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.




Be Thou My Vision Therapist

For those of you who aren’t on the DOC-L Listserve, I wanted to make sure you saw this remarkable essay by Mary Barnett, a Yale Divinity School student, who is a patient of Phyllis Liu, O.D., FCOVD, in Connecticut.

Be Thou


Be Thou My Vision Therapist

Our whole business in this life is to restore to health the
eye of the heart whereby God may be seen.
Augustine, Sermon 88.5.5

I have glasses for seeing far, glasses for seeing close, glasses for seeing far and close at the same time as long as I look through the right place, contacts for looking good as long as I am absolutely positive I will not need to read anything, reading glasses to wear over the contacts for seeing close up which I can’t ever find because they are usually right here.

I take my glasses on and off constantly. For a while this summer, I had both a pair of reading glasses and sunglasses perched on my head. It sort of worked. I have a big head. This makes life complicated and reduces to separate categories things that should go together. I have developed the habit of shutting my eyes whenever I have a serious decision to make or something important to say to someone. It helps things merge. To see my children, I take my glasses off.

Disturbances in vision while disorienting, prod us to stop taking what we see for granted. When at age 40 I finally realized I wasn’t seeing what everyone else was seeing, I called the doctor. Then, being an Enlightenment creature, I began wondering how vision works in the first place.

We see what we expect to see, until we don’t. We can call the eye doctor (we aren’t seeing things) set up a consult with a psychiatrist (we are seeing things) or try to convince a religious professional, a time-travelling medieval saint or maybe that wild-eyed guy on the street corner, that we’ve had an actual vision. They will all agree at least on this: nobody is seeing exactly what everyone else is seeing.

Since our eyes are not the open windows on the outside world that we experience them to be: if I adjust the clarity and thickness of the panes that I am looking through; if I go out and buy a better pair of glasses, will I finally see what’s really going on out there?

Richard Rohr, a contemporary Franciscan monk illuminates the alternative orthodoxy of the mystic tradition. “Hugh of St. Victor (1078-1141) wrote that humanity was given three different sets of eyes, each building on the previous one. The first eye was the eye of flesh (the senses), the second was the eye of reason (meditation or intellectual reflection), and the third eye was the eye of true understanding (contemplation). Third-eye seeing is the way mystics see. They do not reject the first eye; the senses matter to them. Nor do they reject the second eye; but they know not to confuse knowledge with depth or mere correct information with the transformation of consciousness itself.”

I eat this stuff up. The italics are mine. But wait a minute, I have two eyes and it turns out even they don’t agree with each other.

Many of my visual frailties are age-related. If you don’t have them, you will. But like my mother and several cousins, I was also born with a mild strabismus. My eyes were slightly crossed. One floated up while the other wandered in. Occasionally they met above my nose and then swam lazily back to their proper posts, facing front. My parents waited for things to straighten themselves out and when they didn’t, they took me, at age 3, to the best eye surgeon in Boston.

Dr. Gunderson wasn’t like Dr. Allen, the pediatrician I saw yearly, who understood the general purpose of doctors appointments: reassuring parents, getting measurements, giving shots. Dr. Gunderson talked to my mother politely but only really warmed up when he asked her about me and they’d speak quietly for a few moments, as if I were an important and serious and somewhat delicate subject and then he’d turn and smile at me so broadly and look so deeply into my eyes that I knew they and I were miraculous and beautiful. My perspective was essential even though my eyes didn’t work right. The way he looked at me, I knew I was really there. The surgery was successful although like much in the late 50’s, the specifics were under-discussed. I launched into life post-surgery with a lingering suspicion that they had messed with other parts of me while they were in there, under the hood so to speak. I appreciated Freud when I got around to him in college.

Nonetheless, I was fine. I merely started nursery school half a year late and wore a black eye patch for a while to strengthen the eye whose muscles had been shortened or tightened or lengthened or whatever it was they did to them. But it wasn’t until I was an adult, and I read “Stereo Sue” by Oliver Sacks in the June 2006 issue of The New Yorker, that I realized that I actually see differently, out of only one eye at a time and they switch back and forth. So I was over 40 years old when I found out that I don’t see depth, I just think I do. Up until then, my illusions had worked just fine.

I’ve had clues. I remember the stereoscopic glasses we put on in fourth grade to look at a wavy photo of a giant millipede. Everyone screamed and in the excitement, I did too. All those little legs! But I finally realized why their screams had that…edge. To me, the bug looked exactly the same with the glasses off.

It’s a minor disability. Depth perception apparently varies a lot, even within normal ranges. What can this possibly mean? If you experience the millipede projecting up from the page 1.7 inches and someone else perceives the height as a mere .75 inches, what is in the space in between? Is awareness of dimensionality a complex aspect of personality, like intelligence or verve? (Of course, I think, remembering the blockhead who cut me off this morning.) But wait a minute. I’ve got depth. Why can’t I see it?

Our two eyes have slightly different vantage points on the world, strategically located 2.5 inches apart, in most adults. We see to the far left with our left eye and up to 90 degrees to the right with our right. Our eye placement is adaptive, giving us a wide horizontal visual field. We can scan the plains. Watch for tigers in the trees. Merge into traffic. If one eye is impaled by a tree branch or dislodged by a 120 mph tennis serve at Wimbledon, we have a handy spare. Having two slightly different angles on the world has another surprising advantage. Try this and see. Line your fingers up one in front of the other. Now imagine you are a tiger and the front finger is a tree with a rabbit hiding behind it. Shut one eye and the back finger pops into view. (Dinner!)

The triangular area directly in front of our eyes however is shared territory. Our brain receives the images from each eye and fuses them, relying on their similarity and their disparity to generate the sensation of depth. This is the miracle of convergence and I know it’s a miracle because I can’t do it. Depth perception in the sagittal plane separates foreground from background, tree from forest, chameleon from camouflage. It is for catching prey and threading needles or looking (deeply) into someone else’s eyes. Most salient however is the fact that depth perception is embodied. It’s a sensation. It confirms not just what we see but where we feel we are.

When the disparity between the two images from our two eyes is too great however (e.g. when the eyes don’t line up properly or one eye sees better than another) the brain can’t deal with the discrepancy and suppresses one of the images. The eyes alternate, turning on and off in succession although this all happens below the level of consciousness. As a result, depth is deduced following secondary clues (shading, position, motion parallax) instead of perceived. This unconscious maneuvering reminds me of the Clapper, that gadget (for turning lights on and off without getting up from your chair) that used to be only available only on TV. Clap on. Clap off. No need to engage with the switch. No way to see how awareness operates. How unconscious decisions are being made. In a case like this, the first step toward perceiving depth is disorientation. It’s seeing double.

Frustrating and demoralizing as this sometimes is, I’m beginning to see my slight handicap as an unexpected gift. I’ve become aware of what I can’t see and am looking for it. Twice. But effort is only half the battle. To see depth I need to practice religiously the eye stretching exercises my vision therapist has given me. I also need to let go of what I’ve seen before.

Our eyes are not windows. Our vision is not instantaneous or “natural” but unconsciously processed and projected. An image of the world is developed in our head. And then we walk into it.

Born in 1955 and raised Unitarian in an upper middle class family in Providence RI, I learned that being smart mattered. Your brain was your angle. Your genes were your foundation. In the great grey First Unitarian Church on Benefit Street we learned that Jesus was a great guy, a really great guy in fact, on a par with the Buddha or Krishna or Gandhi or Martin Luther King, all equally Holiday worthy, but not the Son of God. Believing Jesus was the Son of God would mean that you believed you possessed a truth that was not culture bound and relative. This was dumb. No one was chosen except maybe by history or the membership committee of the golf club. My parents fought for causes, eventually left the country club and protected the environment before it was fashionable. There is a brook on our family property in Massachusetts that is one of the few places left in New England where sea brown trout, the salters John Adams fished for, still swim upstream to spawn. In the early 1970’s, my parents convinced the surrounding landowners to protect the land with stringent conservation restrictions. They didn’t see Jesus but they saw trout. They believed in the importance of a future they weren’t in and they didn’t need a resurrection to feel connected to it.

My brother once asked my Boston-centric Brahmin maiden aunt if Unitarians were in fact actually Christian. Aunt Hopie lay propped up in the chaise lounge from which she lived her mysteriously handicapped life on a powerful horizontal. At my brother Jamie’s question, however she sat up. Her eyes glowed a coastal blue. “Of course we’re Christian,” she said. “The real kind.”

Christian mystic, Richard Rohr refers to all brands of religious certainty as dual-consciousness thinking (on/off, either/or instead of both/and), regardless of its theological complexity, political correctness or inclusive values. It doesn’t matter how right our opinions are. “Either-or thinking gives one a false sense of control.” “The small mind works by comparison and judgment; the great mind works by synthesizing and suffering with alternative truths. The ego cannot stand this suffering, and that is exactly why it is so hard for many religious people to grow up.”

Clap on. Clap off. I know I have depth but can I really believe that you do too?

St. Julian of Norwich (c.1342-c.1416), a medieval mystic, had a radical experience of depth within the confines of her anchoress’s cell, in spite of severely restricted vision. The book she wrote Revelations of Divine Love is a classic text of Christian spirituality, the first text in English written by a woman. What she “saw” however still makes many religiously secure people nervous. Can her radical perceptions really be orthodox? It’s a good question. Julian reported seeing beyond the small reality of hell into the greater mystery of God’s merciful love. She saw that sin was necessary or “behovely” rather than merely a limitation. She saw that “all would be well and all manner of things will be well.” She saw Christ as a mother. She saw God as a womb in which we are endlessly being born and out of whom we will never come.

My transformative experience of depth happened in a Friendly’s.

I stopped transfixed in the doorway. Something was different. The waitresses and the booths had receded. A great gulf had opened up. Even my shoes seemed farther away. White block letters launched themselves from the back of the sign above the counter. VANILLA CHOCOLATE PISTACHIO. The expanse of space between me and the ice cream counter was not a nothing, not a lack of something; not a spiritual placeholder for a more material reality, like my address or a desk. It was the actual room I inhabited which also inhabited me. I was marinating in this glorious viscous substance which, now that I became aware of it, took an effort to cross. I had a choice.

True stereopsis, writes researcher Dhanraj Vishwanath in a current issue of “Psychological Review” is the vivid impression of tangible form, immersive space and the compelling sensation of being able to act upon it.

The slim necklace of trim on the back of leatherette banquette. The waitress’s apparent sadness. My feet inside my shoes. The child in the next booth kicking the back of my seat. Everyone matters. We aren’t in a movie.

In other words, depth isn’t just something that happens out there but is also the internal space that opens inside us, creating a visceral sense of the really real.

“The perceptual quality that we hold so dearly as giving us a grasp on reality” continues Vishwanath “is an entirely phenomenal construct-with no external referent.”

Woops, I guess I was wrong. We are in a movie. But we are simultaneously shooting it.

I panic. (Clap on.) Since our vision is manufactured and processed, since our experience of reality is hopelessly tainted with ourselves does this mean that what we see out there is not objectively and verifiably real?

Argh, says my husband, are you just figuring this out? That other people have other points of view? (Clap off.)

I persist. I believe in God and posit something that is not relative; that doesn’t depend on my seeing Him clearly. God as Trinity renders God in three dimensions: height, width, depth; a space I go into rather than an opinion I have. I take my glasses off.

“Theology, says theologian Karl Barth “knows the light which is intrinsically perfect and reveals everything in a flash. Yet, it knows it only in the prism of this act, which however radically it may be understood, is still a human act.”

I open my eyes and go in search of another imperfect pair of glasses.

My new vision therapist has recently added prisms to my prescription to train my eye muscles to relax, to make them let go of how they are used to working so my brain can let go of how it is used to seeing. Augustine recommends something similar in Psalmos 99.5: you must “prepare the means of seeing what you love before you try to see it.” It occurs to me then that to experience God I need a pair of glasses big enough for my whole body. What I really want is a prism suit! I shut my eyes and realize that is exactly what I already have.

For years, anatomists trying to understand the secrets of the body have cut away at the connective tissue that holds our organs in a sticky white web. They scrape away at the fascia to get at what they think is the meat. Meanwhile, a teacher of mine coaches people with spinal cord injuries to apprehend with a different perceptual system. They are learning to try to curl and uncurl their toes. The results though small are not imperceptible. Apparently what was considered useless, what was cut away and discarded, is intelligent beyond our current capacity to understand it. There’s a milky way of intelligence imbedded beneath our skins. When we narrow our bodies, we narrow our world.

“The spiritual wisdom of divine union is first beautifully expressed in Sanskrit in the Vedas (the oldest Hindu text, around three thousand years old) as a ‘grand pronouncement’: Tat Tvam Asi” writes Richard Rohr. “This phrase contains condensed wisdom that could likely be translated in the following ways:

YOU are That!
You ARE what you seek!
THOU art That!
THAT you are!
You are IT!”

Or as Plotinus said, “We are what we desire and what we look at.”

“My body is pin-hole camera, taking snap shots of God which I can’t develop by myself,” I say, scrambling an egg.

Wow, that’s deep, says my husband, unimpressed.

The worm thinks it strange and foolish that man does not eat his books, says Tagore.

Practicing my religion makes me more aware of the all the prisms I look through: my culture, my faith tradition, my assumptions, my numerous pairs of glasses, my naked eyes. I am full of blind spots. Ultimate reality remains hidden behind a veil. Christianity is just another pair of glasses; the kind with prisms in them like my new vision therapist has given me; but that might actually work. Somehow these new potentially cheesy, glory-hallelujah, bargain-rate, Christian glasses bring my body into focus, not just my little eyes or my little pea brain. I see the enormity of the space between me and other people. I’m immersed in it. The world doesn’t impinge on me anymore. It is miles away. We are miles away from each other.

Calvin, that quintessential reformed theologian, quotes the medieval mystic Bernard of Clairvaux in one of his famous Institutes, reminding me that contrary to the popular imagination, the Protestant tradition is not devoid of mystical imaginings.

“Bernard neatly compares to faithless servants the proud who claim even the slightest thing for their own merits because they wrongly retain the credit for grace that passes through them, as if a wall should say that it gave birth to a sunbeam that it received through a window.”

That’s it, I think, that’s it. I’m here to catch the light. Otherwise it would just keep going. I am the wall!

I am the walrus, says my husband.

This universe dwarfs me way beyond my capacity to imagine it. This makes me feel oddly necessary. It is so much more likely I would never have been here at all.

Meister Eckhart (1290-1327) put it this way in one of his Sermons, “The eye through which I see God is the same eye through which God sees me; my eye and God’s eye are one eye, one seeing, one knowing, one love.”

In the Oliver Sack’s New Yorker article, Susan Barry describes an instance of binocular vision that is revelatory. Stepping out into a snowfall, she experiences being within the world instead of observing it. “Before the snow would have appeared in a flat sheet, on a plane slightly in front of me. But now I felt myself within the snowfall, among the snowflakes. I was overcome with a deep sense of joy. A snowfall can be beautiful, especially when you see it for the first time.”

Several months ago, I was walking by my church in downtown New Haven. I passed a man 20 feet away, lying on the ground. He was badly rumpled. He looked like he might smell. Often men lie on the ground around our church, sleeping off a bender. It was a busy street in the shopping district near Yale, mid-winter, the middle of the day. Many people were passing him by, confirming my assessment of what I was seeing. Now, this isn’t a Christian or a Christmas story about how I suddenly became a good Samaritan. I am not. If I knew for sure what I was seeing I probably would have kept going. But for a split second my mind stopped. I thought: maybe this is not what I think it is. Maybe this is not someone who wants to be left alone. As I was straining to pull him up off the ice, his daughter came running out of Lord and Taylor and took his other arm.

Amblyopia and Slow Reading

It’s been over a year since I blogged about amblyopia and reading disorders, and the December 2017 issue of the Journal of the American Association for Pediatric Ophthalmology and Strabismus contains commentary on the subject as part of a Symposium on Pediatric Ophthalmology and Childhood Reading Difficulties.

Screen Shot 2018-02-02 at 4.57.03 AM

Insightful observations about amblyopia and slow reading are shared by two Ph.D. researchers, Eileen Birch and Krista Kelly.  Here are some key passages from their commentary:

“Using natural, binocular silent reading of age-appropriate paragraphs of text, we recently reported that children with amblyopia read slowly compared with controls and non-amblyopic strabismic children, regardless of amblyopia type (i.e., strabismic or anisometropic).  Unlike earlier reading studies that focused on strabismus, our study clearly identified that amblyopia alone is sufficient to impair reading. Importantly, comprehension did not differ significantly between amblyopic children and controls, indicating that amblyopic children did not read slowly because they had dyslexia or a learning disability.”

“Unlike dyslexic readers, amblyopic children in our study read more slowly because they made more forward saccades during reading. It is likely that the increased number of forward saccades during reading reflects oculomotor control system deficits. Amblyopia is associated with substantial fixation instability … Taken together, slower saccade initiation, saccade amplitude variability, and increased frequency of secondary saccades can be expected to significantly slow reading speed in amblyopic children.”

“Saccadic eye movements clearly play a key role in efficient reading, a key component of academic achievement. There is a solid evidence base demonstrating slower initiation of saccades and more variable saccade amplitudes in amblyopic individuals. Even though it usually results in poor vision in just one eye, amblyopia can reduce reading speed in natural, binocular reading by 20%-50% and negatively affect academic performance. We have also found that amblyopic children are slower at transferring answers from a standardized test to a Scantron answer sheet compared with visually normal controls. Longer Scantron completion times may exacerbate the problem of slow reading when amblyopic children are administered standardized tests that are time- sensitive, limiting the child’s academic success. The child’s academic achievement, in turn, is a major contributor to the child’s developing self-perception, which has been shown to be affected by amblyopia.  Positive self-perception has an important influence on well-being and quality of life.”

Birch and Kelly conclude:  “While currently there is no evidence that training eye movements will help amblyopic children read faster, parents and educators can work together to implement accommodations (e.g., extra time) to help amblyopic students succeed in their daily school tasks, and improve their performance on the timed, stan- dardized tests that are critical for promotion and admission to magnet schools, TAG programs, high schools, and colleges.”



We could argue over what constitutes “evidence” that training eye movements can enable amblyopic children to read faster (many of our practices are built on such successes), but the take-home message here is that amblyopia is a visual disability that deserves special considerations.  In an invited commentary on Elsevier’s Practice Update for Eyecare, Dr. David Damari, Dean of the Michigan College of Optometry at FSU and a consultant to the National Board of Medical Examiners on Visual Disabilities, noted that the request for accommodations on standardized testing must be documented with performance tests for each individual making such requests.  Which visual performance tests are given weight by testing agencies is an entire subject unto itself.

Screen Shot 2018-02-02 at 11.47.20 AMMuch as CITT-ART is undertaking gold standard research on the transfer effects of training convergence insufficiency to reading, one can anticipate that analogous gold standard research on training amblyopia and its transfer to reading may be undertaken at some point in the future by PEDIG (Pediatric Eye Disease Investigator Group).

Clear Thinking About Vision Problems


WTM Logo Susan Wise Bauer is an accomplished historian and home schooling guru who is the curator of the Well Trained Mind Forums.  I picked up a copy of her new book on the strength of a recommendation in the Wall Street Journal last week, and was pleasantly surprised with her discussion about functional vision problems.  Before getting to that, permit me to state that I always derive an extra measure of satisfaction from discovering critical thinkers who think clearly about vision problems.  That she is a critical thinker with a sparkling intellect is certainly evident in this interview with Ms. Bauer from 2010:

Back to the book, which is a wonderful resource from a variety of angles.  First, after identifying broad distinctions between disorder, disability, and difference, Ms. Bauer notes: “The borders between the three are vague and inconsistent because people are organisms, not mathematical equations; our weaknesses always involve both mind and body, and the labels we put on them shade imperceptibly into each other.”

Having said that, she classifies functional vision problems as a set of disorders that can be medically diagnosed.  She writes: “Vision function problems are potentially a huge block to learning.  Most children get standard vision screening at their pediatrician checkups, but more subtle problems are often missed.  Farsightedness, eye teaming problems (both eyes cannot stay focused on the same point), and poor tracking (inability to keep eyes focused on a single line of print) are generally missed in standard vision tests, because most children can focus properly for short periods of time … A child with a vision function problem can pass a traditional eye test at the optometrist with flying colors, but still struggle to see text properly …


… The difficulty can show up as short attention span, daydreaming, or lack of interest – and is often misdiagnosed as a learning disability.  Screening by a vision specialist who is a member of the College of Optometrists in Vision Development ( should always come before a child is labeled as dyslexic, dysgraphic, or having ADHD.”

The section concludes with commentary by a mother, M.J., who writes regarding optometric vision therapy: “The vision function therapy took thirty-two weeks, less than a school year, and permanently fixed those vision function problems.  This was life-altering both at school and at home.  My child, who thought she was stupid and uncoordinated and hated school, started believing herself smart and able and loving school, simply because her vision was finally working properly.”

Ms. Bauer concludes this chapter with an ACTION PLAN, advising that every struggling child need to have physical difficulties ruled out.  She advises to consult a College of Optometrists in Vision Development member if a child has any of the following signs:

  • while reading, skips or rereads lines
  • reads and/or completes homework at a snail’s pace
  • has poor reading comprehension
  • reverses letters or confuses similar letters
  • has a short attention span while doing written/reading-based work
  • rubs eyes, had headaches, says eyes are tired
  • cannot write on lines, has poor copying skills
  • can answer questions orally but not in writing
  • has trouble with basic math concepts of size and position
  • tilts head oddly while reading words or numbers

If ever you’re having a rough day, and wondering about the extent to which we’re making a difference in the world, pull this out and read it again.

Dyspraxia and the Spaces Between Us

Once again I find myself drawn to the Dave Matthews Band, this time as an association to The Spaces Between Us: A Story of Neuroscience, Evolution, and Human Nature, a new book by Professor of Neuroscience and Psychology at Princeton, Michael Graziano.

From the inside jacket liner to Professor Graziano’s book: “A six year-old child has an inborn difficulty processing the buffer zone within a few feet of his body.  The consequences reach into every aspect of his life – walking without bumping into things, using a fork, writing and reading, but especially social interaction.”  The six year-old child turns out to be Michael Graziano’s son, and we will return to his story in a moment.

GrazianoGraziano is a researcher who experiments principally with monkeys, best known for his work on peripersonal neurons, the neuronal correlates of peripersonal space.  On page 9, he lays the groundwork for the social implications of what we might call periocular space:   “They say the eyes are the windows to the soul.  When you think about it though, the eyeballs themselves aren’t really the windows.  If you could look at a pair of eyeballs minus the rest of the face, you wouldn’t learn much.  I suppose you’d learn where the eyes are looking and how dilated the pupils are, information indicative of the person’s state of mind.  But the broadband on that information is limited.  Really, for reading another person, everything surrounding the eyes matters most.  The windows to the soul are the eyelids that can narrow skeptically or open wide, the eyebrows that move and shape expressively, the sly wrinkles at the outer corners or on the bridge of the nose, the upward bunching of the cheeks – the many tensions and relaxations rioting around the center.”



The story heats up on page 37 when Graziano discuss the near space network.  Neurons that monitor the space around the body through touch and vision can be found in at least three other brain areas in addition to the putamen, two subregions in the parietal lobe (7b and VIP), and the polysensory zone of the motor cortex.  Although he says nothing in his book about binocular vision and eye movements, others such as Clery et al have mapped out the near space network with regard to peripersonal space coding, and the near space network in relation to vergence tuning and oculomotor structures.



It’s appropriate to interject a reminder here about the genius of optometrist Fred Brock in this regard.  Although he didn’t label it as such, Brock intuited key regions of space that he partitioned through a seemingly simple tool of a string with three beads.brock-regions-of-space2

It would be simplistic to think of the Brock String merely in terms of “physiological diplopia” or as an elegant “anti-suppression” feedback tool.  True, it can be these things.  But equally if not more important is the ability to for the patient to connect the projection of the eyes through a volume of space that has become discontinuous or fragmented.  That is one reason, I believe, why convergence in often compromised in patients with developmental disabilities or acquired brain injury.  Not because there is anything fundamentally wrong with eye muscle properties, but because of a fundamental deficiency in the patient’s use of the near space neuronal network.


Back to the story of Graziano’s son, which he saves for the final chapter, The Personal Dimension of Personal Space.  Graziano has previously shared this heart-wrenching saga as an essay in Aeon, and at the time referred to the condition as apraxia rather than dyspraxia.  People seem to use the terms interchangeably, sometimes speaking of praxis in general.  Others, particulalriy in the UK, prefer Developmental Coordination Disorder or DCD to describe the disability. (I cited some of the terminology issues with dyspraxia awhile back.)  It is this step outside the laboratory that makes what Graziano has to say so compelling to parents and clinicians alike as he opens the final chapter:

“I thought I’d share a difficult experience my family had a few years ago.  It illustrates almost every important point I want to make about personal space.  When the ability to process personal space is compromised, almost everything else is affected – sometimes in weird, unexpected, even devastating ways.  It’s not just a matter of academic science, of monitoring neurons and measuring reaction times.  Personal space is a real thing that impacts real lives culturally, socially, and emotionally … I’ll try not to get too high up on my soapbox about the condition called dyspraxia.  It’s sometimes called the hidden disability because so few people know about it and so few people – teachers, parents, or children – can see it even when it’s standing right in front of them crashing into things.  Dyspraxia is a gap between what you know in your head and what you can do in the physical world.  It’s a difficulty with movement control, especially when learning new complex skills.”

Dyspraxia Graphic

Regarding his son, Graziano continues: “We now know that he couldn’t build a good spatial foundation from the core of his body.  Personal space, after all, is an outward extension of the body schema.  Without that anchor point in his body, he couldn’t build up a proper understanding of the space around him or coordinate movements and postures of his arms and hands within that space.  He lacked the foundation on which the more delicate writing movements are normally built.  He couldn’t properly wrap his peripersonal space around a pencil in his hand.  And he couldn’t judge the spacing on a page.  For example, other children start writing at the top left margin.  My son may have learned the concept, but in practice he would plop the first mark down anywhere, sometimes in the center, sometimes on the right side of the page.  He tended to neglect the left side of the page, a common spatial disturbance in dyspraxia sometimes called pseudo-neglect.  True clinical neglect is when specific damage to the brain such as a stroke, erases a persona’s ability to orient to one side of space  It’s stark.  But children can develop a more subtle pseudo-neglect if they can’t fully tune up their mechanisms for processing space.”

Powerful stuff.  A new form of “pseudo-CI”.  Not because the principal problem is with accommodation, but because of pseudo-neglect due to disorganization of the near space.  As Graziano notes, you may understand the concept of near personal space; but you just can’t see it very well.  And as Graziano emphasizes you may be able to deal with near space under certain circumstances, but it requires an intense amount of effort and concentration, “like a drunk person trying to pass a sobriety test”.   This contributes to the maddening inconsistency of performance, and the admonition that a child could achieve if he simply tried harder or learned more self-discipline.  Grazianos’ son was expelled from school, and suffered what Michael refers to as a form of post-traumatic stress disorder over the anxieties he faced.  Ironically his stress was not exacerbated by bullies in the schoolyard, but by the bullying of adults in the educational system in New Jersey who thought they knew it all.  It took the hiring of an advocacy attorney, independent evaluations by experts, and a lawsuit to provide the right type of school environment and support programs enabling his son to thrive.

In Graziano’s son’s case, an approach emphasizing vestibular-based therapy is what finally seemed to result in a breakthrough.  In particular, Graziano credits astronaut training as he observes:  “The astronaut training seemed to put a missing piece in place.  Suddenly he began to understand the space around him.  The other therapies, that had spun their wheels in the mud for two years, now suddenly caught traction and began to work … We bought a trampoline, a welcome addition to the therapy because it was more a game than a chore.  Our pediatrician looked at us squint-eyed and said, “Are you serious?  You know that, as a pediatrician, I’m not supposed to sanction that”.

And as Graziano concludes:  “Personal space has a hidden impact on education.  Mathematics, the most abstract branch of human thought, grows developmentally out of spatial processing … How can you learn to read and write if you have trouble with the spatial relationships of letters, words, or even the whole darn book with respect to yourself?  All the basics of education are at risk of derailment.”

A Vision of Literacy

We’ve discussed the role of vision in reading many times before, from “traditional” optometric angles such as the perspective of the AOA to the literacy point of view in academia.  I came upon the role of vision in literacy from an unexpected source last week, though while reading in my usual place.


The source is Rob DeSalle’s new book, Our Senses: An Immersive Experience.  A seemingly unexpected source because Rob is curator of the American Museum of Natural History in New York, but the connection isn’t as far-fetched as you might think.  Rob’s mind is delightful, as you’ll see in this clip, and his sense of curiosity and down-to-earth approach to learning and teaching shines through.

From his exhibition designed for the public about the brain, Rob went on to curate the American Museum of Natural History’s latest exhibition, Our Senses: An Immersive Experience, in essence the live companion to this book.

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The exhibition, which opened to the public in November, seems to be a delightful experience, and I’m planning a field trip there with a few of our grandkids soon.  In the  interim, the book serves as a teaser – and the chapter that really caught my eye (Chapter 18) is titled “Bob Dylan’s Nobel: Language, Literacy, and How the Senses Interact to Produce Literature”.  Here are some key quotes:

“The portal for the neural information that is needed for literacy is usually through the retina and hence the eyes … As with all of the senses, when the initial information enters the brain from the sensory collection organ (in the case of literacy, the organ is the retina) there is an initial rapid processing of the information (fig. 18.3) …

Literacy Pathways

… Remember that the information form the retina in early visual processing goes through several areas of the visual cortex specifically the pathways known as V1, V2, V3, and V4.  Western writing uses the V1 and V2 pathways to sort out and recognize the characters used in literacy.  By contrast, recognition of characters in Chinese writing uses the V3 and V4 pathways … One of he more interesting developments with the acquisition of literacy in the visual word form areas is that this pathway in the brain learns to suppress the tendency to lump mirror images of objects … Examples from the Western alphabet include b/d/p/q.  And hence the adaptive reason for this so-called mirror invariance of our nonliterate ancestors needs to be overcome to acquire literacy.”

DeSalle concludes his book with a highly significant paragraph in Chapter 20 on the limits to what we can sense, and the future of our senses.  It deserves a drum roll, please.


“The average adult in the Western world faces a computer screen or a smartphone screen for about ten hours a day, according to a 2016 Nielsen survey.  Given that we sleep about seven to eight hours a day, this means that more than half the waking day in many cultures is spent staring at a computer or smartphone screen viewing virtual images the whole time.  We are only beginning to understand the impact of this changed sensory realm on the human condition.  In a direct comparison of reading comprehension among tenth graders, researchers in Norway assessed the difference between reading on a computer screen versus old-fashioned hard copy.  The surprising result was that these students comprehended the written word on paper much better than on screen.  Why this might be so isn’t well understood, but it does point to a possible dichotomy in the way we learn and comprehend reading as humans.  Reading comprehension is a downstream effect of vision [my emphasis added – what a great line!!!], and some researchers are concerned about the long-term impact that computer and smartphone screens might have on the human visual system in a more upstream manner.  Humans did not evolve to peer endlessly at a small, light-emitting rectangle … How this restriction in the visual field is affecting our eyes and their potential evolution is a subject that needs attention.”

“I’m Focusing on Me and the Dog Now”

Cathy is a 57 year-old who wore a gas permeable contact lens on her right eye for about 13 years when she was a child and into her early 20s.  Early on she did some patching of the left eye, but it has been over 30 years since she wore a contact lens, or any prescribed glasses for that matter.


As she became presbyopic and started to use over-the-counter reading glasses of various powers, Cathy noticed that when she looked through them at distance her better eye was blurred but the amblyopic eye could actually see better.  It seemed that the stronger the reading power, the better the right eye could see at distance.  Cathy has a close friend, Sharon, who began her career as a fine artist.  On her website Sharon writes:

My “learning to see” the art in paintings and the art in life, at the Barnes Foundation, serendipitously led me to “teaching others to see” as a vision therapist and later as a natural vision educator. I was attracted to yoga because it reminded me of dance, which is a form of art, and also because yoga is a philosophy or “way of seeing”. For some time thereafter I explored the interconnection of art, yoga and vision to each other and to life. All along all I’ve wanted is harmony. That yearning led me to explore the healing arts and also to recognize the therapeutic value of art making. I realized that all meaningful activity is therapeutic – which led me to the work of occupational therapy. Along the way I added color light therapies, Zero Balancing®, and essential oils to my tool box. By weaving it all together I provide a holistic approach that empowers and supports people as they participate in their own self-care and healing process.”

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Cathy had related to Sharon that she was progressively experiencing neck pain caused by subtly rotating her head to the right to favor her left eye.  At night she would find herself closing or covering the right eye to watch TV.  It was as if the right eye had slowly been awakened through the progressively stronger reading glasses that she was wearing.  Yet her brain was not ready to use that eye beyond arm’s length for detail for any extended period of time.  Sharon suggested that Cathy consult with me.

As we reviewed her history last week, and I asked Cathy what motivated her to pursue doing something further about the use of her right eye, she replied with a twinkle in her eye: “Well, the kids are gone …  so I’m focusing on me and the dog now.”


Cathy’s unaided visual acuity was 20/200+1 through her right eye and 20/20-1 through her left eye.  She was able to see 20/30+2 with the auto-refractor value through her right eye.  She suppressed the right eye centrally on a vectographic target, and was briefly diplopic on an anaglyphic target, but in short order began to fuse.


I took out a +3.50 sphere spectacle lens from my trial set, asking Cathy to hold it in front of her right eye and walk around while visually exploring.  She had no diplopia “in the real world”, and everything was merry and bright!  Cathy will return to our office tomorrow for our resident, Dr. Vincent, to fit her with a soft lens for her right eye.  We anticipate that she’ll adapt well, and wear the lens full time.  We’ll also begin optometric vision therapy so that Cathy can make up for years of lost time when she hadn’t been functioning binocularly, and to safeguard against binocular decompensation down the road.

Identifying children’s vision and learning problems – AOA Chairside Guide provides a useful focus

In this one minute VisionHelp video, educational specialist Wendy Rosen, author of the book The Hidden Link Between Vision and Learning, outlines when a child struggles in reading and learning it should be the top priority to have a comprehensive optometric vision evaluation. It is especially critical to understand that, while 20/20 eyesight is important, having clear distance eyesight alone does not rule out serious vision problems that affect reading, attention and learning.

In fact, most of the visual problems that affect learning can be missed if the doctor’s testing does not go beyond eye sight, refraction and ocular health testing. To provide helpful tools for Doctors, the American Optometric Association InfantSee and Children’s Vision Committee in conjunction with Optometry Cares – The AOA Foundation, have created a comprehensive Pediatric Vision Evaluation “Tool Kit”. This was outlined by Dr. Press in his most recent VisionHelp Blog post, entitled: New AOA Resource Kit.

Within this collection of excellent resources are Chairside Guides that provide detailed descriptions of diagnostic testing for a comprehensive vision exam, including targeting and identifying children’s vision and learning problems. Here is an example of the 6-12 year old Chairside Guide.



For parents who have a child who struggles in reading, learning and/or attentional problems, be sure to bring your concerns to your optometrist. For Doctors, it is especially important to apply these optometric tests nicely outlined  by the American Optometric Association. AOA members click here to get access to the entire AOA Resource Kit.

Because, as stated by Wendy Rosen, “Having this knowledge could potentially impact the entire course of a child’s life!”

Dan L. Fortenbacher, O.D., FCOVD