The Truth About Visually-Based Reading Disability (Part 2)

In part 1, I discussed symptoms that occur in a condition for which I have suggested the name “Visually-Based Reading Disability (VBRD).”  In part 2, I will describe some of the likely underlying conditions that may cause VBRD and review some of the relevant scientific literature.  Let’s review some of the most common symptoms in VBRD:

1. Letters/words become blurry or turn double
2. Letters/words seem to float all over the page
3. The page gets “glary” and hurts eyes
4. —Loss of place when reading/ re-reading
5. —There are frequent small word errors (both omissions and substitutions)
6. Words move or shimmer on the page
7. —Can read well when words presented individually, but not when the same words are in a paragraph

Symptoms 1 & 2 are particularly common in”visual input” disorders such as convergence (eye teaming)  and accommodative (focusing) disorders.  These occur when a person cannot maintain or sustain convergence or accommodation for the time needed to perform near tasks such as reading, studying, take notes, or working on a computer.

Recently, some members of the College of Optometrists in Vision Development  embarked on a Tour de Optometry lecture series to inform current optometry students about the exciting specialty area of  developmental optometry.  Two of the slides used (below) give a reasonable simulation of what a patient with convergence and accommodative insufficiency experience.

convergence insufficiency simulation:

accommodative insufficiency simulation:

Convergence insufficiency, in particular, has been extensively researched through National Eye Institute funded multi-center clinical trials.  It has been found to be a treatable both symptomatically and objectively, most efficaciously with office based vision therapy.

Symptoms on the above list #4-7 may be more indicative of a visual processing problem.  Specifically, there are two pathways in the brain that are involved in visual processing during reading.  The magnocellular (M-cell) and parvocellular (P-cell)  pathways.  Here is a brief summary of these pathways as they relate to visual processing.

M-Cell pathway:

• Mainly involved in peripheral vision and sensitive to motion detection
• Responds to high temporal frequency and low spatial frequency
• Responds to reduced illumination
• Saccades during reading activate this pathway.

P-Cell pathway:

• Mainly in central vision and insensitive to motion detection.
• Involved with processing of color information
• More responsive to stationary or slow moving targets
• P-Cells are foveally activated during fixations and extract the details of the text.

Eye movements during reading involve fast eye movements (saccades, M-cell), and pauses to process information (fixations, P-cell). Reading therefore  involves the repetitive alternation of saccades and fixations.  There is good evidence that the M-cell system is impaired in many poor readers.  The role of the visual magnocellular system is probably to mediate steady direction of visual attention and eye fixations on words. Thus many children with reading difficulties have unsteady eye control and this potentially causes the letters they are trying to read to appear to move around  (Stein, 2003).  If this is difficult to imagine, then think of the situation of driving in a car between two cities and hearing two radio stations at once.  You will most likely either change the station or turn off the radio!  This is a good auditory analogy of the type of visual confusion a patient with VBRD probably confronts on a daily basis.  They may “turn off the radio” (stop reading) or feel compelled to read slowly and re-read because of the visual confusion VBRD causes.

In part 3 of “The Truth of Visually-Based Reading Disability” ,  I will discuss diagnostic tests available to us to aid in the diagnosis of VBRD and review our treatment options.

The Truth About Visually-Based Reading Disability (Part 1)

There is a growing body of scientific evidence pointing to the existence of what can best be categorized as “Visually-based Reading Disability” or VBRD. (Visually Based Reading Disability)

What is a VBRD?   It can best be described as a reading disorder where visual signs and symptoms predominate.  Here are some examples:

• Letters/words become blurry or turn double
• Letters/words seem to float all over the page
• —Loss of place when reading/ re-reading
• The page gets “glary” and hurts eyes
• —There are frequent small word errors (both omissions and substitutions)
• Words move or shimmer on the page
• —Can read well when words presented individually, but not when the same words are in a paragraph

Charles Fortenbacher has done a marvelous job depicting what written text might look like for a child with VBRD 

This can be contrasted to the more typical symptoms of a phonologic or “language-based reading disability” whose signs and symptoms include:

• Difficulty learning the alphabet or letter order
• Associating sounds with the letters that represent them
• Identifying or generating rhyming words, or counting syllables
• Segmenting words into individual sounds, or blending sounds
• With word retrieval or naming problems
• Learning to decode written words
• Distinguishing between similar sounds in words; mixing up sounds in   polysyllabic words (auditory discrimination) (for example, “aminal” for   animal, “bisghetti” for spaghetti)

Of course, the possibility exists that a child will have both “visual” and “language” components to their reading disability.

Visually-based reading disability can be insidious in nature, as children who have these visual symptoms often are “good” readers.  They may have good reading comprehension, and their independent reading level is often at grade level, or one to two years behind at most.  But they are often visually uncomfortable, inefficient, and rarely read for pleasure.  Many times they are labeled  ”lazy” or are underachieving compared to their potential.

How can you find out if your child has VBRD?  The best way is through a comprehensive examination by a developmental optometrist.  You can find one through the College of Optometrists in Vision Development Locate a doctor

In part 2, I will discuss some current theories about the underlying basis of visually-based reading disability and what some potential treatment options are.

Don’t Keep Your Eyes on the Ball!

Take a good look at Larry Fitzgerald, the superlative wide received for the Arizona Cardinals.  His eyes aren’t on the ball as he catches it; they’re well above and beyond the ball.

Larry attracted some more national attention last weekend when he caught three TD passes during the early part of the Pro Bowl.  You may recall that we’ve blogged about Larry before, and how is grandfather, the late Dr. Robert Johnson, did vision therapy with him when he was a child.  I went back to listen to the great NPR piece about Larry a few years ago, and was reminded about how Dr. Bob first began to work with his grandson because of learning issues.  So his facility in highly advanced peripheral vision and eye-hand coordination allowing him to survey the field while not having to keep his eye on the ball wasn’t first developed with sports in mind.  It was more of a by-product of helping his eyes work more efficiently with his brain, and the rest of his body, as Dr. Bob explains.

I smile every time I walk down the hallway of my office where we proudly display Larry Fitzgerald’s signed plaque.  It reads:

“Optometric Vision Therapy made a big difference in my life and my career. I was fortunate that my vision problems were caught early in life. Learning-related vision problems can have a serious impact on a child’s education. Don’t wait, take action today!”

- Leonard J. Press, O.D., FCOVD, FAAO

The Concussion Crisis – Part 3: Dr. Ruben Echemendia

Thanks to Dr. Nick Despotidis for bringing the following video to my attention.  It’s a wonderful interview with neuropsychologist Ruben Echemendia, a leading expert in sports-related concussions and head trauma, who discusses what changes are needed to make professional and amateur sports safer and why experts are especially concerned about concussions among youth.  You can download a PDF transcript of the video through the Converstations/PSU website.

And as a bonus, read this article by Hall of Fame former goaltender Ken Dryden, supplied courtesy of Dr. Michael Gallaway.

- Leonard J. Press, O.D., FCOVD, FAAO

What We Learn Before We Are Born

Pop quiz: When does learning begin? Answer: Before we are born.  In this TED talk,  Science writer Annie Murphy Paul reviews new research that shows how much we learn in the womb — from the lilt of our native language to our soon-to-be-favorite foods.

- Leonard J. Press, O.D., FCOVD, FAAO

 

Gray’s Anatomy of the Spalding Variety

The Gray’s Anatomy I grew up with wasn’t the TV show spelled with an “e”.  It was a classic in the field of medicine, an instant classic since Drs. Henry Gray and H.V. Carter published the first edition in 1858.  The graphic detail was exquisite, and it became the benchmark for similar works in atlas form that would follow, such as the brilliant art work of Frank Netter.  But there’s another Gray who made an even greater impression in certain circles, the author and playwright Spalding Gray.

This Gray was equally artistic and brilliant, though in quite a different medium.  An article about him that appeared in the UK in 2004 by Gaby Wood captured the essence of a man whose first name is normally associated with sporting goods.   But it was the shades of gray that he traversed that brought him fame if not fortune, and he came to mind today with the release of a new book that compiles his journals.  There is no doubt as Wood noted that Gray’s monologues charted new territory, somewhere between Jean-Paul Sartre and Jack Benny, his material building to a crescendo like a dry-witted Scheherazade.

Though the new compilation of his journals may appeal to hard-core Gray fans, it was really Gray’s Anatomy that made him so compelling to Optometrists.  In that sparkling work, Gray describes his emerging awareness of distortion in the vision of his left eye.  What he relates sounds like some sort of cellophane maculopathy, though those were the days well before traditional diagnostic methods of treatment strategies were promising.  So Gray embarks on a quest to find some help for his fading vision.  Left to fend for himself, Gray explores a variety of alternatives.  O.D.s in New Jersey immediately recognize Gray’s description of a Candyland-like house in the mold of Howard Finster.  Though the doctor isn’t named, Gray’s description of the practice, with the doctor’s aging mother as the receptionist, his opera-singing brother and other inanimate accoutrements, is unmistakably Ben Lane’s office in Lake Hiawatha, New Jersey.

Though Gray’s description of Lane’s nutritional guidance isn’t flattering, the playwright is prone to exaggeration.  Ben Lane in particular and the Ocular Nutrition Society in general have come a long way since the days of Gray’s Anatomy.  In contrast, Spalding sadly took his own life, plunging himself into the depths of New York’s East River.  His tragic demise was unrelated to his maculopathy, more the outcome of a horrific car accident he suffered in 2001 after which he wasn’t the same.  He consulted with famed neurologist, Oliver Sacks, in the months prior to his suicide, but Spalding Gray was a puzzle who was not meant to be solved.

- Leonard J. Press, O.D., FCOVD, FAAO

The Camaraderie of a COVD Meeting

We’re here in Las Vegas, for the 41st Annual Meeting of the College of Optometrists in Vision Development.  What better way to kick off the week than a poolside cafe gambling joke shared by my good buddy Dr. Irwin Suchoff with Dr. Iz Greenwald, Miriam and me.

A guy walks by a store where there’s a parrot on a perch who chimes up: “Nu, vus machsta yid?”  The guy is amazed that this bird speaks Yiddish, so he promptly offers the storekeeper a hundred dollars for the bird.  He gets the parrot home and can’t wait to train him.  The bird is an eager student, and learns the Jewish prayers.  Turns out he has a beautiful voice, and learns how to do the entire liturgy not only in Yiddish, but in Hebrew!.  The guy goes to his synagogue to boast about his bird to the Rabbi, and requests that permission be granted to his parrot to lead the Congregation in prayers for Rosh Hashana.

The Rabbi deems this a most unusual request and denies it, considering it to be sacrilegious.  The man pleads with the Rabbi, knowing how beautiful and special the service will be because of the bird’s skills, and asks he him if he can’t make a special appeal to the Board to vote on this request.  The Board convenes and they doubt the veracity of the congergant’s claims.  Impossible!  Presposterous!  They begin to bet over whether or not this is possible.  The first board member bets a hundred dollars that the bird can’t do it, and the bidding quickly escalates.  Finally the Board forms a pool, betting the congregant four thousand dollars that the bird can’t lead services.  The man takes the bet, and comes Rosh Hashanah the congregation is hushed as the bird dons his talis, the holy prayer shawl.

There is silence.  The bird doesn’t make a peep.  The guy urges him on.  Come on!  I know you can do it!  B’rosh ha-sha-nah …”  But the bird remains silent.  The Rabbi loses his patience and motions the designated cantor to the podium, sending the parrot and the congregant packing.  The man looks at the parrot in disbelief and yells: ‘What was that?!?!?  I know you can do it!  Don’t you realize you just cost me four thousand dollars?!?!?

To which the parrot replies: “Shut up.  Do you realize what odds we’re going to get on Yom Kippur?

- Leonard J. Press, O.D.,  FCOVD, FAAO

Oliver Sacks Magnificent at AMNH Tonight

Just got back from Oliver Sacks’s lecture at the American Museum of Natural History tonight.  It was a packed house at 77th and Columbus, and Oliver did not disappoint.  First of all, I have to tell you that this is the first time we attended a lecture of this nature in the Museum’s auditorium, and it is drop dead gorgeous with great acoustics.

Oliver began with brief personal background, but I daresay that everyone in attendance was already well aware of his resume.  He quickly got into the substance of The Mind’s Eye.  He noted at the outset that it’s generally not a good idea for a doctor to take on friends as patients, but it’s very rewarding for doctors to become friends with patients that they care for.  This is a particularly luxury that a celebrated neurologist has, who takes on a limited number of patients.  Yet Sacks was clear that he never accepts seeing a patient with the idea that they are going to going to become an interesting case study to write about.

I was particularly pleased that Oliver spent a significant portion of his talk on the experiences of  Stereo Sue.  As many times as we’ve been exposed to Sue Barry’s story, it’s still a joy to think of the significance of the collaboration that she first undertook with her developmental optometrist, Dr. Theresa Ruggiero, and subsequently with Dr. Oliver Sacks.

Wish I had known that there was going to be a live steam of the video tonight, but I can tell you now that the AMNH is going to put the video on its YouTube channel later this week.  I’ll give you a heads-up on that when that’s posted.  Bottom line is that Oliver was clear that the key to Sue’s outcome was that she saw a behavioral optometrist, and that her experience was so compelling that they agreed that there must be thousands of other people out there like her who should be given the option of undertaking vision therapy.

Oliver was struggling with his vision (he shared with the audience that he is now totally blind in his right eye), his hearing, and his gait, but his mind is as sharp as ever and his message remains a strong counterbalance to misinformation about vision therapy.

- Leonard J. Press, O.D., FCOVD, FAAO

When a Binocular Problem is Two Obvious

I’ll be holding a conference later today with a young adult patient to review his findings from last week.  Here’s how he reasoned the source of his problem.  About four years ago Earl noticed that he was beginning to experience nausea when riding as a passenger in a car.  He has managed this by making sure that he is always the driver.  But about a year ago he began to have the sensation that both eyes weren’t working right together, the experience being worse with his contacts than glasses.    Earl asked his optometrist about this, who couldn’t  find anything wrong.  He tweaked his contact lens Rx (-5.75 Focus Dailies) but had no other suggestions.  He then decided to try an ophthalmologist, and she tweaked his Rx as well, but became annoyed when Earl said: “You know, when I cover the right eye everything’s fine; when I cover the left eye everything’s fine.  It’s only when both eyes are open together that things don’t feel right.”  The ophthalmologist reassured Earl nothing was wrong, and advised him to move on.

Well long story short, Earl has significant convergence insufficiency.  You can see it easily on his Keystone Visual Skills profile, with normal distance findings as compared to high exophoria and exo diplopia at near.  There are other clues that you would get from the diagnostic evaluation if you looked for it.  Sure enough, patients with Earl’s amount of myopia and CI have a significantly greater demand on convergence and accommodation with contact lenses as compared to glasses.   So if you listen to Earl, and respect what he’s telling you, he has virtually diagnosed his own binocular problem.  Perhaps his problem was “two obvious” to be revealed by the fact that he was very comfortable monocularly, and only felt out of sync binocualrly. and that this was exacerbated when he wore contacts as opposed to glasses.

- Leonard J. Press, O.D., FCOVD, FAAO

Sarah’s Vision Therapy Story

Dr. Carl Hillier was kind enough to share a booklet created by one of his many successful vision therapy patients.   The booklet was so cute and well done that I asked Dr. Hillier if we could post it on our visionhelp blog.  So here is Sarah’s work:  What is Vision Therapy and How can it help me?  The snapshots are followed by a link to the PDF of the booklet.  My screen shots came out a bit dark, so in case you have trouble accessing the PDF, here’s the text:

Vision therapy is something that makes your eyes work together better.  The doctors work to make your eyes focus by doing exercises with your eyes.  There are some machines that make your eyes work together.  My favorite one has letters on a big board and whatever letter lights up I have to press and I can go up to 151 letters!  When I started I was only at 101 letters.  I have made alot of progress.  That’s why I’m glad I did vision therapy.

Vision therapy can also help you with stuff like focusing at school and finishing homework faster and easier.  I have been doing so much better in school and I think it is because of vision therapy.  So I am so happy!

There is work that you have to do at home.  It is kind of like homework, but more fun.  I loved doing the hanging ball from the ceiling.  You hit the ball with different body parts.  My favorite level is the second to last one.  It is where you lay on the floor and you cover one eye, the ball spins and you have to follow it with your finger.

The people that I work with at Vision Therapy are Dr. Hilliar, Christy, Brenda, Linda, and Mr. Jim.  My family is very supportive too!  They get excited for me when I improve and it makes me feel happy!  I hope this happens for you too!

Sarah Zappelli’s Vision Therapy Story

 

 

- Leonard J. Press, O.D., FCOVD, FAAO