The research is abundant and the evidence is clear…visual efficiency problems impact reading and learning. In addition to good visual acuity (eye sight), the American Optometric Association (AOA) defines visual efficiency problems as dysfunctions of visual skills involving binocular vision (eye teaming), accommodation (eye focusing) and/or oculomotor (eye tracking) abilities as well as eye hand coordination and visual perception. The AOA defines these visual skills needed for school success. Problems associated with these areas are usually developmental delays or associated with a neurological event, such as a concussion or traumatic brain injury and can be effectively treated with office-based vision therapy.
For over 10 years it has been my honor and privilege, as an Adjunct Clinical Professor at Michigan’s College of Optometry at Ferris State University (MCO), to present to the 3rd year optometry students on developmental vision and rehabilitation. With the gracious permission of Dr. Mark Swan, Professor of Pediatrics and Developmental Vision at MCO, on October 26, 2018, it was my pleasure to lecture along with my 2 residents, Dr. Jamie Jacobs and Dr. Kelsey Starman in Dr. Swan’s Developmental Vision Course.
Our lecture was entitled: Vision Problems that Impact Reading and Learning. The emphasis in our lecture was to go beyond the academics of these complex issues and provide a level of appreciation for the important role the doctor has of integrating the science and art of vision therapy/rehabilitation in a private practice to obtain the best outcomes for patients.
Our lecture involved 3 cases reports of patients treated by the doctors and vision therapists in our practices. Included were the “before” and “after” visual clinical findings as well as reading performance on a variety of standardized reading tests. In addition, each case report included three separate published papers in peer reviewed journals citing the connection between visual efficiency problems and/or the proven results of office-based vision therapy on treating visual efficiency problems involving binocular vision dysfunction, accommodative dysfunction and/or oculomotor dysfunction.
Therefore, in this lecture we presented not just 1 research paper but 9 research papers from around the world that shows the connection between visual efficiency problems and reading/learning problems.
As parents we all want the best for our children and when they struggle to read, learn or grow academically there can be frustration and worry about what to do to find help.
Since vision is the dominant sensory system through which we read, learn and grow academically, vision care professionals need to be involved to identify any problems involving the eyes and vision and remediate and prevent the struggle that occurs when poorly developed vision or a neurological event, such as a concussion, interferes with learning.
However, reading and learning problems can be multifactorial and therefore, when a child is having academic struggles it is important to consider that for many, a professional “team approach,” working together for the common good of the patient, will help ensure the best opportunity for learning. A partnership is developed between the parents and these professionals.
Help for parents to learn more about the symptoms and behaviors that may indicate a learning related visual problems…and what can be done
Help for professional partners to learn more about well-designed screening protocols and research studies that will help integrate children with learning related visual problems into their clinical practice
Help for vision care providers to gain immediate access to the evidence based, best practice protocols for evaluating children and adults to ensure that they are prepared for optimal learning
What do the Winter Olympic Games have in common with vision-based reading and learning research?
The Winter Olympics brings together the finest athletes from around the globe to compete and show the world how there can be a universal interest in Winter sports and desire to be the best. While you may never have tried to do figure skating or snowboarding the half pipe, when you watch the performance of the these premier athletes in the Winter Games you begin to appreciate the magnitude and complexity of what they are doing, and it touches your mind and heart.
The visual system plays a direct role in the magnitude and complexity of individual performance abilities in every aspect of life. For the Olympic athlete, having good visual efficiency, using both eyes to team, good depth perception, tracking, focus, visual processing and visual motor integration skills are all needed to have peak performance.
But, what about when it comes to the proficiency of a child’s abilities in the day-to-day act of reading and learning? Indeed clarity of sight is important, but there are many visual problems that affects a child’s ability in reading and learning that may not be easily recognizable by just correcting a refractive condition with glasses. For example, vision problems that affect binocular vision (eye teaming) and accommodation (eye focusing) are critical to reading and learning even with 20/20 eye sight. But, some may ask, “Where is the research?”
Awareness for visual efficiency problems, such as Convergence Insufficiency (CI) and its impact on reading and learning, has been reaching the research international stage coming in from around the globe including Canada, India and South Korea, to name a few.
Here are a few examples of the latest in the “Research Olympics” on Vision and Learning:
Published in the Journal of Optometry, September 2017, entitled:Visual and binocular status in elementary school children with a reading problem, concluded: “The results in this study show that children with an IEP for reading also present with abnormal binocular and/or accommodative test results. To thoroughly investigate the binocular vision system, we recommend that tests of accommodation, binocular vision, and oculomotor function should be performed on all children, especially those with identified reading problems.”
The United States has been the leader in vision therapy research for vision and learning problems thanks to the tireless efforts by the Convergence Insufficiency Treatment Trial (CITT)“Olympic Team”. Over the last 2 decades the US (CITT) Team has lead this research and published papers that have been voluminous showing that accommodative vergence problems, such as Convergence Insufficiency and Accommodative Disorder can have a major impact on near visual performance such as reading and attention.
While, like the Olympics, research is complicated and technical, thanks to the dedication of these “Olympic Research Teams” from around the world, what we know now should touch our minds and our hearts. Vision related reading and learning problems do exist in every country and there is effective treatment with vision therapy. No longer should children who struggle with reading and learning problems be overlooked from having a binocular/accommodative or other visual problems.The research is clear, but the bigger question is how will we respond to end this senseless struggle for those with vision-based reading and learning problems?
Wouldn’t it only make sense for any child who struggles in reading or learning to have of a comprehensive eye and vision evaluation because, if a visual problem exists, effective vision therapy treatment could be a game changer in that child’s life!
When a child struggles to read it can be very frustrating, not just for the child but for the parents and the teachers. No parent wants to see their child having trouble with something as important as reading. The same is true for teachers. In many school systems, teachers are now expected to have their students reach certain reading standards and if they don’t, that child may be faced with repeating a grade level.
Meet Wendy Rosen, a former classroom teacher and educational consultant and author of the new book: The Hidden Link Between Vision and Learning, Why Millions of Learning Disabled Children are Misdiagnosed. In this 6 minute VisionHelp interview, which premiered at the 2017 COVD Annual Meeting, Wendy gives an explanation for why so many children struggle with vision-based learning problems and how to find help they need.
Last week I witnessed the astonished look on a father’s face when his 7 year old little girl (we’ll call Jenny) struggled with some routine chair-side vision tests. His surprise was not during the measurement of her ability to read the eye chart. She read the 20/20 line of letters like a pro. But, when I asked Jenny to visually look at and follow a moving bead on a stick, Jenny responded as if she couldn’t or wouldn’t do it. Observing his daughter’s seeming lack of compliance, Dad began to go into a coaching mode. “Jenny, look at the bead!” , he repeated as I moved it very slowly in front of her face. Then in almost a sense of exasperation he said, “Come on, Jenny, you have to do your best for the doctor”, as if this was a routine personal frustration he had for his 7 year old daughter. Jenny’s face just grimaced as if this was almost a painful process.
So I stopped the visual tracking test and gave Jenny a break. Then I asked her to put on some red/green anaglyph glasses. Sometimes kids call them the 3-D glasses. I asked her to look at a penlight that I positioned about 3 feet in front of her face. Then I brought the light in toward her nose and asked her to tell me when she saw it go double. Jenny reported double at about 14 inches. I repeated the test 2 more times and she consistently reported the light separating into 2 lights further and further away from her face. When her Dad saw this, he thought Jenny was simply “playing around” and said, “Jenny, this is important, you have to try harder!” So, I removed the red/green glasses from Jenny and asked Dad to put them on. I did the same test on him, except he saw the light remain single up to about 2-3 inches from his nose. Now he was starting to get it!
Jenny’s parents situation is not unusual because every family has their own unique side to the story when unaddressed vision problems cause reading and learning problems. It usually begins with a child who is bright and yet struggles in school. In this case their almost 8 yr old daughter, Jenny was having a difficult time reading. She even had extra tutorial support and attention at school. But, her parents were prepared to retain her in the first grade, even though her teachers said Jenny was capable of “just barely” reading 2nd grade material and suggested that she be promoted to 2nd grade. However, while Jenny could read single words at a time, what she struggled with was reading them in a sentence, losing her place and slow to do her work. Her parents felt a bit remorseful of having to make a decision to retain her in 1st grade because Jenny was good in math and was mature enough to handle the transition to 2nd grade. But, because of the reading discrepancy Jenny’s parents thought they should retain her in 1st grade, while on the other hand they were worried that she would get bored and grow to dislike school and feel the emotional sense of failing when her peers were moving forward. They were visibly torn!
Fortunately for Jenny, one of the teachers helping to tutor her, spotted some of the hallmark signs of a visual tracking problem and made the referral to our office. At first, Jenny’s dad was convinced that his daughter couldn’t have a vision problem because she had passed the school eye sight test and the pediatricians vision screening. But, he and his wife wanted to make sure so they made the appointment.
I met with Jenny’s parents outlined a treatment plan of twice a week office-based optometric vision therapy and within 4-5 months I expect Jenny will be visually fully functional and able to apply herself in the classroom. Jenny got started last week in treatment, and because we were able to clearly identify a discernible visual problem that can be completely remediated with the proper evidenced-based treatment in a relatively short period of time, Jenny’s parents decided to place her forward into 2nd grade.
If you are like so many who are searching for answers, this story about Jenny helps to give some insight. However, it is probably safe to say that you have questions about how a child, possibly your own child can pass the school or pediatrician vision screening, reportably have normal sight (20/20) and yet have vision problems that cause significant problems in school, such as reading!? Yes, while Dr. Press and I have written about this extensively on the VisionHelp Blog, sometimes it’s better to hear about it from a parent who has been through it before.
With that thought in mind, here is a video of a mother, Michelle, whose son Dimitre had his crossed-eye surgically aligned, did occlusion therapy and had 20/20 visual acuity, but still had serious vision problems that blocked his abilities to read, learn, ride his bike and even make friends. Take a look and see if this helps explain why 20/20 sight is simply not good enough to define vision readiness for reading and learning in the classroom…
For more Facts about vision problems that affect reading and learning, here are some helpful sources:
A nephrologist by training with a master’s degree in clinical epidemiology, Dr. F. Perry Wilson writes a weekly piece for Medscape called Impact Factor. An associate professor at Yale School of Medicine, Dr. Wilson is director of the Yale Clinical and Translational Research Accelerator, dedicated to the process of applying discoveries generated in the laboratory and in preclinical experiments to the development of clinical studies and the design of clinical trials. You can get a taste for his perspective from this piece he did on Kids and Screens:
I “discovered” Dr. Wilson through his new book, How Medicine Works and When It Doesn’t: Learning Who to Trust to Get and Stay Healthy. I highly recommend Dr. Wilson’s book, which has the feel of an insider’s look at a cross-section of issues that comprise the guts of Medicine these days. By it’s cover, you might think that the book is about medicine with a lower case “m”, as in medication or pharmacology, but it is really about the totality of the practice of Medicine, with a capital “M”. I loved the book right from the get-go. So let’s delve into it, shall we?
On the first page of the Introduction, Dr. Wilson writes: “Doctors are often a bit trepidatious about meeting a patient for the first time … I usually take a beat before I open the door, a quick moment to forget my research lab, my paperwork, a conversation with a coworker, to turn my focus to you, the patient, waiting in that room. It is my hope standing just on the other side of an inch of wood, that you and I will form a bond, or, more aptly, a ‘therapeutic alliance’ … But that alliance doesn’t come easily. And lately, it has been harder to forge than ever … Eleven seconds. That’s how long the typical doctor waits before interrupting a patient.” Regarding the therapeutic alliance, Dr. Wilson offers a number of valuable lessons:
Lesson #1: Give the patient ample time to talk, while you engage in attentive listening. However, one of the most important skills a doctor has, as Dr. Wilson puts it, is to “read the room”. By that he means gauging whether the patient is with you, as you continue the process of putting together data and information with the clinical presentation in front of you. Because in the case that Dr. Wilson cites the patient had been to many doctors before without resolution to her problems, he said: “Listen, not everything is super clear-cut in Medicine. I think part of this might be a manifestation of depression. It’s really common. Maybe we should try treating that and seeing if your energy improves”. Right then he knew he lost her. From her facial expression. From her silence. Reading the room he sensed that that there would be no therapeutic alliance, driving the patient away from both himself, and from conventional medicine. Which leads Dr. Wilson to his next lesson.
Lesson #2: The most powerful force in Medicine is trust. Medicine does a phenomenal job for many patients, but also fails others who feel abandoned, ignored by the system, or overwhelmed by medical information. Dr. Wilson writes, regarding the case above: “That personal failure was a failure of Medicine writ large – our failure to connect with patients, to empathize, to believe that their ailment is real and profound, and to honesty explain how medical science works and succeeds, and why it sometimes doesn’t. We doctors have failed to create an environment of trust, and into that vacuum others have stepped.”
Lesson #3: Patients crave certainty as much as they value honesty. Dr Wilson writes: “Health is never clear-cut; nothing is 100 percent effective. Anyone who tells you otherwise is selling something … Traditional doctors like me are trained early on to hedge their bets. Patients hate this. Ask a doctor if the medication you are being prescribed will work, and they will say something like ‘For most people it is quite effective’ or ‘I think there is a good chance’ or (my personal pet peeve) ‘I don’t have a crystal ball’. This doctorly ambivalence is borne out of long experience. We all have patients who do well, and we all have patients who do badly. We don’t want to lie to you. We’re doing the best we can. And, look, I know that this is frustrating … Physicians, if they are being honest, will admit that their best advice is still a guess.”
Lesson #4: It is not wrong to be skeptical about Medicine, but it is wrong to be cynical. Dr. Wilson writes that doctors are not perfect. They stand in the midst of a torrent of information that would have been inconceivable thirty years ago. Some of that information is good and reliable, and some of it is bad or at least questionable. But, as he phrases it, “all of it is colored by our own biases and preconceptions”.
Lesson #5: Anecdotes should not form the primary basis of a medical decision, but they are not without value. As one who is steeped in research and epidemiology as much as he is in patient care, Dr. Wilson emphasizes that while anecdotal evidence may not have the cachet of hard data gleaned from research design, it can still be value. Furthermore, social media amplifies anecdotes far more efficiently than dry old data sets, and excels in getting information to patients. It is time to drop the pejoratives on both sides of the divide.
Lesson #6: The word “doctor” comes from the Latin docere – to teach. Dr. Wilson writes: “We are supposed to be teachers, helping our patients learn how to best care for themselves”. But sometimes doctors don’t live up to their own expectations. They are not what they want to be. They are not what others need them to be. They are mortal, and they are simply what they are.
Lesson #7: Motivated reasoning in Medicine influences the perceptions of both doctors and patients. We all begin with underlying beliefs, and refuting that in the face of evidence requires considerable cognitive effort to change. Patients tend to doubt diagnoses that they don’t want to be true, and seek out opinions and data that leads to the conclusion they wish to be true. Dr. Wilson writes: “Instead of examining facts and reaching conclusions, we reach a conclusion and go on the search for facts. The public is not alone in this. Doctors do it too. And you need to know how to recognize it when they do.”
Lesson #8: Most doctors have three main drives when it comes to patient care. It may either knock you for a loop, or bring a smile of recognition to your face, when you read what those three drives are that Dr. Wilson highlights. They are:
To make people better
To not make people worse
To avoid needing to deal with the insurance company
Lesson #9: Doctors should be better able to avoid cherry-picking studies to support their personal preferences. Dr. Wilson writes: “Bring others into your circle, share the facts with them, and then (and this is the hard part) listen to what they say, even if their conclusions don’t agree with your. Especially if their conclusions don’t agree with yours.” We’ve all encountered this with so-called “Policy Statements” issued by Medicine that discount or dismiss alternative studies, opinions, or approaches.
Lesson #10: Metacognition can be tiring, and introspection is hard work, but they are critical functions. Dr. Wilson writes: “When we make a decision, we need to ask ourselves why we made it. And we need to be honest about the answer. Was it really a rational appraisal of the facts at hand, or maybe just maybe, could it be that you used the facts to justify the decision you were going to make anyway?”
Perhaps we might sum this all up by highlighting phraseology contained in the Hippocratic Oath:
Nicholas Kristof was the first journalist to blog for the New York Times, and the two time Pulitzer Prize winner left the newspaper last year with plans to run for Governor of his home state Oregon. But alas the Supreme Court had other ideas, and when it ruled him ineligible due to failure to meet residency requirements, he returned to the newspaper to pick up where he left off. Just in the nick of time, as far as we’re concerned to write an excellent Opinion column that appeared in today’s print edition of the Times titled “A Time for Gifts of Meaning“. You’ll need to sign up to be able to read the column, so I’ll give you the gist of it.
In announcing their selection as a Kristof Holiday Impact Prize winner this year, The Vision To Learn website notes:
“Most children in low-income communities across the country – urban and rural – do not have the glasses they need to see the board, read a book, or participate in class. Vision To Learn is working to ensure that all kids have the glasses they need to succeed in school and in life.
Vision To Learn provides vision screenings, eye exams and glasses to every child who needs them, all free of charge to the child and their family. The organization has helped more than two million of the nation’s hardest-to-reach children in more than 750 low-income communities across the country. About 85 percent are Black and Latino children and more than 90 percent are from families who live in poverty.
Research shows that students who are provided with the glasses they need do better in school and have better life outcomes. Your contribution to Vision To Learn will help provide more children with vision screenings, eye exams and glasses, which will give them the opportunity to learn, grow and succeed.”
Here is a one minute video clip acknowledging the service delivery model:
And here is a 2:27 video made several years ago as a “proof of concept” stating the need:
Here is an excerpt rom Nicholas Kristof’s description in today’s column:
“Austin Beutner, a businessman who for a time was superintendent of the Los Angeles schools, founded Vision to Learn because he saw that when children can’t easily see the board, they become fidgety and then are labeled disruptive or slow learners. Unable to read well, they struggle in school and are more likely to drop out … Vision to Learn’s model addresses real world problems. Researchers have repeatedly found that many kids who fail school screenings never actually get glasses. Even vouchers for free glasses are often not redeemed. Or kids break their glasses or hide them because they think glasses are for nerds … A published study found that when Vision to Learn provided glasses to low-achieving students in Baltimore, the impact on learning was slightly greater than from tutoring and significantly greater than from longer school or new technologies.”
Those are three noteworthy elements, so let’s focus on them a bit more:
Kids who fail vision screenings, particularly in low income areas, typically don’t go for follow up examinations. Either access remains a problem, as suggested in this JAMA Health Forum viewpoint earlier this year, or it simply isn’t made a priority with everything else going on in the family and child’s life.
Kids breaking, losing, or hiding their glasses because they think glasses are for nerds. This is a real problem in certain communities and cultures, where children succumb to peer pressure to “look cool”. They essentially sabotage their own success, and the idea of bringing in role model athletes to make it cool may be helpful.
Glasses that aid visual function can be as, if not more effective than tutoring. The study referred to in Baltimore may sound vaguely familiar. If so it is because we referenced the origin of it here 8 years ago, so permit me to elaborate.
In that blog, I embedded a special report from Wilmer Eye Institute at Johns Hopkins University in Baltimore. It described the planning of a pioneering study:
“The crushing disadvantages of poverty are many and profound. The last burden any impoverished child needs is the inability to read well. And yet, for as many as eight in 10 elementary school students who live in pockets of poverty across the U.S., reading is a tremendous challenge. Exactly why remains a mystery. ‘We don’t know if these kids have a fundamental reading problem, such as dyslexia, or whether there is something more basic at play in the form of eye and vision problems—problems that we might correct with early eye screening and intervention, says Michael Repka, M.D., M.B.A., the David L. Guyton, M.D., and Feduniak Family Professor of Ophthalmology and chief of the Division of Pediatric Ophthalmology and Adult Strabismus at the Wilmer Eye Institute. Toward that goal, Repka is one of three co-directors on a multidisciplinary team of researchers from Wilmer and the Johns Hopkins School of Education who have commenced a first-of-its-kind study in Baltimore City schools.
The study will not only search for answers to these vexing questions, but it will also seek solutions to them. The team hypothesizes that vision problems, including refraction difficulties, eye misalignment, magnification problems, etc.—not a fundamental inability to read—are at the heart of reading deficits for at least some of the struggling readers in low-income communities. These challenges are relatively easy to overcome. The hope is that in doing so, reading scores will improve. ‘We know that kids who fall behind in reading are less likely to succeed in life, but there has never been a study that separates the kids who can’t read from the kids who are struggling to see clearly,” says David Friedman, M.D., Ph.D., M.P.H., director of the Dana Center for Preventive Ophthalmology, the Alfred Sommer Professor of Ophthalmology and one of the study’s co-directors. Friedman and Repka are world-renowned vision specialists with expertise in public health as well as clinical research and care. Their collaborator is Robert Slavin, Ph.D., director of the Johns Hopkins School of Education’s Center for Research and Reform in Education.”
Vision to Learn turned out to be the philanthropic venture that provided screenings, examinations, and glasses to that population of students in Baltimore, and their findings were published last year in JAMA Ophthalmology. Of note in the methodology: “A mobile eye clinic from Vision To Learn, a project partner, visited each school. Eye examinations were conducted by licensed optometrists after parents provided consent. Students who needed eyeglasses selected frames at the examination. Eyeglasses were manufactured by Warby Parker and dispensed to students at school approximately 2 to 4 weeks after the examination. Students were provided replacement eyeglasses as needed within 1 year of their prescription. The costs of the eyeglasses were covered by the program. Vision for Baltimore staff provided implementation support to schools throughout the study.”
The published study notes that the gains made during the first year were not sustained in the second year. Specifically, “At 2 years, a positive intervention impact was observed on i-Ready reading scores (ES, 0.08; P = .23) and mathematics scores (ES, 0.08; P = .20); however, these were not statistically significant. No impact was seen on PARCC reading scores (ES, −0.04; P = .46) or mathematics scores (ES, 0.00; P = .95)”. The theory advanced is that the glasses were not replaced in the second year if they were scratched, broken, or lost, and hence the visual problems underlying the academic difficulties likely recurred.
In their press release last September on the study, Johns Hopkins University highlighted in its subtitle: “Three-year clinical study is the most robust analysis to date linking access to eyeglasses with higher test scores, especially for students having the most trouble in school”.
The Hilton DoubleTree Hotel in Grand Rapids, Michigan was the location for the Annual Michigan Vision Therapy Study Group (MVTSG) Meeting – January 28-29, 2022. With a focus on one of the most critical areas of Developmental Vision and Rehabilitation, the theme for this year’s Conference was Vision and Learning.
The quality and depth of the presentations were exceptional with our presenters coming to us from around the State of Michigan, the US and Internationally. Setting the stage for the meeting was a comprehensive presentation by Dr. David Cook, on the topic of creating effective treatment protocols for vision problems that affect learning based on the developmental models of pioneer, Dr. A.M. Skeffington. Dr. Neil Renaud presented on understanding and communicating common mental health disorders that can be triggered by developmental vision problems associated with struggles in learning. There were examples involving conditions of ADHD, anxiety and depression, but with proper treatment how these conditions could be helped and often remediated. Dr. Mohamed Moussa and Dr. Issac presented on how virtual learning and excessive screen time is associated with a variety of vision problems including progressive myopia and binocular and accommodative dysfunction that also lead to poor attention and reading and learning problems and more. Dr. Abeer Ahemd and Kadija Daw presented an extensive and dynamic model of vision therapy activities to improve the visual readiness and transfer to Math skill development. Dr. Steve Ingersoll presented a fascinating “top-down” approach to visual processing and reading and learning. Dr. Steve Curtis presented a “bottom-up” model for accelerating fundamental visual readiness that involved a multisensory integration model. Presenting Case Reports were resident doctors from Michigan’s College of Optometry at Ferris State University, Dr. Sophia Capo and from the Illinois College of Optometry, Dr. Jeress Pendleton and Dr. Kelsey Trast, on challenging patients they’ve encountered with audience participation to discuss treatment strategies. Dr. Brad Habermehl, Associate Professor of Western University College of Optometry and MC of our meeting, provided a lecture on pain management. And the Wow Vision Therapy Team – Dr. Alyssa Parz, Dr. Alicia Bultsma, Dr. Sana Haque, Dr. Lester Efianayi, Connie Glanzer, COVT and Dr. Dan L. Fortenbacher presented an extensive model for diagnosis and treatment for visual processing, visual memory, visual imagery and visualization. The primary emphasis of their presentation was how to transfer the established visual development to one of the most elusive objectives for those who struggle with reading and learning, that being metacognition and executive function or the ability to set goals, plan, strategize, sequence steps, manage time, stay focused, multitask and have working memory to achieve goals and confidence.
The Michigan Vision Therapy Study Group has a long standing tradition of meeting every year for the last 40 years on the 3rd or 4th weekend in January with a Mission to continue to grow in our knowledge, understanding and best practices for doctors and therapists in developmental vision and rehabilitation.
Below is our photo gallery (click on the pics to view close-up and advance).
The legendary MVTSG meeting continues next year…and beyond.
With the havoc wreaked by COVID you may have missed publication of this article in PLOS ONE last year, as did I: Development of global visual processing: From the retina to the perceptive field. The corresponding author is Uri Polat, who is affiliated with The School of Optometry and Vision Science and The Mina & Everard Goodman Faculty of Life Sciences, of Bar Ilan University in Ramat-Gan, Israel. If the name Uri Polat is familiar to you it may be because he co-authored a seminal paper with Dennis Levi in 1996 that was the first nail in the coffin of the concept that amblyopia can’t be improved after age 7. In 2013 I blogged about the clinical appreciation of developmental crowding, and how that relates to young children with delays in reading acquisition as well as for patients with amblyopia who function as if they have a learning disability.
I like Polat’s use of the term “perceptive field” in this new PLOS ONE article. Although optometry students learn about receptive fields in the visual cortex, Polat and colleagues coin the term perceptive field which has a more developmental ring to it regarding retinal development. In the abstract they write: “Our data suggest that the developmental processes at the retina and visual cortex occur in the same age range. Thus, in parallel to maturation of the PF, which enables reduction in crowding, foveal development contributes to increasing contrast sensitivity.”
The age range where there is typically a big crossover point is around age 6. Clinicians are familiar with this in terms of when children are better able to keep place on the whole line when reading a Snellen Chart rather than requiring pointing or the isolating of letters. It is why developmental saccade tests like the King-Devick and DEM have norms beginning at age 6. Understanding and appreciating crowding serves as the basis for why children’s books have larger print and liberal spacing until age 6, and then each year thereafter progress toward smaller print with tighter spacing, in essence becoming relatively more crowded.
Helping children who lag in retinal and/or cortical development is done through many types of sheets or workbooks that progress from larger font and spacing toward smaller font and spacing. This is the sequence followed in Michigan Letter Tracking (Ann Arbor Series) workbooks, and more recently in a variety of Petrosyan workbooks available through Bernell, or computerized through Anteo. Versions of this are customizable in other computerized programs such as Binovi and Neuro Visual Trainer, and an auto-pacing function built into the ambiNet program. Downloadable Hart Chart Decoding sheets are fun for this as well, zooming the size in or out, as well as Dr. Sarah Lane’s downloadable worksheets.
Although all VT practices deal with “retained crowding” at some level, less common is a parallel approach to training contrast sensitivity.
Doing this with letters likely transfers to reading performance, while doing this with Gabor patches is becoming popular with computerized programs that enhance dynamic visual skills as required for night driving and sports vision. With all of these approaches, using Polat’s terminology, we can say that we are training the perceptive field.
In Neural Science and Vision – Part 5, we mentioned Lea Hyvärinen, MD, PhD and her book What and How Does This Child See, 2nd edition co-authored with Namita Jacob, published at the end of 2019. Our blog introduced Dr. Hyvärinen as a developmental/behavioral ophthalmologist who spoke at the COVD meeting in 2012. Since then, as is apparent in her book, Dr. Hyvärinen has evolved in the direction of neuro-rehabilitative ophthalmology to parallel neuro-rehabilitative optometry. Inventor of the eponymous Lea tests, Dr. Hyvärinen has few if any ophthalmologic peers in the U.S., her closest analog perhaps being Dr. Gordon Dutton in the U.K. In a lecture in the U.K. in 2012 regarding transdisciplinary assessment, Lea presented a slide noting that the role of the optometrist is principally in function and optics, in contrast to the the ophthalmologist who primarily addresses anatomy and disease:
In lectures she has given, as well as in the epilogue to the 2nd edition of her book, Lea emphasizes that the ICD system is useful for defining visual impairment, but not for classifying visual functioning. For the latter, and for clinical purposes of intervention, the ICF (International Classification of Functioning, Disability, and Health, 2001), and its pediatric version, the ICF-CY (ICF for Children and Youth, 2007) is more pertinent. It seems as if there has been movement in this direction internationally with regard to collaboration between Medicine and Education (see this co-presentation from Dr. Hyvärinen and this 2018 publication from Frontiers in Education regarding disability research involving pre-schoolers).
The subtitle of Lea’s book is Assessment of Visual Functioning for Development and Learning, speaks volumes. Let’s take a look at some of the key concepts she embraces.
Regarding fixations: “It is important to observe fixation and other oculomotor functions in situations that require concentration for looking at small or complex pictures and during reading. During these functions, fixations, saccades, and scanning eye movements should be automatic. If a child needs to consciously fixate and focus on a small target, these two simultaneous motor functions may demand too much of the child’s limited capacity and cause overload or lose head control … If reading from the black board or working on a near vision task requires too much motor capacity, posture control may be lost and the child lies flat on the desk. There should be a constant adjustment based on observation of the varying balance between the capacity for using vision and the capacity for postural control so the student can concentrate on his tasks.”
Regarding saccades: “Some children have the greatest difficulties in controlling their eye movements when crossing the midline. Their eyes may close briefly at midline or there is a jerk in the following movement. This rarely reported phenomenon has been observed in children with ‘athetosis’ who often cannot use vision at midline.”
3. Regarding acuity, accommodation, convergence, and the need to consider plus lenses at near: “The sensory task is easier during the short measurement of visual acuity than during the reading of a text which may require so much brain capacity, the motor functions become irregular or weak. Observe the effects of reading glasses: how reading speed and errors in reading and comprehension of the content vary when the child reads with/ without reading glasses.” Lea also stresses the need to maintain balance between the intra-ocular muscles (controlling accommodation) and extra-ocular muscles (controlling versions and vergence), and the need to conduct dynamic retinoscopy on any child with developmental challenges.
4. Visual field as pertaining to reading: “During reading, several functions occur simultaneously. While reading a word, a visual map of the text is created. The map is instantly passed to planning of oculomotor functions in the executive command functions (in the frontal lobes), which get ready to activate the 12 eye muscles as soon as fixation is detached from the word.”
5. As pertains to the visual complexity of reading: “Reading is the most common problem in school referrals. It is a good example of numerous brain functions supporting a demanding task. Reading requires several simultaneous functions in the visual processing and in the visuomotor functions before the information can be used as language. In Chapter 2 we learned that fixation and saccades are more demanding than the conscious fixation and saccadic movements assessed during clinical examinations.”
6. Regarding trans-disciplinary collaboration: “Sometimes changes in motor functions are complex and require close collaboration between the doctors and the school to find optimal devices and ergonomic solutions. The educational resource centers together with the rehabilitation ophthalmologist, orthoptist, optometrist, rehabilitation team, and the school’s occupational and physiotherapists can tackle these problems which are difficult to treat at the hospitals because they lack the special knowledge on inclusive education.”
7. As related to #6: “Children with visual processing disorders may also have other problems in brain functions: in attention, executive functions, motor functions, and auditory processing functions. Many children have atypical peripheral functions in their eyes and ears. The assessment of these children’s many atypical functions and planning of early intervention and education should be supported by information from all medical specialties involved, optometry, and social services. With adequate support, children with complex problems in brain functions may develop, study well, and become the next generation of young workers who can provide first-hand information on what it means to grow and learn using atypical brain functions.”
8. With regard to the importance of communication: “Oculomotor functions can be observed after a short training, but the interpretations are often difficult. A perfect assessment is not the goal. The goal is to understand the information related to the child’s problems and to discuss the child’s functions and functioning at school. Doctors are becoming aware of the need to describe oculomotor functions better and describe behaviors that indicate a problem in oculomotor functions.”
9. Motion perception as related to neurology: “Visual information moves as magnocellular information via the retinal ganglion cell axons to the ‘superior colliculus’ in the tectum and the ‘pulvinar’ in the thalamus. Pulvinar connects to area V5 and through it but also directly to V1, V2, V3, and parietal cortex …The tectopulvinar pathway supports visual functions if the retinocalcarine pathway is damaged between LGN and V1 in the optic radiation, which is a common finding in brain damage around the ventricles. In this damage, form perception may be lost but motion perception may function.”
10. As related to #9: “One of the typical unusual behaviors of children with poor motion perception is walking fast and bumping into large objects. If the child can perceive only very slow movement, objects in their side vision are blurred and uncomfortable when they move at their usual speed. Objects disappear completely if the speed is increased. When the “blurred tunnel” disappears, objects far away become visible because their relative speed is low. Since the objects close by are not seen, the child may bump into large objects and people. This is often misinterpreted as a sign of poor attention, but in reality, the child is functionally blind in relation to the objects he passes close by.
11. Regarding spatial awareness and orientation: “Perception of near and far space need to be assessed as separate functions. Some children function well in the small egocentric space and are quick in building puzzles. They seem to have no difficulties in solving three-dimensional puzzles (if they have good picture perception and recognition) but have major problems perceiving and remembering relationships in large allocentric spaces.”
12. Lea is a proponent of schools using pictures, numbers, on transparent film or plexiglass so that recordings can be made of eye hand accuracy in scanning and localizing, as well as head and eye position as the patient is responding.
Lea’s slim volume doesn’t follow a typical textbook format, and reads more like a hard-bound monograph. But it is well-organized for its purpose, and provides valuable videos as well as a copy of the complete text in its accompanying USB. At $99 for the hardback and thumb drive, it is a worthwhile investment.