Dr. Fortenbacher’s Expert Opinion on Vision-Related Learning Problems

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We’re pleased to let you know that the interview that I did with our VHG colleague, Dr. Dan Fortenbacher on Vision-Related Learning Problems (VRLPs), was along the Most Watched items on the heavily trafficked Elsevier Practice Update Eyecare website this week!

That fact is largely due to the succinct manner in which Dr. Fortenbacher distilled the many clinical facets and considerations of VRLPs in his concise overview.  Our featured interview was published in the Expert Opinion section of Practice Update Eyecare on June 22, 2020.

If you already subscribe to the site, you can access the interview here.  Although we strongly encourage you to take advantage of this free service, we are also providing a separate direct access link provided at the courtesy of Elsevier.  For your convenience, here is  the transcript of the interview, which appears in its entirety on the Elsevier Practice Update Eyecare site as well.

Dr. Press: Hello. This is Dr. Leonard Press, Associate Editor for Elsevier’s PracticeUpdate for Eye Care. Today, I’m joined by Dr. Dan Fortenbacher. Dr. Fortenbacher received his Doctor of Optometry from the Michigan College of Optometry at Ferris State University in 1979.

His interest in developmental vision and rehabilitative vision therapy began early in his career, working with helping children who struggled with binocular vision problems and vision-related learning problems. In fact, it is vision-related learning problems that is going to be our topic today.

Dr. Fortenbacher is a Board Certified Fellow of COVD, the College of Optometrists and Vision Development, and lectures extensively on developmental vision, neuro-optometry, and vision therapy. Dr. Fortenbacher is a past-examiner for the International Examination Certification Board of COVD. He has served in several leadership positions on the state and national level.

He served as President of the International COVD in 2007 to 2008 and has developed models of innovation in the delivery of developmental binocular and neuro-optometric vision rehabilitative care.

In addition to his private practice in Grand Rapids and St. Joseph, Michigan, Dr. Fortenbacher is also a clinical professor at the Michigan College of Optometry at Ferris State University and an adjunct faculty position at the Southern College of Optometry, where he is the program supervisor for the WOW Vision Therapy and Rehabilitation Private Practice Residency. Dr. Fortenbacher, thank you for joining us today.

Dr. Fortenbacher: Thank you Dr. Press. It’s a pleasure to be with you.

Dr. Press: You’re welcome. Let’s start off by discussing what exactly do we mean by vision-related learning problems? I know that the American Optometric Association has a clinical practice guideline on the subject, but for those that aren’t familiar with the term, exactly what do we mean by that?

Dr. Fortenbacher: That’s a great question, because when we look at the entire genre of vision conditions, when we separate those out into categories, the first category we often think of is ocular disease. That’s an important aspect for all of our patients, to sort that out and rule out if there is any condition with ocular disease.

Another category falls into the refractive category the need for lenses to address and compensate for refractive error, and that’s important for all of our patients, as well. But in general terms, the majority of the patients that we see that fall into the vision-related learning problems category have healthy eyes and their refractive condition is not influencing that performance problem because they have their visual acuity up to 20/20.

We’re really referring now to a category of vision problems that are influenced by aspects of how well the individual can use their two eyes together: binocular vision; fixate and follow, whether eyes are spot to spot, that’s the ocular motor component; and then the focusing, or accommodative aspects, strength, accuracy and flexibility of accommodation.

Those three sensory motor areas, oftentimes referred to as visual efficiency categories, are the really important elements that have to do with how we can use our eyes to take in information. Then beyond that has to do with how well you can process that information, so visual perceptual abilities, the ability to make sense of what you see, is another important element of being able to read effectively, learn effectively, and then apply that to academic performance.

Then the third aspect has to do with your ability to integrate that with other sensory functions. Eye-hand coordination is one example, fine motor and gross motor skills, and it could fall into also vision and auditory processing or vision and balance skills.

All of these are part of the umbrella of what we’re referring to and very important that we sort that out when we’re working with our patients, and that’s, I think, what we’re going to be talking about today.

Dr. Press: You made an excellent point, that this has nothing to do with visual acuity or eyesight, and the common misconception that 20/20 means perfect vision clearly isn’t relevant to learning. For example, reading, when you read newspaper print, you can do that with 20/50 visual acuity. What types of vision problems, or how can vision problems specifically affect reading or other elements of academic performance?

Dr. Fortenbacher: I think that when we look at the term “vision” as it relates to reading and learning, it’s important to, of course, rule out any ocular disease or any visual acuity problems to begin with. But, as you said, the majority of the kids that we see have 20/20 and the issue isn’t with being able to see small. It’s about being able to see easy, to be able to see with the two eyes together. This is where, in the front end of the evaluation, the doctor really needs to take a thorough history to get an understanding for how the child is having difficulty. Now this could be just from the basics of blurred, double, you see words overlap, you have trouble with eyestrain headaches, or other areas that have to do with performance.

It also can get into—and this is where I would recommend for the viewers to check out the COVD Quality of Life Assessment Questionnaire, which is a 30-point items of categories that could be affecting a child, and they are graded from zero (never) to four (always). The nice thing about that is you get a profile and you can see where those symptoms fall in as to how they could relate to an individual’s performance, and then looking at the visual components of that.

Back to your question of visual acuity. The majority of kids that we see can see 20/20, but what they’re having trouble with is the ease of which they do a task, and usually it’s a near-centered visual task. They can see the small print, but they’re having trouble with using the two eyes together. That extra effort, if it isn’t working for them well enough, they can actually have overlapping images. They can have the strain and effort that it takes to sustain that, so that sustaining that binocular function makes a difference.

If they are fighting hard, they can make it work, but they pay the price usually in headaches and eyestrain, or they give up and then they have poor attention. That’s where you see some of the ADHD-like behaviors. That’s going to affect in the teaming, it can be affecting their focusing, as well as the tracking skills.

Dr. Press: The way you’re describing it—losing place, confusion, letters running into each other, blur, eyestrain—it sounds so intuitive that these would be impediments to reading and learning. Why is it, then, do you think that there is a certain amount of controversy or confusion since it seems relatively straightforward?

Dr. Fortenbacher: That is true. There is plenty of literature, plenty of research to show the connection between these sensory motor areas and reading performance. The difficulty, I think, comes into, where some of the confusion is, is that when the eye health professional, the eye doctor, is looking at that child from an eye disease model and a refractive model, that if you don’t dig just a little deeper into it, you can miss some of these fundamentals of sensory motor function.

Some of the tests that can be done by the optometrist or ophthalmologist are really quite basic just from a standpoint of evaluating the function of these three categories. One basic test is just called the “ near point of convergence test.” The examiner can use something as simple as an ink pen or a pencil. Or they could use a penlight and have the patient wear red-green glasses. But the most basic way to do it is just use a pen or pencil and move it on the z-axis towards the bridge of the patient’s nose and measuring at that point where they see it come apart or double.

What the research shows is the norm is 7 cms, about 2 to 3 inches, so anything beyond that would be indicative of convergence insufficiency condition. There are different gradations of that.

There’s other aspects of binocularity that has to do with your ability to sustain that fusion. That range of fusion is another important aspect. That gets into some of the more comprehensive tests we’re doing. But an examiner could also do this by just using, from their chairside, a prism bar. They could simply hold the target—again, it could be a pen or a pencil—and use this in front of the patient, base-out, and then flip it around and do base-in, and measure that range of fusion. There are norms established as to what would be acceptable at that distance.

Another simple test to do would be to ask the patient to fixate and follow on me and just watch it with their eyes while it moves. This tracking test is important to do that while the patient is observing. You also want to ask some simple questions, like, “Watching the beam or watching the pen, what’s your favorite color? Do you have any pets? What’s your favorite food?” These are some examples of cognitive loading. You’re looking at that performance while you’re adding a distraction, much like what they have to deal with in a classroom setting. A very simple test like that can be done in just a few seconds.

Then, finally, one that’s easy to do is just a prism flipper, a +2.00 or -2.00 flipper, while the target they’re looking at is a 20/30 print, just holding up a Snellen 20/30 and asking them to make it clear, tell you as soon as it’s clear. They should be able to clear that in about 1 to 2 seconds on each set of lenses over about five or six cycles, and that’s another accommodative flexibility test.

Those three areas are not that hard to test and very relevant to the categories that involve vision performance in reading and learning.

Dr. Press: It sounds like one of the main reasons that some of these areas are considered somewhat controversial is that people really aren’t teasing out, or looking at, problems in a way that you’ve suggested with some relatively easy screening tests or chairside tests can be uncovered. Do you think there might be any other reason? Are people reticent to delve deeper into this because they think there isn’t adequate research showing these interrelationships?

Dr. Fortenbacher: I think some of the confusion comes into play when we talk about vision reading when you look at the definition of reading. When we look at children having trouble with reading, we look at this as two general categories: the child who knows the words, but are having trouble reading quickly and understanding what they’re reading, so those are kind of the reading fluency issues versus the child that has a reading disability. Those are children who are significantly below where they should be for their age or grade level, and that is more into a more language base, but still problematic area for that child, sometimes referred to as dyslexia.

But that reading disability versus the reading fluency are two different categories. A lot of times when we talk about vision problems that affect reading, the assumption is if you fix the teaming, tracking, focusing, then suddenly your dyslexic child is going to now be able to read at age level. That’s not the case. They still need academic support. They need educational therapy or some other means to help them come up to speed in those areas.

But your child that has fluency problems, if they’re able to read at age and grade level, but they’re just losing their place due to ocular motor dysfunction, or they’re having trouble with words overlapping or seeing double, a combination of issues, you treat that and they can take right off. These are children that know how to read, but they have the inefficiency in reading due to the visual problem.

Part of the confusion, I think, is in the different areas, whether it be in education or in medicine, is not really understanding what we’re referring to when we say a reading problem. Both categories, a reading disability or reading fluency problems, can have vision problems that influence their performance, but the one that is the most, I would say, challenging are the ones that have the vision problems and dyslexia.

You need to fix or treat the vision problem and then collaborate with education therapists, reading tutors, to help them in their reading performance, and I think that’s where some of the confusion is.

Dr. Press: Perfect. I want to thank you for joining us today Dr. Fortenbacher. You certainly shed good light on what we mean by vision-related learning problems, how to detect them and how to manage them. We look forward to readers learning more about this subject on Elsevier’s PracticeUpdate Eye Care and other sources which we’ve related to. Thank you again, Dr. Fortenbacher.

Dr. Fortenbacher: My pleasure. Thank you, Dr. Press.

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