Any child with an IEP for reading problems needs this testing

A child who enters the classroom with delayed visual readiness skills for the demands of their grade level, has a clear disadvantage over the child who has developed the necessary visual skills for reading and learning. 

Published in the Journal of the American Medical Association (JAMA) in July 2018, entitled: Frequency of Visual Deficits in Children With Developmental Dyslexia, researchers at Harvard Medical School, Department of Ophthalmology,  looked at the 3 categories of visual function known as sensorimotor visual abilities. These visual abilities are referred to as binocular vision (eye teaming), oculomotor (eye-tracking) and accommodation (eye focusing). The researchers found that nearly 80% of the impaired readers had visual dysfunction in these sensorimotor visual readiness skills compared to children with normal reading abilities.

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.

Therefore, any child who struggles in school, especially in reading, or has an IEP (Individualized Education Plan) should have a Comprehensive Developmental Vision Evaluation. This assessment, in addition to ocular health and refraction (testing for corrective lenses), evaluates a child’s visual readiness skills in sensorimotor function plus visual perception and visual integration abilities. For additional information go to the VisionHelp Vision and Learning Project

With this testing, a parent will know if their child has the visual readiness skills to be ready for the demands of school, including reading, homework, attention and concentration and handwriting. More important if there is a problem with visual readiness skills, a plan can be outlined to provide the help needed for that child to succeed.

Dan L. Fortenbacher, O.D., FCOVD

Finding the vision connection to childhood reading problems and unhappiness begins with a simple question

Once upon a time there was a young boy who loved to read. He even hid books beneath his bed at night and would sneak them out to read with a flashlight under the covers. That young boy was me! To be sure, reading gave me happiness!

There are several things in life that we hope for our children. Certainly a couple of those top things are for them to have confidence and happiness. This is especially true when it comes to the school environment. After all, this can set the stage for the future success of that child including an enjoyment for reading which is not only important for a child’s academic success but research shows reading is linked with happiness. Conducted in 2016,  the University of Liverpool’s Centre for Research into Reading, Literature and Society (CRILS), found that those who read report better connections with others and greater feelings of happiness overall. 

Yet, given the potential for positivity of reading, we know there are many children who dislike reading. Parents are aware of their child who struggles with reading and often the assumption is that the child is either “not trying hard enough” or has a form of dyslexia (reading disability). These two explanations are usually frustrating for both the child and the parent. On one hand, it implies the child needs more parental controls for the perceived behavioral problems for lack of effort, which adds to more unhappiness. On the other hand, when a type of reading disability exists, then a combination of compensatory strategies or accommodations and educational tutoring is needed to help develop the reading performance. However, even with all the extra parental attention and academic help, there often exists an unaddressed effort to the task of reading which makes it a struggle and unenjoyable. 

As outlined in numerous VisionHelp Blog posts, the visual system plays a foundational role in a child’s ability to successfully read. What’s more, we have evidence based clinical practice guidelines by the American Optometric Association (AOA) that outline what tests all optometrists should be performing on school-age children with reading and/or learning problems. But, too often these important visual tests are overlooked if the doctor is not aware of any parent concerns regarding a child’s reading. And, to be sure, most school-age children will not simply volunteer this information.

Therefore, the solution to this disconnect could be solved by the answer to a simple question which should be a part of every school-age child’s comprehensive eye health and vision examination.  The question for the doctor is easy. Every child should be asked, “Do you like to read?

If the answer is, “No”, then a few more questions are in order to learn if a child is experiencing any academic difficulties. The next step for the doctor should be to include additional testing to identify if there are sensorimotor conditions in binocular vision (eye teaming), accommodation (eye focusing) and oculomotor (eye movement) abilities. 

In fact, the American Optometric Association (AOA) Evidence-Based Clinical Practice Guideline, The Comprehensive Pediatric Eye and Vision Examination (CPG-2), gives a detailed and thorough overview. It is an excellent paper and one that all eye care providers should study. However, it’s 65 pages long and while an excellent resource for the doctor’s personal library, it’s sheer length could lead to possible procrastination for the reader.  But, thanks to the work of Dr. Carole Hong of the VisionHelp Group, you can access an excellent summary of the AOA CPG 2 in an easy to read, concise 2 page downloaded PDF available on the VisionHelp Vision and Learning Project, entitled, AOA Evidence-Based Clinical Practice Guidelines: Comprehensive Pediatric Eye and Vision Examination 2017 – Clinical Pearls

Here are three examples:

  • When a child’s history or initial testing indicates a possible developmental lag or learning disorder, additional testing should be performed to rule out a learning-related vision disorder.
  • Vision problems such as accommodative, binocular vision, eye movement, and visual information processing disorders can interfere with academic performance.
  • Vision disorders that occur in childhood may manifest as problems well into adulthood, affecting an individual’s level of education, employment opportunities, and social interactions. 

The Comprehensive Pediatric Eye and Vision Examination 2017 – Clinical Pearls can be helpful for doctors, teachers, occupational therapists, psychologists, educational therapists and other professionals who work with children who struggle with reading. When a vision-based problem exists, proper lenses and vision therapy can bring happiness to a child’s life by developing excellence in visual readiness skills to help facilitate making reading easier, more enjoyable and setting the path for academic success.

But, first it begins with the question…”Do you like to read?”

Dan L. Fortenbacher, O.D., FCOVD


Why a “Cocoon Management Model” for neuro-developmental vision problems can be detrimental

Evidence-based research in medicine has confirmed that those who have suffered from chronic symptoms following a concussion, otherwise known as an mTBI (mild traumatic brain injury), experience, among other health concerns, vision problems involving sensorimotor (eye coordination) such as

  • Oculomotor Dysfunction
  • Convergence Insufficiency
  • Convergence Excess
  • Accommodative Dysfunction
  • General Binocular Dysfunction

In addition dysfunctions in visual perception, visual processing and integration are common. These conditions will trigger symptoms involving, double vision, poor depth perception, transient blurred vision, light sensitivity, headaches associated with reading, trouble keeping their place when reading, poor attention and concentration, reduced confidence and much more. These vision problems can have a tremendous impact on a patient’s “wellness” that negatively affects the post-concussed individual’s ability to go back to the classroom or to work. 

Published in the Journal of the American Medical Association (JAMA) Neurology, April 2018, Dr. Christopher C. Giza, et al, wrote an article entitled: Determining If Rest Is Best After Concussion. What the authors outlined is that in the past, the accepted practice in medicine for those who have been concussed was “cocoon therapy”;  a form of severe restriction of activity designed to reduce brain activity by reducing sensory, motor and cognitive stimulation. However, new research in neuroscience indicates that the “rest is best approach” model of treatment can actually be detrimental to the patient’s long term recovery. Instead what they concluded was, “a more refined approach of individualized management of activity after mTBI, with initial brief rest followed by controlled reintroduction of cognitive activities, non risky physical activities and eventually a return to normalcy”, is good for rewiring brain function. This is also spelled out in the research published in January 2016 in ScienceDirect entitled: The interplay between neuropathology and activity based rehabilitation after traumatic brain injury,  where there are multiple studies that show, following the initial “acute phase” of the  injury, it is critical to the patient’s recovery to have therapeutic physical activity and rehabilitation that promote adaptive neuroplasticity and hence recovery.

Therefore research is now showing that “rest is not best” when it comes to neuro-development for those who are dealing with the consequences of an mTBI. Instead, a proactive therapeutic action-oriented treatment plan is more effective. When this involves dysfunction in sensorimotor visual coordination and/or visual perceptual, processing and integration, office-based neuro-optometric vision rehabilitation should be an integral part of the patient’s overall care.

But, if this is true for those who have had an mTBI,  what about when a patient presents with a history of no trauma, yet has dysfunction in sensorimotor and/or visual perceptual abilities? The cause of these dysfunctions can be associated with delays in neuro-development and often associated with many of the same signs and symptoms found with mTBI. They also commonly affect reading and learning which impacts attention and concentration and often interferes with classroom performance.

These conditions involving sensorimotor, binocular vision (eye teaming), oculomotor (eye tracking) and accommodation (eye focusing) and visual perception, processing and integration have been outlined in multiple research studies. But when it comes to prescribing treatment, too often patient (or parents of children) are told that they will “outgrow” the problems or that they should use compensatory strategies for reading and learning thereby allowing the patient to accept the problem and apply techniques to “work around” the deficit.

The question for physicians, optometrists, ophthalmologists, psychologists and all those in the medical community who evaluate children and adults that present with chronic signs, symptoms and behaviors that are similar to those of an mTBI, yet there is no history of trauma:  What is best for the patient? “Rest”, ie “let time take its course” and hopefully all will work out? Or, to be more proactive by identifying, diagnosing and helping the patient to obtain targeted vision rehabilitation/vision therapy to accelerate the neuro-development of the visual system responsible for the dysfunction?

In conclusion, while conservative models of care come with good intentions, not having awareness of the clinical science may contribute to unanticipated consequences in the lives of patients. When a neuro-developmental vision problems exists, just as in the patient who has chronic symptoms following an mTBI, rest is not best. What’s best for the patient is the opportunity to take action and develop function. Anything less is a Cocoon Management Model of care.

Dan L. Fortenbacher, O.D., FCOVD

The importance of finding the hidden link between vision and reading to help the struggling child

Parents of school-age children who have struggled in reading and learning are often looking for answers to many questions. A common concern might be, “Why did my bright child continue to have difficulty with reading fluency and/or paying attention in the classroom this year, even with extra help?”

To provide some direction, two years ago the VisionHelp Group interviewed educational specialist, Wendy Rosen, author of the book, The Hidden Link Between Vision and Learning, Why Millions of Learning Disabled Children are Misdiagnosed and produced videos. Here is one example entitled: Misdiagnosing Learning Disabilities

In the video, Wendy mentions the diagnosis, “Convergence Insufficiency”, a binocular vision dysfunction usually associated with a reduced convergence ability and commonly identified with the Red/Green Penlight Near Point of Convergence (NPC) test. This test which can be done in about 30 seconds is one tool in the eye care provider’s binocular vision assessment tool kit.

But not so fast,  as outlined in my recent VisionHelp Blog post and also featured as the Elsevier’s Practice Update Story of the Week, there is new Harvard Medical School research published in the American Journal of Ophthalmology entitled: Receded Near Point of Convergence is Not Diagnostic of Convergence Insufficiency. What they found was that while the majority of  post-concussed patients (89%) had a reduced near point of convergence, what they also found was these patients had a high incidence of poor visual tracking (oculomotor dysfunction), eye focusing problems (accommodative dysfunction) and poor eye teaming and focusing flexibility (binocular vergence/accommodative dysfunction)

The conclusions by the JAO Harvard researchers was that, “Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.” In other words, these complex visual problems should be addressed with a comprehensive evaluation process followed by a comprehensive model of treatment to meet the patient’s individual visual needs.

So why bother doing a Near Point of Convergence Test on school-age children, especially those who have not  been concussed? Because a reduced NPC is one important measure found with Convergence Insufficiency. Furthermore,  research shows that those children with vision-based reading and learning problems also have a high frequency of oculomotor, accommodative and binocular vergence/accommodative problems!

Therefore, the importance of assessing binocular vision, plus additional sensorimotor areas, is critical to assessing those children with reading and learning problems. When the initial testing  diagnosis identifies a reduced near point of convergence, it is essential to have a comprehensive sensorimotor and visual perceptual evaluation so that an accurate diagnosis can be made.

Once identified, as outlined by the American Optometric Association CPG-18,  the best approach to treatment involves as comprehensive model of office-based vision therapy working one-on-one with a skilled vision therapist (typically 45-60 minutes 1-2 times per week in-office with assigned home support activities) in conjunction with lenses, prisms, and/or therapeutic tints prescribed and supervised  by an experienced Doctor of Optometry in developmental vision and rehabilitation. Furthermore, it’s important to clarify that home-based models of treatment with periodic office-monitoring visits have been found by clinical trial research to be no better than a placebo in treating these conditions.

For more information check out the VisionHelp Vision and Learning Project.

Dan L. Fortenbacher, O.D., FCOVD

Visual function deficits contribute to reading acquisition in children with reading problems a focus of the MVTSG 2019

What did the researchers at Harvard Medical School, Department of Ophthalmology at Boston Children’s Hospital, published in JAMA -Ophthal, and leaders in neuroscience agree upon in 2018?

There is an unmistakable association with vision problems, not corrected with glasses or contacts alone, involving binocular vision, oculomotor, accommodation and visual processing linked with children who have reading problems.  

As written in an earlier VisionHelp Blog post, in July 2018 the Journal of the American Medical Association, JAMA-Ophthalmology, published the research conducted at Boston Children’s Hospital at Harvard Medical School, Department of Ophthalmology,  showed a significantly high amount of visual problems, not involving eyesight or need for corrective glasses, rather involving eye teaming (binocular vergence), tracking (oculomotor) and focusing (accommodation). The data that showed this preponderance of vision problems in children with developmental dyslexia was a staggering 79% in those children with developmental dyslexia vs 33% in the control group.

Here is the paper entitled: Frequency of Visual Deficits in Children With Developmental Dyslexia

Furthermore, John F. Stein, Ph.D.,Emeritus Professor of Neuroscience at the Department of Physiology, Anatomy and Genetics, University of Oxford, in his recent paper published in February 2018 entitled, What is Developmental Dyslexia, cites research showing the visual processing deficits, particularly in the magnocellular temporal visual visual processing system as a key in those with a reading disability known as developmental dyslexia.

To bring this important information  to an audience of doctors and vision therapists, our Team presented on January 25, 2019 at the Annual Michigan Vision Therapy Study Group Meeting on the topic of Going Beyond Visual Efficiency Problems in the Effective Remediation of Developmental Dyslexia.  We presented how developmental optometrists can  effectively help children with these visual-based reading problems by utilizing an evidence-based comprehensive model for diagnosis and treatment. This model begins with a thorough eye health and vision evaluation along with key diagnostic tests  that identify  visual efficiency problems (binocular, oculomotor and accommodative) and/or those areas involving visual processing deficits that impact reading performance. For those children who can be identified and treated, once their visual system has been developed with capable visual readiness abilities with vision therapy,  improvements in their reading emerges. Depending on each child’s reading delays, educational therapy may still be necessary to accelerate the reading and learning process. However, once a child has the visual readiness abilities for reading and learning they respond much quicker to reading interventions than with inadequate visual readiness abilities.

Indeed, the focus of this year’s  Michigan Vision Therapy Study Group by all of the presenters and their Teams of Vision Therapists was to demonstrate techniques for office-based optometric vision therapy for developing these necessary visual intake and processing skills for maximizing results in reading and learning.

The Michigan Vision Therapy Study Group is recognized as a legendary 1.5 day vision therapy educational meeting  that has taken place every year in the month of January in Michigan for the last 4 decades.  It is a volunteer project with the intent of bringing together doctors and vision therapists with a passion for collaboration, teaching and expanding understanding of methods for helping patients to acquire better vision development through vision rehabilitation and vision therapy.

This year’s team of presenters were: Dr. Curtis Baxstrom, Dr. Dan Fortenbacher, Dr. Alyssa Bartolini, Dr. Jamie Jacobs, resident, Dr. Kelsey Starman, resident and vision therapists, Dr. Mohamed Moussa, Abeer Ahmed, MBChB  and vision therapists, Dr. Bradley Habermehl, Johann Schlager, extern and vision therapists, Dr. Daniel McIntosh, resident, Dr. Tiffany La, resident, Dr. Corrie Pollock, resident, Dr. Paula McDowell and Dr. Andrea Shank.

Michigan Vision Therapy Study Group – 2019

Dan L. Fortenbacher, O.D., FCOVD

Vision Therapy Through a Patient’s Eyes

Harvard Symbol

It is inevitable for those of us in the field of vision therapy to wonder about the impact we’re making on a young person’s life.  If we do our jobs well, we get considerable positive feedback.  But once in awhile you come across something so remarkable that it begs to be shared far and wide.  The following essay was written by a graduate of our VT program as part of her requirement for college entry into Harvard University.  To preserve patient confidentiality, I won’t reveal her name other than to say that it means “springlike” in Hebrew, and it is indeed a breath of fresh air.  Veritas …

“The terror I experienced as a child waking into the JCC lobby overwhelmed me.  Aided by my vivd imagination, my misaligned eyes interpreted the marble floor as a still pool of milky water.  I was convinced that if I stepped forward, I would be sucked down and lost forever.  For years I couldn’t enter a bank or museum without toe-testing to ensure the floor’s solidity.

This flawed perception resulted from strabismus with intermittent esotropia, which prevents my eyes from synchronizing or focusing correctly.  Years of eye tests did not uncover the functional difficulties this caused; the ability to read an eye chart does not predict how one reads books, road signs, and smartboards.  Because I was well spoken, teachers assumed inconsistent performance was due to effort, not ability.  For years I struggled to keep up, having extreme academic highs and low, often in the same subject.  I became frustrated from working my hardest with mixed results and not knowing why.

In time I developed coping mechanisms, which in turn became academic strengths.  I relied on my creativity, developing strength as an artist in multiple fields and experimenting with assignments to find ways to express what I uniquely saw.  By researching subjects in great depth, thus encountering recurring names and concepts, I could not only read faster but gained mastery of subjects and formed passionate opinions on topics as diverse as Benazir Bhutto’s legacy to the function of Egyptian funerary portraits.  I also improved my memory and stamina, and realized that re-reading texts, initially for comprehension, also yielded deeper insights, appreciation of nuance, and attention to detail.  Reading “The Bridge of San Luis Rey” by Thornton Wilder has become an annual post-finals ritual that consistently teaches me new lessons on community, love, and connection.

My coping strategies faltered, however, under the weight of my workload in a dual-curriuclum yeshiva high school, not to mention while learning to drive.  (Yikes!)  I began vision therapy to improve my peripheral vision, depth perception, and eye muscle control.  By looking through lenses and prisms, I suddenly saw the world as others viewed it.  How humbling to perceive depth and volume as never before, freshly viewing the movement of ocean waves and grass.  Quite literally seeing the world with new eyes led me to re-examine my intellectual views as well, opening my mind to alternate perspectives so ideas that had to be set in stone now became fluid.

Around this time, I was introduced to the work of Carol Dweck on growth mindset, Sheryl Sandberg on resilience, and Angela Duckworth on grit, whose statement that ‘when you keep searching for ways to change your situation for the better, you stand a chance of finding them’ particularly resonated.  Their theories on persistence struck a chord with me, validating my past efforts and renewing my determination to master my studies.  In my first year following vision therapy, I not only achieved the school’s highest grade in AP Art History and aced the AP, but took special pride in curating a virtual museum exhibit on 18th-20th century ritual objects from Africa, Indigenous America, and the Pacific Islands as a window to women’s roles in non-European societies.  This project not only satisfied my own intellectual drive, but allowed me to share my findings with others who may never have considered the relevance of this art to contemporary questions about motherhood, female power, and the balance between the roles of men and women.

This academic fire also sparked a new flame: the desire to transmit my passion for art, history, and culture to others.  As an educator, I would be able to especially appreciate differences and encourage students by sharing my difficulties and ultimate success.  Knowledge of history and art history enriches people’s lives by helping them understand and navigate the world around them, cultivating deep satisfaction and joy.  Though my poor eyesight presents ongoing obstacles, I now envision a life using lessons learned in overcoming challenges to infuse the lives of others with beauty and meaning.”

New JAMA research shows reading problems linked to treatable vision problems

Eye Teaming…Tracking…Focusing

When speaking with parents about their child’s eye coordination instead of speaking about problems with vergence, accommodation and oculomotor function, terms that will automatically trigger a “deer in headlights” look, I’ve learned it is far better to refer to these essential visual skills as “teaming…tracking…focusing”.

These three eye coordination abilities are essential for reading fluency. Specifically, when referring to these visual functions, Eye “Teaming” is another way of saying we have two eyes and they must work together in what is known as binocular vision. The skill of using our binocular vision is referred to as “vergence” which is commonly thought of as convergence or divergence. When an individual has trouble with convergence they may demonstrate under convergence, known as convergence insufficiency, or over convergence known as convergence excess.

The vergence system also must work synergistically with eye “Focusing” otherwise known as  accommodation. When a child or young adult has trouble with accommodation that is referred to accommodative dysfunction which can also be an under-focusing ability, accommodative insufficiency or poor focusing flexibility, accommodative infacility.

Eye “Tracking” is another way of saying our eyes need to visually fixate (look at), follow in a smooth pursuit (follow) and saccade (move spot to spot). Problems in these visual tracking skills is known as an oculomotor dysfunction.

This week I saw a 9 year old boy going into 4th grade who was referred to me by his primary care optometrist with a condition of accommodation-vergence dysfunction involving convergence excess and oculomotor dysfunction. He had no refractive error, 20/20 visual acuity at distance and near and normal healthy eyes. He complained of headaches, eye strain, period words overlapping when reading and poor attention for reading. He was a bright boy who did well when presented with oral learning but got exhausted when trying to read. His referring optometrist had tried reading glasses but they didn’t seem to make any significant difference in the boys reading or symptoms. His parents both attended my exam and where noticeably concerned and frustrated by his struggles in reading and battle with homework.

Indeed no surprise that my examination concurred with his referring doctor. His problem wasn’t with his eyes (per se) or his eyesight. He had a relatively common visual dysfunction of eye teaming, tracking and focusing. The good news is that this condition is completely treatable with vision therapy and with office-based treatment it will make a dramatic difference in his life.

Even though this story is a common occurrence in the clinical practices of offices of developmental optometrists who provide vision therapy, in reality around the US, most of these children who have visual based reading problems are overlooked. They fall through the cracks of the educational assessment system because they pass the visual acuity test (20/20) and further testing of their eye teaming, tracking and focusing is not even checked. But as of July 19, 2018 published in the JAMA Ophthalmology a research paper was published by prominent researchers from Boston’s Children’s Hospital and Harvard Medical, entitled: Frequency of Visual Deficits in Children With Developmental Dyslexia, found deficits in visual function in binocular, accommodation and oculomotor abilities of those children with developmental dyslexia vs normal readers.

In addition to this new research, to help parents and professionals, the VisionHelp Group has created the VisionHelp Vision and Learning Project which provides additional information.

As outlined in a previous post, entitled: Solutions for your child who struggles in school starts by knowing what to ask your eye doctor, every child who struggles in reading should have a comprehensive eye health and vision evaluation by a doctor of optometry who will also ask questions about your child’s reading abilities and perform the necessary testing. No child should have to endure the struggle of an undetected problem with eye teaming, tracking and focusing!

Dan L. Fortenbacher, O.D., FCOVD

Crystal Part 2: Reading by Ear or by Eye?

We cited Chapter 34 of Professor David Crystal’s Cambridge Encyclopedia of Language in Part 1, ending with the introduction to his review on the theories of reading.  Let’s pick up where we left off, with his section titled Reading by ear or by eye?

Crystal Cover

“Most people have encountered the struggle that takes place as a child is learning to read.  A major feature of this task is that words and letters are ‘sounded out’.  It is as if reading is possible only if the symbols are heard – reading ‘by ear’.  One theory of reading therefore argues that a phonic or phonological step is an essential feature of the process – a theory of ‘phonetic mediation’.  The view implies that reading is a serial or linear process, taking place letter-by-letter, with larger units gradually being built up.”  Professor Crystal offers the following diagram to represent that process:

IMG_4482He continues:

“The alternative view argues that there is a direct relationship between the graphology and the semantics, and that a phonological bridge is unnecessary (though it is available for use when reading aloud).  Words are read as wholes, without being broken down into a linear sequence of letters and sounded out – reading ‘by eye’.  Readers use their peripheral vision to guide the eye to the most likely  informative part of the page.  Their knowledge of the language and general experience helps them to identify critical letters or words in a section of the text.  This initial sampling gives them an expectation about the way the text should be read, and they use their background knowledge to ‘guess’ the reminder of the text and fill in the gaps.  In this view, a text is like a problem that has to be solved using hypotheses about its meaning and structure.”  Professor Crystal represents that model with this diagram:


Permit me to highlight two crucial points implicit in what David Crystal has written:

  1. The commonality to both of these models is that the process of reading printed text (as opposed to Braille or audio books) always begins with visual analysis.
  2. Covering one eye to address binocular vision problems comes at the price of reducing peripheral vision substantially, impairing the important role of parafoveal preview in reading.

The arguments for and against the two distinct models of reading, ‘by ear’ and ‘by eye’, are complex and multifaceted, as Professor Crystal points out.  He summarizes these arguments as follows.

Support for the ear:

  • Associating graphemes and phonemes is a natural process, which cannot be avoided when first learning to read.
  • Letter recognition is very rapid – about 20-30 milliseconds per letter – which is enough to account for the average reading speed of 250 words per minute.  However it is similar for both silent and oral reading, and close to the norms for spontaneous speech.
  • Most words in a text are of very low frequency, occurring only once over long periods, and some will be completely new to a reader.  This limits word expectancy, thereby requiring some degree of phonological decoding.
  • When people read difficult material, they often move their lips, as if the phonology is needed to help comprehension.
  • It is difficult too see how the ‘eye’ theory can account for the relative ease of reading the many variations in font typology and handwriting.
  • Reading ‘by eye’ would seem to be a complex process of each word going through a retrieval process, and we tend to prefer parsimonious explanations.

Support for the eye:

  • Fluent readers are not confused by homophones such as two and too, for which phonology is no help.
  • For homographs like tear (a word that has the same spelling as another word but has a different sound and a different meaning) there is no way of deciding which pronunciation is involved until after the reader has selected a meaning.
  • The fact that different sounds are written identically, and different letters can have the same pronunciation, complicates a phonological view, with some orthographic rules seeming totally unrelated to phonology.  At least 25% of English words have irregular spelling where phonology doesn’t work, and these words are among the most frequently used in the language.
  • Individuals with phonological dyslexia are unable to pronounce simple nonsense words (e.g. pob), but are able to read real words, showing that a non-phonological route from print to meaning must exist.
  • The ‘ear’ theory doesn’t explain how some people are able to read at speeds in excess of 500 words per minute, given the time to convert letters to sound.  This poses less of a problem for the ‘eye” theory, simply requiring that readers increase their sampling as they speed up.
  • In tachistoscopic exposures, individuals identify whole words more rapidly than isolated letters.  For example, for brief exposures of BAG, BIG, A, I, or IBG, and asked whether they have just seen an A or I, people perform best with familiar words.  This is known as the word superiority effect.

Crystal concludes that a compromise theory is in order.  Neither approach explains all aspects of reading behavior.  It is likely that people make use of both strategies at various stages in learning and in handling different kinds of reading tasks.  The ‘ear’ or phonetic approach is important during the initial stages.  Likely after repeated exposures to a word, a direct print-meaning pathway is established.  The ‘eye’ or whole word approach better accounts for how we become fluent readers.


Many of the points underscoring the importance of visual input and visual analysis in silent reading efficiency are made in two other books that I commend to you.  One is Eye Movements and the Fundamental Reading Process, authored by Taylor, to which I contributed a chapter.  Another is Models of the Visual System edited by Hung and Ciuffreda that contains a chapter on Models of Reading Disability and Their Implications authored by Harold Solan.  As fond as I am of these sources, the Encyclopedia of Language further crystallizes the salient points.

A critical question for every school-age child who struggles in reading

A critical question for every school-age child who struggles in reading is: 

“Do you ever see words come apart like this when you read?” (while showing them the following)

If they respond yes, it is highly likely that they have a binocular vision problem that is interfering with their reading fluency. 

Unfortunately, too often children will “pass” the basic school or health department vision screening eyesight (20/20) test, but  still have a significant vision problem that involves coordinating their two eyes and focusing on the print when reading. They may have an undetected binocular vision problem. In fact, newly published research out of the the University of Waterloo has found that the chance of a child who qualifies for an Individualized Education Plan (IEP) has a much greater likelihood of having a binocular vision problem.

But, what is a binocular vision problem? Simply stated, we have two eyes and they must work together as a coordinated team. If a child has trouble with this fundamental skill to coordinate their two eyes effortlessly, especially for near vision tasks such as reading, then they will typically have trouble with sustained attention on reading, exhibiting ADHD behaviors and/or they will see print overlap (as shown above) and when they try to overcome with effort, they experience headaches and often emotional side effects.

Surprisingly, most children who have a history of seeing the print double while reading never tell their parents. When asked why they never told their parents most say they thought that was just normal! This is why it is important to show them the example and ask them directly, “Do you ever see print come apart when reading?”

However, even if a struggling child states that they don’t see words “come apart” when reading, another step you should take is to complete the VisionHelp Vision and Learning Checklist. If you see a significant number of “3’s” and “4’s” be sure to make an appointment for your child to have a comprehensive eye and vision evaluation and show your eye and vision care provider the completed Vision and Learning Checklist. This will help your Doctor know that he/she should be alert to the concern and run the necessary testing that can identify a child with a vision related reading/learning problem.

For more information, take a look at the VisionHelp Vision and Learning Project. This site is dedicated to helping parents,vision care doctors and professional partners on how to diagnose and effectively treat these vision conditions that can improve a child’s reading, learning and overall quality of life.

Please help share this “critical question” so that a child with a binocular vision may be more easily recognized and helped. Imagine how, with greater awareness, we might end the senseless struggle for those children with vision-based reading/learning problems.

Dan L. Fortenbacher, O.D., FCOVD

A turning point – how correcting common binocular vision problems resets a child’s reading future

In this post, Developmental Optometrist, Dr. Alyssa Bartolini writes about about the impact that vision therapy has on the lives of children through the story of one of her patients. Dr. Bartolini specializes in developmental vision and rehabilitation and practices in Grand Rapids, Michigan at Wow Vision Therapy and new member of the VisionHelp Group.

One of my favorite parts of vision therapy is graduation day! It is an exciting event when our patients often invite their whole family to see all of the progress they have made throughout vision therapy. While the changes that occur after vision therapy vary with each patient, for the child who had a vision-related reading or learning problem prior to treatment,  the transformations we often witness in their abilities and confidence from their first exam to graduation day can be dramatic.

Recently, I was particularly touched by the graduation of an 8-year-old boy. On the surface this patient’s case seemed fairly simple. He was diagnosed with some of our most common diagnoses: convergence insufficiency, accommodative dysfunction, oculomotor dysfunction, and visual perceptual delays. However, I very clearly remember his first exam because he was extremely impulsive and struggled to stay on task. His mother was a teacher and informed me that he was recently diagnosed with ADHD. Despite being on ADHD medication, he was still falling behind in school (especially with reading) and his parents were struggling to figure out a way to effectively help him in the classroom. During the exam, I quickly realized that this patient was overloaded because his visual system was not providing him with accurate information.

After his first exam we performed an assessment of visual processing to further understand what was contributing to his struggles in the classroom. During the testing he relied heavily on his auditory system and was very fidgety.  We found that in the areas of visual discrimination, visual memory, visual directionality, and visual motor integration he performed at a 4-5 year old age equivalent. His Visagraph eye movement recording was at a 1st grade level and he scored at a <6 year old level on the King Devick saccadic eye movement test. This significant delay in visual perception and saccadic eye movement was a major factor in his struggles in the classroom.

Over the course of this patient’s vision therapy treatment plan his eye teaming, focusing and tracking all greatly improved. All areas of visual perception also improved to above his age and grade level. His mother reported that he went up 15 points on the reading section of his most recent MAP testing. An even bigger change for this patient was that his personality transformed. As his visual system became more stable and he could interpret what he was seeing more accurately, he became much more focused, had less anxiety, and we saw a huge increase in his confidence.

The AOA’s Clinical Practice Guideline Care of the patient with Learning related vision problems describes how important it is to thoroughly assess the binocular system and visual perceptual abilities in patients that are struggling in school. It states, “Visual efficiency comprises the basic visual physiological processes of visual acuity (and refractive error), accommodation, vergence, and ocular motility. Visual information processing involves higher brain functions including the non-motor aspects of visual perception and cognition, and their integration with motor, auditory, language, and attention systems.” 

This is also supported in a recent paper published in the Journal of Optometry, November 2017 entitled: Visual and binocular status in elementary school children with a reading problem. The Faculty of Science researchers at University of Waterloo found that children between the ages of 6 and 14 who all had an Individual Education Plan specifically for reading, more than three quarters of the students had good eyesight, but when they were tested for binocular vision, more than a third of the group scored below published norms. They concluded that it is very important to do tests of accommodation, binocular vision, and oculomotor function on all children, especially those with identified reading problems.

The Vision and Learning Checklist created by the VisionHelp Group is also a helpful tool that healthcare professionals, and teachers can use to identify patients that may have vision related learning challenges.

Once these patients are identified, it is important to educate families that an in depth binocular vision assessment, as well as visual perceptual testing, may be able to determine the root cause of their struggle in the classroom. Effective vision therapy can greatly help these patients, just like it did with the sweet 8-year-old boy who recently graduated with a huge smile on his face, and newfound confidence.

Alyssa Bartolini, O.D.