we can use lenses, prisms, filters, syntonics, and other tools to influence these systems and ultimately enhance how they integrate and allow vision to function more effectively.
Applying Skeffington’s Model in Vision Therapy and Patient Care
This model has fundamentally changed how I approach patient care. At Miami Vision Therapy, the goal is not just to improve eyesight, but to enhance how the visual system works with the body and brain. Using lenses, prisms, filters, syntonics, computerized tools, and targeted therapy activities, we help patients build awareness and control of their visual system, improving comfort, efficiency, and how they interact with their environment.
Conclusion
I hope this model serves as a helpful framework as you continue working with patients who have binocular vision and visual perceptual challenges. It has truly been a game changer in how I understand and treat my own patients.
For more articles on vision therapy, binocular vision, visual development, and other topics, feel free to visit my blog at: https://www.miamivt.com/blog.html