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.

How 3D Legends Are Made

Please allow me to introduce you to Barry B. Sandrew, Ph.D., and his company, Legend 3D.

Better yet, let me introduce you to Dr. Sandrew’s blog reflecting on the growth of 3D.  A blog like this is so well done that I can do no better than to point you in its direction and get out of the way.  You’ll particularly enjoy the experiences of  “Binocular Bruce” as his stereoscopic 3D vision emerges for the first time while watching the 3D film, Hugo.

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

Monroe “Puggy” Farmer – Part 5 (Final): Thinking Outside the Bag

Tonya is sitting in my office on Friday, as we continue our interview over a lunch break during the SUNY Residents’ Seminar.  As noted on our SCO website link, it’s important for us to discern that the Residency applicant understands the distinction between institutional and private practice residency experiences.

Interviews can be stressful, and I was impressed with the thought that Tonya had given to why she was applying to our Residency program.  Although no one should be as open as the gentleman above, Tonya was refreshingly forthcoming in noting that she had made application to several other private practice residencies, and two institutional residencies.  But what she told me next almost floored me.  She had decided not to interview at one of the institutions, because of that College of Optometry’s response to her inquiry.  In her cover letter she indicated interest in, among other things, vision-based learning problems and how vision influenced behavior and development.  The reply that she got was that she should seriously consider whether this program was a good fit because, essentially, they “don’t believe in that stuff”.

It was almost inconceivable to me that a College of Optometry faculty member would write that to an applicant.  To be fair to that program, I’ve not yet seen it in writing.  But is it possible?  Absolutely, and I found out why over the weekend.  I participate in an online forum regarding dyslexia.  Last night a dyslexia researcher who trivializes the role of vision cited an article in defense of her position.  It was published in Perspectives on Language and Literacy, a quarterly publication of the International Dyslexia Association, Winter edition 2011, co-authored by an optometrist from — you guessed it — the same College of Optometry that told Tonya they wouldn’t be a good fit for her Residency interests.

Here is what that article concluded:

“Given the evidence in this article and other reviews (American Academy of Pediatrics, 2009; Barrett, 2009), children with academic problems should be referred for vision exams using the same criteria as any other child. Visual acuity is critical for supporting reading, and people need to be able to see print sharply, clearly, and comfortably. However, routine screening for ‘vision-related learning problems’ is not warranted and would not be expected to have a major impact on the reading performance of children and adults with well-defined reading disabilities …. The fact that vision therapies (and therapies based on visual information processing) continue to proliferate despite decades of research reflects in part the degree to which parents are desperate to remediate reading problems.”

One might say it’s disappointing to see a College of Optometry faculty member put her name on an article that regurgitates the anti-VT bias of the American Academy of Pediatrics.  Indeed, as Dr. Fortenbacher and I have pointed out, the Section on Ophthalmology of the AAP doesn’t even follow the guidelines of the CITT study that office-based vision therapy is preferable to home based VT.  Nor, by the way, does this College of Optometry offer any office-based vision therapy, but that is a subject for another day.  On this day I will encourage Tonya to continue her vision quest.  Irrespective of where she does her Residency, I am confident that she will travel far on the path that Dr. Monroe “Puggy” Farmer put her on at age 6.  She is already a step ahead of the faculty member at a College of Optometry who dismissed the AOA’s Clinical Practice Guidelines on Care of the Patient with Learning Related Vision Problems out of hand.  She can think outside the bag.

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

 

Sports Vision: Nike Strobe Glasses Featured in SI

Nike SPARQ Sensory Training is featured in the January 9, 2012 issue of Sports Illustrated.  The strobe glasses can be ordered through Bernell, and their site has downloads of some nice video.  They can also be ordered through strobegoggles.com, a site that does a nice job positioning Optometry as the authority in sports vision assessment and has the videos on its site as well.  Interest in sports vision has been building steadily over the past few years, and one suspects this major exposure in Sports Illustrated will give it a major boost.  Dr. Karl Citek, former student and colleague at SUNY now at Pacific, has a pithy PowerPoint on the strobe glasses, and here’s a copy of the research paper from Duke University that he cited.  Here’s a sampling of some of the nice videos out there.

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

A New Year’s Snellen Resolution

We’ve long struggled to effectively communicate the distinction between “sight” and “vision”.  Oh, I don’t mean we’re not effective in creating this distinction. We know how basic this is, and tools such as the great George Page video makes the distinction so obvious.  Obvious to us, that is.  But the public still seems to have a difficult time grasping this.  The past decade of laser surgery to “correct vision” has only served to confound the issue, as marketing wrapped the idea of “perfect vision” as related to seeing 20/20 or better.

So at what point do we decide to accept that the public isn’t getting the message the way we’re sending it?  Those Snellen Charts with the International “NO” symbol around them aren’t deterring the public from conflating sight with vision.  Here’s a typical example from the website Health Central:

To determine how clearly a person can actually see, the Snellen eye chart is used, with rows of letters decreasing in size:

• From a specified distance, usually 20 feet, a person reads the letters using one eye at a time.
• If a person can read down to the small letters on the line marked 20 feet, then vision is 20/20 (normal vision).
• If a person can read only down through the line marked 40 feet, vision is 20/40; that is, from 20 feet the patient can read what someone with normal vision can read from 40 feet.
• If the large letters on the line marked 200 feet cannot be read with the better eye, even with glasses, the patient is considered legally blind.

Heck, even the www (widely worshiped wikipedia) conflates visual acuity, spatial resolution, and “20/20 vision”.  So what do you say?  Is it time, on this first day of January 2012 to drop the charade?  I’m going to make an argument that it is.

Fernette and Brock Eide, two physicians outside of the vision care field who have a greater grasp of what we do in developmental/behavioral optometry than most of their colleagues, put together a great PowerPoint on The Different Ways of Seeing.  Therein lies the best argument for shedding the distinction between eyesight and vision.  There is no verb for vision, at least not in the eye or vision care field.  If you Google Visioning you’ll come up with uses of the verb, but related to strategic thinking and planning.  When we think of vision operating as a verb in the ophthalmic and vision care fields, we’re stuck with some aspect of seeing.

No other sensorimotor modality has this verbiage problem.  In the auditory domain the public seems to have accepted that hearing sharply doesn’t equate to the full range and cognition of the auditory system.  The idea of central auditory processing deficits as distinct from auditory acuity is now widely recognized.  I suspect that is in part owing to ENTs keeping their noses, or at least their ears out of the domain of expertise of audiologists and speech-language pathologists.  This makes it simpler for educators and the public to receive a coherent message.  We have no such unanimity in the “eyecare” field.  So for this year, at least, let’s drop the tired and ineffective distinction between “vision” and “sight”, and go down the auditory path.  There’s hearing, and there’s central auditory processing.  In fact, the auditory field has dropped the central and they simply refer to it now as auditory processing, or the brain part, as distinct from hearing, or the ear part.  Ear is structure, auditory processing is function.

In parallel fashion, there is sight and there is visual processing.  Simple.  Screw the Snellen Chart and 20/20-isms and vision.  It’s as irrelevant as decibels.  Do you hear what I hear?

Robert Lederman Shoots and … Swish!

Special thanks to Robert Lederman for bringing the game “Swish” to our attention.  Just put in an order for several sets, and it looks like a tremendously challenging yet fun way to get at the heart of visual spatial skills through visualization and mental rotation.  It’s a really nice complement to the principles  of visual spatial thinking introduced by Harry Wachs, to visual imagery as introduced by Elliot Forrest and elaborated by John Abbondonza, and visualization as conceptualized by Lynn Hellerstein.

A quick Google search is all you need to remind yourself how much continued interest there is out there on formalized study of  visualization abilities and scientific approaches to visual-spatial rehabilitation/therapy.  But sometimes it’s good to let therapy be fun – particularly with transparent cards like that provide immediate feedback on whether the mental rotation provides a match, and if not to see where the misfit occurs.

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

Understanding Vision and Brain

Wish I could promise you that this piece will provide you with an understanding of how vision is inseparable from the brain, but it’s more of a teaser than a primer.  You may have come across the Vision Sciences Society (VSS) from an essay that I wrote in the JBO about Perceptual Learning, based on experiences that Paul Harris, Sue Barry and I had at a VSS meeting.

To acknowledge the contribution of visual illusions to understanding the top-down influence of the brain on vision, the VSS holds a contest for best  visual illusions of the year.  The winning illusions for the 2011 contest can be found here.

 

 

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

Transplanted Corneas Are A Window To The Soul

You may remember the movie At First Sight, starring Val Kilmer and Mira Sorvino, based on the true story of Virgil, penned by Oliver Sacks.

The Sacks story on Virgil’s bilateral corneal transplants, To See and Not to See, was also published as a clinical vignette in his book, An Anthropologist on Mars.  Here is an excerpt.  It’s a striking and poignant reminder of how vision is a learned process, and the dynamic and inseparable interplay of eyes, brain, and visual pathways.  Virgil’s story was a forerunner of Mike May’s experiences, which I wrote about in the Journal of Behavioral Optometry.

Let’s transition from Oliver Sacks to Mind Hacks, the superb blog from authors Tom Stafford and Vaughan Ball.  Their post today bears the title above.  It lends a fascinating note on the social meaning of eyes and why people are much more reluctant to donate the cornea after death than other bodily organs, citing a recent article from the journal Transplantation.  Here is an excerpt that speaks volumes:

“Medicine and science have long understood the body as a “machine.” This view has fitted with medical notions of transplantation, with donors being a source of biologic “goods.” However, even a cursory glance at the rituals surrounding death makes it apparent that there is more to a dead body than simply its biologic parts; in death, bodies continue as the physical substrate of relationships. Of all the organs, it is the eyes that are identified as the site of sentience, and there is a long tradition of visual primacy and visual symbolism in virtually all aspects of culture.

It therefore seems likely that of all the body parts, it is the eyes that are most central to social relationships. A request to donate the eyes therefore is unlikely to be heard simply in medical terms as a request to donate a “superfluous” body part for the benefit of another. That the eyes are not simply biologic provides one explanation for both the lower rates of corneal donation, compared with that of other organs, and the lack of adequate corneal donation to meet demand.”

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

 

 

 

 

http://visionhelp.wordpress.com/2011/06/02/mind-hacks-and-medical-foibles/

 

 

Optometry Today: Alzheimer’s and Parkinsonism as Neurocognitive Dimunition of Vision

It has been at least two years since Geoff Shayler first contacted me from overseas, and we began exchange about the neurology of vision, vision development, and visual loss.  The lost and found of vision.  I had forgotten how much I enjoyed our exchanges until Geoff posted a reference last night on the VT-DOC list to his marvelous Optometry Today series of articles on the subject.

 

Here is the link to Geoff’s four part series, beginning with an exquisite model that sets the stage.  Enjoy!

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