Learning Related Vision Problems
Learning Related Vision Problems
Learning Related Vision Problems
PRACTICE GUIDELINE
OPTOMETRY:
THE PRIMARY EYE CARE PROFESSION
Doctors of optometry (ODs) are the primary health care professionals for
the eye. Optometrists examine, diagnose, treat, and manage diseases,
injuries, and disorders of the visual system, the eye, and associated
structures as well as identify related systemic conditions affecting the
eye.
Optometrists provide more than two-thirds of the primary eye care
services in the United States. They are more widely distributed
geographically than other eye care providers and are readily accessible
for the delivery of eye and vision care services. Approximately 37,000
full-time equivalent doctors of optometry practice in more than 7,000
Care of the Patient with communities across the United States, serving as the sole primary eye
care provider in more than 4,300 communities.
Learning Related The mission of the profession of optometry is to fulfill the vision and eye
care needs of the public through clinical care, research, and education, all
Printed in U.S.A.
Learning Related Vision Problems iii iv Learning Related Vision Problems
INTRODUCTION
I. STATEMENT OF THE PROBLEM
Optometry has a long history of caring for individuals with learning
problems.1-3 Parents, teachers, and therapists often seek diagnostic A. GENERAL CONSIDERATIONS
evaluation to determine whether a vision problem could be a factor
contributing to learning problems. In addition, intervention strategies 1. Effects
developed by optometry have been incorporated into conventional
therapeutic approaches for these individuals. Thus, Doctors of The standards of learning competencies required meeting changing
Optometry function as members of a multidisciplinary team of health societal needs and conditions are increasing. Full participation in
care practitioners and special education professionals in the science, technology, business, and the professions requires increasing
comprehensive care of individuals with learning problems.4,5 The Joint levels of learning, particularly reading.7 Therefore, learning problems are
Organizational Policy Statement on Vision, Learning and Dyslexia a public health issue of widening significance.8 They can decrease the
addresses these issues (See Appendix Figure 1).6 quality of life for the affected individual, delay academic achievement,
and reduce employment and earnings opportunities.9,10 Self-esteem and
This Optometric Clinical Practice Guideline on Care of the Patient with peer relationships can be negatively influenced.11,12 There is also the
Learning Related Vision Problems describes appropriate evaluation possibility of lasting effects on family function, with stresses placed on
methods and management strategies to reduce the risk of vision the community and family for financial and service resources.13
problems’ interference with the learning process. It contains
recommendations for timely diagnosis, intervention, and, when The emphasis on reading achievement reached national prominence with
necessary, referrals for consultation and/or treatment by another health the sweeping No Child Left Behind Act of 2001, Public Law 107-110
care provider or education professional. This Guideline will assist (NCLB) that reauthorized the Elementary and Secondary Education Act -
Doctors of Optometry in achieving the following goals: - the main federal law affecting education from kindergarten through
• Diagnose learning related vision problems high school. NCLB is built on four principles: accountability for results,
• Improve the quality of care provided to patients with learning related more choices for parents, greater local control and flexibility, and an
vision problems emphasis on doing what works based on scientific research. Reading
• Select appropriate evaluation instruments to evaluate learning related First is the academic cornerstone of the No Child Left Behind Act.
vision problems Reading First provides grants to states to help schools and school
• Select appropriate management strategies for patients with learning districts improve children's reading achievement through scientifically
related vision problems proven methods of instruction. The program funds instructional
• Minimize the adverse effects of learning related vision problems and programs, materials and strategies, screening, and diagnostic and
enhance quality of life classroom assessments.
• Inform and educate other health care professionals, parents, teachers,
and the educational system about the nature of learning related vision Undetected and untreated vision problems are of great concern because
problems and the availability of treatment. they can interfere with the ability to perform to one's full learning
potential.6 When these vision problems have an adverse effect on
learning, they are referred to as learning related vision problems.
Statement of the Problem 3 4 Learning Related Vision Problems
The definition of learning related vision problems is not universal among 6. Visual Efficiency and Learning
educators and other health professionals. Too often it is interpreted
narrowly as distance visual acuity. Although distance visual acuity is Visual efficiency is related to learning, and the avenues for visual
relevant for such tasks as copying from the whiteboard, other aspects of efficiency problems to impact learning potential are numerous.41-43 Eye
vision involving efficiency and information processing are fundamental discomfort may make it difficult to complete school tasks or homework
to such near-point activities as reading, writing, and other classroom and assignments in a timely manner. Distraction or inattention may become
learning activities. Proper diagnosis of learning related vision problems secondary complications. Task avoidance is a frequently overlooked
therefore requires comprehensive evaluation of visual efficiency and effect. The presence of severe asthenopia during visual tasks can lead to
visual information processing skills. less time on task, decreasing the opportunity for practice and learning,
particularly in vocabulary development, comprehension, and reading
5. Reading Disabilities and Dyslexia mechanics. A harmful associative relationship between eye discomfort
and the learning activity can develop, leading to disinterest and poor
For the majority of individuals with learning disabilities, reading motivation for traditional learning activities.
disability is their primary deficit.28,29 The role of phonological
processing deficits in the understanding of reading disability is Blurred, diplopic, or distorted text can be expected to decrease word
significant.30-33 These deficits are manifested in the failure to use or processing speed and efficiency, reduce reading rate, and compromise
properly understand phonological information when processing written reading comprehension. Inadequate attention allocation for information
or oral language. This is seen in the inadequacy of phonemic awareness processing can exist when attention is diverted to manage the visual
(synthesis, analysis, segmentation), the poor understanding of sound- efficiency problem at the expense of the ongoing processing required for
symbol (or later grapheme-phoneme) correspondence rules, and the learning. The proliferation of computer-assisted instruction in the school
improper storage and retrieval of phonological information. There can setting -- notwithstanding the dramatic increase in computer use at home
also be difficulties with short-term and long-term memory that affect and school -- has created an even greater demand for visual efficiency.
comprehension.
7. Visual Information Processing and Learning
The use of the term “dyslexia” to describe some form of reading
disability has been the subject of much discourse.34 Its application has The importance of visual information processing skills for learning is
ranged from the description of reading difficulties only associated with self-evident.44-46 Visual information processing skills provide the
traumatic brain injury to a general synonym for all developmental capacity to organize, structure, and interpret visual stimuli, giving
reading disabilities. It is best understood as a cognitive deficit that is meaning to what is seen. Veridical visual information processing leads
specifically related to the reading and spelling processes. There are two to perceptual constancy, creating a stable and predictable visual
situations in which the term dyslexia now commonly applies. The first is environment. These are important attributes for every learning situation.
when the reader has difficulty decoding words (i.e., single word Visual information processing skills considered separately and
identification) and encoding words (i.e., spelling).35,36 The second -- a collectively are related to learning ability and contribute to the total
frequent presentation in optometric practice -- is when the reader makes variance in academic achievement.47-58 Individuals with learning
a significant number of letter reversal errors (e.g., b - d), letter problems can present with distinct patterns or combinations of visual
transpositions in words when reading or writing (e.g., sign - sing), or has information processing deficits.
left-right confusion.37-40
Statement of the Problem 7 8 Learning Related Vision Problems
8. Timing of Vision Related Learning Problems efficiency problems is thought to be in the 15 to 20 percent range.73-78
Accommodative dysfunctions have been reported to occur in 60 to 80
During pre-school and the early school years, academic instruction percent of individuals with vision efficiency problems; with
places relatively greater demand on a child’s visual information accommodative insufficiency the most prevalent subtype and
processing skills.59 There is an emphasis on recognition, matching, and convergence insufficiency the most common vergence anomaly.21
recall. Periods of sustained near work are infrequent, and visual stimuli
(i.e., letters) are relatively large and widely spaced. Visual efficiency Convergence insufficiency is of particular interest because it has been
and visual processing speed become relatively more significant later in shown to have an impressive prevalence rate among school-aged
the educational process. Reading demands increase with the need to children, with accommodative insufficiency an important co-morbid
achieve grade-appropriate rates of reading with comprehension (fluency) condition.79 The Convergence Insufficiency and Reading Study Group
over more extended periods of time, when letters and text become (CIRS) found that a considerable number of children with convergence
smaller and more closely spaced. Equally, this increase in sustained and/or accommodative insufficiency report symptoms of blurred or
periods of near work becomes a significant risk factor for the double vision.80 These learning related vision problems, when present,
development of visual efficiency problems. Demands for reading and represent risk factors for delayed reading progress. An expression of this
writing fluency create a requirement for efficient and well-timed visual effect can be found in the other reported symptoms of convergence
information processing. insufficiency; namely, slow reading and difficulty with reading
comprehension. The CIRS group found that children with a definitive
B. EPIDEMIOLOGY convergence insufficiency are described as easily frustrated, distractible,
with short attention spans and had problems finishing tasks.81
Estimates of the prevalence of learning problems among school-aged
children range from 2 to 10 percent, depending on the nature of the C. COURSE AND PROGNOSIS
diagnostic process and the definitions applied by individual school
districts.60,61 The prevalence of learning disabilities is subject to some Although some behaviors commonly associated with learning problems
dispute because of the lack of an agreed upon definition with may occur before a child enters school, formal diagnosis of learning
identification criteria. Nationally, nominally 5 percent of all school disabilities usually does not begin until the end of kindergarten or during
children are diagnosed with learning disabilities; a greater number have first grade, because formal academic instruction begins at that time.
milder learning problems. Learning disabilities account for nearly half of During the preschool years, failure to achieve developmental milestones
all children receiving special educational services. Of that number, as may be the first indication of risk for the appearance of learning
many as 75 percent have particular difficulty with reading. While it was disabilities. Delays in gross and fine-motor development, visual
previously thought that males were more affected than females, evidence information processing, receptive and/or expressive language,
now indicates that an equal number of male and females are affected.62-64 particularly phonological processing may be antecedents to learning
Learning disabilities are both familial and heritable.65-67 problems. Family risk factors and heredity are also important
considerations.82-83 Letter identification and phoneme identification
Appraisals of the prevalence of learning related vision problems vary contribute independently to the prediction of learning problems.84 The
considerably, depending on the definitions, sample selection criteria, and purpose of early screening and intervention programs is to identify
the examination methods used. At least 20 percent of individuals with children with developmental delays who may be at significant risk for
learning disabilities are thought to have a prominent visual information learning problems.
processing deficit.68-72 The prevalence of clinically significant visual
Statement of the Problem 9 10 Learning Related Vision Problems
With early diagnosis and appropriate, comprehensive intervention, the II. CARE PROCESS
prognosis is good in a majority of cases. Symptoms of learning
disabilities frequently persist into adolescence and adult life and rarely A. GENERAL CONSIDERATIONS
disappear entirely.85-88
Care of the patient with learning related vision problems involves taking
The clinical presentation of persistent visual efficiency problems may a patient history and examining visual efficiency, visual information
change during periods of remission and exacerbation, depending on processing ability, and visual pathway integrity. The Optometric
prevailing intrinsic and extrinsic influences. Clinical Practice Guideline for the Pediatric Eye and Vision Examination
should be consulted for additional information.89
Visual information processing deficits are usually considered
developmental in nature. With maturation and experience there will be B. PATIENT HISTORY
increases in performance, but the rate of progression of skill
development continues to lag. The patient history is the initial component of the care process and an
important part of an appropriate diagnosis.90 Collection of demographic
D. EARLY DETECTION data usually precedes and supplements the history taking. A
questionnaire completed by the parent or caregiver can facilitate the
Because the evidence that learning related vision problems can be history process. Special attention should be directed to developmental
prevented to any substantial degree is inconclusive, the emphasis is on milestones and academic performance.91-92 Questions should be
early detection. It is recommended that vision examinations be constructed to define the specific nature of the learning and vision
scheduled at 6 months, 3 years of age, and at entry into school,89 at which problems and should be used as a guide for the subsequent testing
time the parents should complete a developmental questionnaire. If there sequence. Information obtained directly from teachers or therapists can
is a history of developmental delay, a screening test like the Denver II be helpful.
can be performed. When visual information processing problems are
suspected, a more extensive evaluation is necessary for the early Language delays are common in individuals with learning problems. As
identification of the child at risk for the development of learning related a result, sufficiently detailed descriptions of learning or visual symptoms
vision problems. obtained directly from the patient may be lacking. This could result in an
underestimation of the severity of the symptoms and should not be the
Most school districts now conduct some form of developmental exclusive source of such information.
screening before children enter school. Such screenings tend not to
explore visual information processing development as extensively as A comprehensive patient history for learning related vision problems
needed. The majority of school vision screening programs only assesses may include:
distance visual acuity. This is woefully inadequate in detecting most Chief concern or complaint
learning related vision problems. Thorough eye and vision examinations History of present illness
during the preschool years, and consistently through the school years Patient visual history
continue to be the most effective approach to early detection of visual Patient ocular history
efficiency and information processing problems. In recent public health Patient medical history
acknowledgements of the need for early detection and intervention, some Exploration of risk factors: peri-natal events, childhood illnesses
states now require a comprehensive eye examination before school entry. Developmental history
The Care Process 11 12 Learning Related Vision Problems
Gross motor Though they are extremely important functional vision disorders to
Fine motor diagnose and treat early, other binocular vision disorders such as
Language constant strabismus and amblyopia have not been found to be associated
Personal/social milestones with learning problems.
Family history
Visual/ocular Some patients with visual information processing deficiencies,
Medical particularly deficiencies of discrimination and memory may have
Academic/educational difficulty making reliable responses during subjective testing. The
Academic/educational history clinician may have to make necessary compensations or use alternative
Previous assessments and interventions testing procedures to obtain relevant information. Reliance on objective
Current assessment, interventions, and placement findings for clinical decision-making may be necessary.
Occupational/physical therapy
Speech and language 1. Visual Acuity
Learning disability
Psychoeducational Assessment of visual acuity in patients with learning related vision
Remedial reading problems should be measured monocularly and binocularly at distance
Behavioral and near point. Patients with sufficient verbal communication who know
Current achievement levels the alphabet can be tested using a Snellen chart. If difficulties are
Reading encountered, an assessment of visual acuity may include the following
Spelling methods:
Mathematics
Writing ¾ HOTV
Academic/education-related medical history ¾ Broken Wheel
Pediatric ¾ Tumbling E.
Neurological
Audiological The Optometric Clinical Practice Guideline for the Pediatric Eye and
Medications Vision Examination should be consulted for additional information.89
Visual efficiency problems are related to learning achievement. An The measurement of refractive error should include:
analysis of the literature on the subject indicates that refractive error -- in
particular hyperopia and significant anisometropia, accommodative and ¾ Static retinoscopy
vergence dysfunctions, and eye movement disorders -- are associated ¾ Subjective refraction.
with learning problems.93-106 Therefore, a thorough clinical investigation
for the presence of these conditions in the individual with learning Because of the importance of detecting hyperopia -- particularly latent
problems is important. hyperopia -- proper fogging technique should be maintained during
retinoscopy and subjective refraction. A cycloplegic refraction may be
The Care Process 13 14 Learning Related Vision Problems
indicated if latent hyperopia or pseudomyopia is suspected, or if clinical signs and symptoms of ocular motility deficiencies can be found
convergence excess or accommodative insufficiency is diagnosed. in Table 1.
Both systems investigate predictive saccades between two fixed targets Unfortunately, naming tasks confound the results because both eye
positioned centrally, equidistant from the midline. Hypometric movement skill and naming speed are required to complete the test
inaccuracies are commonly found in individuals with poor saccadic eye successfully. However, because the DEM incorporates a subtest of
movement control. Excessive head and body movements (motor naming speed that isolates eye movement skill for a more specific
overflow) frequently accompany ocular motility deficiencies. The clinical diagnosis, it’s use is preferred.
The Care Process 15 16 Learning Related Vision Problems
additional information consult the Optometric Clinical Practice spatial directions, and understanding the orientation of alphanumeric
Guideline for the Pediatric Eye and Vision Examination.89 symbols. The clinical signs and symptoms of visual spatial orientation
skill deficiencies can be found in Table 3.
D. VISUAL INFORMATION PROCESSING EVALUATION
Table 3
1. General Considerations Signs and Symptoms of Visual Spatial
Orientation Skill Deficiency
The visual information processing skills that require testing are visual
spatial orientation skills, visual analysis skills, including auditory-visual
integration, visual-motor integration skills and rapid naming.125,126 When • Delayed development of gross motor skills
available, norm-referenced tests are preferred for this purpose.127 Testing
• Decreased coordination, balance, and ball-playing skills
should be conducted uniformly and according to the exact methods
• Confusion of right and left
specified in the test instructions. Specified rule-based scoring procedures
should be followed. Qualitative insights from observation of the test • Letter reversal errors when writing or reading
taker's behavior can provide important supplementary information for • Inconsistent directional attack when reading
diagnosis and management. Attention to task, ability to understand the • Inconsistent dominant handedness
instructional set, cognitive style, problem-solving ability, frustration • Difficulty in tasks requiring crossing of the midline
tolerance, and excessive motor activity are some of the behaviors worth
observing.
Visual spatial orientation skills are frequently subdivided into bilateral
Testing should be done without interruption in a relatively quiet integration, laterality, and directionality. Bilateral integration is the
environment. Individuals with attention deficits may require rest periods awareness and use of the extremities, both separately and simultaneously
between tests or multiple testing sessions. For a comprehensive visual in unilateral and bilateral combinations. Laterality is the internal
information processing evaluation, one or two tests from each category representation and sensory awareness of both sides of one's own body.
can be selected for administration. For a detailed or problem-focused Directionality is the ability to understand and identify right and left
evaluation of a specific visual information processing skill, multiple tests directions in external visual space, including orientation specificity of
from the same category can be administered. written language symbols. Collectively, these contribute to the
development of visual-orthographic skills for the ability to recognize
2. Visual Spatial Orientation Skills whether letters and numerals as correctly oriented. When visual-
orthographic deficits are present, it can be associated with poorer reading
Visual spatial orientation is the awareness of one's own position in space performance.
relative to other objects, as well as the location of objects relative to each
other. It includes body knowledge and control, as well as bimanual Visual spatial orientation skills can be evaluated by several categories of
integration and is understood as a component of overall perceptual-motor tests:
integration development. Visual spatial orientation skills involve the
ability to understand directional concepts, both internally and projected a. Bilateral Integration
into external visual space. These skills are important for balance and
coordinated body movements, navigation in the environment, following ¾ Body Knowledge and Control - Standing Test
The Care Process 19 20 Learning Related Vision Problems
¾ Chalkboard Circles Test. concepts. Non-motor visual analysis skills have traditionally been
subdivided into separate theoretical constructs: visual discrimination,
Body knowledge and control requires the conversion of a tactile stimulus visual figure-ground discrimination, visual closure, visual memory, and
into a motor response -- i.e., moving the extremities in response to touch visualization.
-- while standing. The chalkboard circles test requires the simultaneous
production of large circles with both hands symmetrically and Visual discrimination is the awareness of distinctive features of objects
reciprocally on a large chalkboard, with the eyes fixating straight ahead. and written language symbols, including form, shape, orientation, and
Each of these two criterion referenced tests is scored by observing size. Visual figure-ground discrimination is the ability to select and
performance and comparing it to an age-related criterion. process an object or a specific feature of an object from a background of
competing stimuli. Visual closure is the capacity to identify an object
b. Laterality and Directionality accurately when the details and features available for analysis and
processing are incomplete. Visual memory is the ability to recognize or
¾ Piaget Right-Left Awareness Test recall previously presented visual stimuli, whether individual or grouped
¾ Reversals Frequency Test (RFT) in a specific sequence. Two aspects of visual memory are considered:
¾ Jordan Left-Right Reversal Test, Revised visual sequential memory and visual spatial memory. Visual sequential
¾ Test of Pictures / Forms / Letters / Numbers Spatial Orientation memory requires the recall of an exact sequence of letters, numbers,
& Sequencing Skills (TPFLNSOSS). symbols, or objects. Visual spatial memory requires recall of the spatial
location of a previously seen stimulus and the ability to identify or
The criterion-referenced Piaget Right-Left Awareness test requires a reproduce it. Another feature, visualization requires the ability to
response to verbal instruction to move a named extremity and to place manipulate visual images mentally.
objects to the right or left of another object. The Reversals Frequency
and Jordan tests are both norm-referenced and require the recognition of Visual analysis skills can be tested with the following:
correctly oriented letters and numbers. The Reversals Frequency Test
has an execution subtest that evaluates the frequency of reversal errors ¾ Test of Visual Perceptual Skills, Third Edition (TVPS-3)
that occur when writing letters and numbers from dictation. The norm- ¾ Motor Free Vision Perception Test, Third Edition (MVPT-3)
referenced TPFLNSOSS tests the ability to visually perceive forms, ¾ Developmental Test of Visual Perception, Second Edition
letters and numbers in the correct orientation and to visually perceive (DTVP-2).
words with the letters in the correct sequence.
The clinical signs and symptoms of non-motor visual analysis skill
3. Visual Analysis Skills deficiencies can be found in Table 4.
a. Non-motor Skills
Table 4 Table 5
Signs and Symptoms of Non-Motor Visual Analysis Skill Deficiency Signs and Symptoms of Visual-Motor Skill Deficiency
attention, visual memory, visual information processing speed, second letter "B" and so on. The numbers and letters are placed in quasi-
sequencing, and cognitive flexibility. Depending on test design, visual– random order. The primary variables of interest are the total time to
motor skills, including fine-motor dexterity and speed, ocular motility completion for parts A and B.
and visual search skills are also involved.
The Children’s Color Trail Test is similar but uses colors and numbers
Executive function can be tested with the following: rather than letters, because they are easier for children to process and
recognize than letters. In Part I of the CCTT, quasi-randomly placed
¾ Symbol Digit Modalities Test (SDMT) numbers from 1 through 15, printed on two different colored circles
¾ Children’s Trail Making Test (CTMT) (pink and yellow) are connected in consecutive order by pencil. Part 2
¾ Children’s Color Trail Test (CCTT) again requires connecting the numbers consecutively, but alternating
¾ Wisconsin Card Sorting Test – Revised (WCST-R). between the two colored circles (pink circle 1, yellow circle 2, pink circle
3).
Table 8
Signs and Symptoms of Executive Function Deficiencies The Wisconsin Card Sorting Test requires the matching (sorting) of 64
stimulus cards. Each displays figures of varying forms (crosses, circles,
triangles, or stars), colors (red, blue, yellow, or green), and number of
figures (one, two, three, or four). These are matched to one of four key
• Impaired reading fluency
cards (each with one, two, three and four identically colored symbols
• Difficulty completing tasks in the designated time
(four blue circles, three yellow crosses, two green stars and one red
• Poor sustained attention triangle). Test administration is purposely ambiguous; no instructions on
• Distractibility “how” to sort are given.
• Difficulty switching between tasks
• Poor planning of visually oriented tasks
E. SUPPLEMENTAL TESTING
The following comprehensive assessment batteries are suggested: A brief assessment of phonological processing skill can be beneficial in
determining the relative influence of phonological deficits compared to
¾ Dyslexia Screening Test – Junior (DST-J) visual efficiency problems and/or visual information processing deficits
¾ Dyslexia Screening Test – Secondary (DST-S). in explaining the essential nature of the reading deficiency.
The Dyslexia Screening Tests (DST-J, 6 years 6 months to 11 years 5 Standardized tests that are available to analyze phonological processing
months; DST-S, 11 years 6 months to 16 years 5 months) are a abilities:
comprehensive and diverse series of tests that purports to identify
children who are at risk of reading delays. The tests include both ¾Phonemic Segmentation subtest of the Dyslexia Screening Test
achievement tests (1 minute reading, 2 minute spelling, 1 minute writing (DST)
and vocabulary) and a series of diagnostic tests to access a range of skills ¾Rhyme subtest of the Dyslexia Screening Test (DST)
that may be significant in the development of reading problems. These ¾Nonsense Passage Reading subtest of the Dyslexia Screening Test
tests include measures of phonemic segmentation, rhyme detection and (DST)
nonsense passage reading for phonological processing assessment, ¾Rosner Test of Auditory Analysis Skills (TAAS)
auditory memory, verbal and semantic fluency and fine motor skill. Two ¾Phonological Awareness Test-2 (PAT-2)
additional measures augment these tests by their modeling which predict ¾Test of Phonological Awareness Skills (TOPAS).
The Care Process 31 32 Learning Related Vision Problems
between 1.0 and 1.5 standard deviations below the mean should be extent that visual deficits influence school performance, improvement
considered suspicious and perhaps clinically relevant, depending on the can result from optometric intervention.
overall clinical picture, the nature and type of the learning problem, and
the level of overall cognitive function. Learning related vision problems are usually managed in a progressive
sequence. Treatment should begin with consideration of refractive
Parents and school systems often prefer the expression of performance as status. Careful attention should be paid to the correction of hyperopia
an age or grade equivalent, or as a percentile rank, to enable direct and anisometropia because of their known association with learning
comparison with expected performance levels. It is important to relate problems. Sometimes even slight degrees of hyperopia or anisometropia
visual information processing test results to the current level of cognitive can be problematic.
function as measured by IQ tests (such as the Weschler Intelligence
Scale for Children – IV or Stanford-Binet Intelligence Scales, Fifth Next, visual efficiency deficits should be treated aggressively, using
Edition). In the case of individuals with low average IQ scores, overall lenses, prisms, and vision therapy. The Optometric Clinical Practice
performance in visual information processing in the same range may not Guideline for Care of the Patient with Accommodative and Vergence
be indicative of a problem, but rather the expected level of performance. Dysfunction offers more detailed management recommendations.21 The
specific goal for the treatment of visual efficiency deficits is
G. MANAGEMENT enhancement of the range, latency, accuracy, facility, and sustainability
of accommodative and vergence responses. At the conclusion of
The goal of the management of learning related vision problems is to therapy, ocular motility should be more accurate, and the incidence of
prepare the individual to take full advantage of the opportunities for accompanying head and body movement lower.
learning. Optometric intervention directed toward improving visual
function to its appropriate level183 has been shown to be Correction of refractive error and treatment of visual efficiency
efficacious.21,75,184-191 It does not replace conventional educational dysfunctions can result in improved visual information processing.75
programming but is a necessary complementary intervention to Nevertheless, the treatment of vision information processing deficits
maximize the learning environment and the effectiveness of pedagogy. usually requires vision therapy, which can begin during the later stages
In most situations, optometric intervention for learning related vision of visual efficiency therapy. When deficits in visual efficiency are
problems is delivered in conjunction with other professionals involved in minor, information processing therapy can be initiated at the outset. The
the management of the learning problem from an educational or medical approach is typically hierarchical, beginning with visual spatial
perspective. Interdisciplinary communication, consultation, and referral orientation, then continuing with visual analysis and concluding with
are vital for the most effective management of the individual with visual-motor integration. Attention should be directed toward improving
learning problems. the rate of visual information processing. The goals of visual
information processing therapy can be found in Table 9. Developing
The management of learning related vision problems should be directed intrinsic motivation so that the patient becomes aware of increasing
at the identification and treatment of specific visual deficits. The mastery of the skill being acquired is an important part of the therapy
expectation for intervention should be the reduction or elimination of the program.192,193
signs and symptoms associated with particular visual deficits. The goals
of optometric intervention should be specific and problem oriented,
rather than indefinite such as “to improve school performance.” To the
The Care Process 35 36 Learning Related Vision Problems
and symptoms is necessary. The management plan and prognosis should CONCLUSION
be presented to the patient and parents or caregivers. Communication
with education professionals about the diagnosis, proposed management Learning related vision problems comprise deficits in visual efficiency
plan, and expected outcomes should be initiated. This should lead to a and visual information processing that have potential to interfere with the
coordinated effort with the patient’s classroom teachers, special ability to perform to one's full learning potential. These deficits may
education teachers, and therapists. The importance of continuing eye cause clinical signs and symptoms that range from asthenopia and
care should be discussed with parents or caregivers. Other education and blurred vision to delayed learning of the alphabet, difficulty with reading
health care professionals should be informed about the presence and and spelling, and skipping words and losing place when reading.
nature of the learning related vision problems and their relationship to
extant learning difficulties. Vision related learning problems have a relatively high prevalence in the
population. They respond favorably to the appropriate use of lenses,
prisms, and vision therapy, either alone or in combination. Vision
therapy is usually conducted in-office, and home support activities are
prescribed. The goal of optometric intervention is to improve visual
function to the appropriate level.
III. REFERENCES 11. Elbaum B, Vaughn S. Self-concept and students with learning
disabilities. In: Swanson HL, Graham S, Harris KR, eds.
1. Flax N. Visual function in dyslexia. Am J Optom Arch Am Acad Handbook of Learning Disabilities. New York, NY: Guilford
Optom 1968;45:574-87. Press, 2005.
2. Flax N. The eye and learning disabilities. J Am Optom Assoc 12. Nowicki EA. A meta-analysis of the social competence of children
1972; 43:612-7. with learning disabilities compared to classmates of low and
average to high achievement. Learn Disabil Q 2003;26:171-88.
3. Solan HA. Learning disabilities: the role of the developmental
optometrist. J Am Optom Assoc 1979;50:1259-65. 13. Kauffman JM, Trent SC. Issues in service delivery for students
with learning disabilities. In: Wong BYL, ed. Learning about
4. Grosvenor T. Are visual anomalies related to reading disability? J learning disabilities. San Diego, CA: Elsevier Academic Press,
Am Optom Assoc 1979;48:510-9. 2004.
5. Hoffman LG. The role of the optometrist in the diagnosis and 14. Borsting E. Visual perception and reading. In: Garzia RP, ed.
management of learning-related vision problems. In: Scheiman Vision and reading. St. Louis, MO: Mosby-Year Book, 1996.
MM, Rouse MW, eds. Optometric management of learning-
related vision problems, 2nd ed. St. Louis, MO: Mosby-Elsevier, 15. Torgesen JK. Conceptual, historical and research aspects of
2006. learning disabilities. In: Wong BYL, ed. Learning about learning
disabilities. San Diego, CA: Elsevier Academic Press, 2004.
6. American Academy of Optometry, American Optometric
Association. Vision, learning and dyslexia: a joint organizational 16. Denckla M. Biological correlates of learning and attention: what is
policy statement. J Am Optom Assoc 1997;68:284-6. relevant to learning disability and attention-deficit hyperactivity
disorder? J Dev Behav Pediatr 1996;17:114-9.
7. Becoming a Nation of Readers: the report of the commission on
reading. Washington, DC: National Institute of Education, 1985. 17. Harris KR, Reidy R, Graham S. Self-regulation among students
with learning disabilities. In: Wong BYL, ed. Learning about
8. McAlister WH, Garzia RP, Nicholson SB. Public health issues learning disabilities. San Diego, CA: Elsevier Academic Press,
and reading disability. In: Garzia RP, ed. Vision and reading. St. 2004.
Louis, MO: Mosby-Year Book, 1996.
18. Rowland AS, Lesesne CA, Abramowitz AJ. The epidemiology of
9. Smith M, Mikulecky L, Kibby MW, et al. What will be the attention-deficit/hyperactivity disorder (ADHD): A public health
demands of literacy in the workplace in the next millennium? view. Men Retard Dev Disabil Res Rev 2002;8:162-70.
Reading Res Q 2000;35:378–83.
19. Kavale KA, Mostert MP. Social skills interventions for
10. Belfiore ME, Defoe TA, Folinsbee S, et al. Reading work: individuals with learning disabilities: a meta-analysis. Learn
literacies in the new workplace. Mahway, NJ: Lawrence Erlbaum, Disabil Q 2004;27:31-43.
2004.
References 41 42 Learning Related Vision Problems
25. Fletcher JM, Foormana BR, Boudousquieaa A, et al. Assessment 33. Brady S, Shankweiler D. Phonological processes in literacy.
of reading and learning disabilities: a research-based intervention- Hillsdale, NJ: Lawrence Erlbaum, 1991.
oriented approach. J School Psychol 2002;40:27-63.
34. Benton AL. Dyslexia and visual dyslexia. In: Stein JF, ed.
26. Lerner JW, Kline F. Learning disabilities and related disorders: Vision and visual dyslexia. Boca Raton, FL: CRC Press, 1991.
characteristics and teaching strategies, 10th ed. Boston, MA:
Houghton Mifflin, 2005. 35. Shaywitz SE. Dyslexia. New Engl J Med 1998; 338:307-12.
27. Selznick R, Blaskey P. Psychoeducational evaluation. In: 36. Lyon GR, Shaywitz SE, Shaywitz BA. A definition of dyslexia.
Scheiman MM, Rouse MW, eds. Optometric management of Ann Dyslexia 2003;53:1-14.
learning-related vision problems, 2nd ed. St. Louis, MO: Mosby-
Elsevier, 2006. 37. Willows DM, Terepocki M. The relation of reversal errors to
reading disabilities. In: Willows DM, Kruk R, Corcos E, eds.
28. Interagency Committee on Learning Disabilities. Learning Visual processes in reading and reading disabilities. Hillsdale, NJ:
disabilities: a report to the U.S. Congress. Washington, DC: Lawrence Erlbaum, 1993.
Government Printing Office, 1987.
References 43 44 Learning Related Vision Problems
38. Griffin JR, Christensen GN, Wesson MD, et al. Optometric 47. Kavale K. Meta-analysis of the relationship between visual
management of reading dysfunction. Boston, MA: Butterworth- perceptual skills and reading achievement. J Learn Disabil
Heinemann, 1997. 1982;15:42-51.
39. Terepocki M, Kruk RS, Willows D.M. The incidence and nature of 48. Larsen SC, Hammill DD. The relationship of selected visual
letter orientation errors in reading disability. J Learn Disabil perceptual abilities to school learning. J Spec Educ 1975;9:281-
2002;35:214-33. 91.
40. Badian NA. Does a visual-orthographic deficit contribute to 49. Fischer B, Hartnegg K, Mokler A. Dynamic visual perception of
reading disability? Ann Dyslexia 2005;55:28-52. dyslexic children. Perception 2000;29:523–30.
41. Garzia RP. The relationship between visual efficiency problems 50. Goulandris NK, Snowling M. Visual memory deficits: a plausible
and learning. In: Scheiman MM, Rouse MW, eds. Optometric cause of developmental dyslexia? Evidence from a single case
management of learning-related vision problems, 2nd ed. St. Louis, study. Cogn Neuropsychol 1991;8:127-54.
MO: Mosby-Elsevier, 2006.
51. Farnham-Diggory S, Gregg LW. Short term memory function in
42. Grisham D, Simons H. Perspectives on reading disabilities. In: young readers. J Exp Child Psychol 1975;19:279-98.
Rosenbloom AA, Morgan MM, eds. Principles and practice of
pediatric optometry. Philadelphia, PA: J.B. Lippincott, 1990. 52. Morrison FJ, Giordano B, Nagy J. Reading disability: an
informational processing analysis. Science 1977;196:77-9.
43. Garzia RP. Optometric factors in reading disability. In: Willows
DM, Kruk R, Corcos E, eds. Visual processes in reading and 53. Solan HA, Ficarra AP. A study of perceptual and verbal skills of
reading disabilities. Hillsdale, NJ: Lawrence Erlbaum, 1993. disabled readers in grades 4, 5, and 6. J Am Optom Assoc
1990;61:628-34.
44. Groffman S. The relationship between visual perception and
learning. In: Scheiman MM, Rouse MW, eds. Optometric 54. Keogh BF, Smith CE. Visual motor ability and school prediction:
management of learning-related vision problems, 2nd ed. St. Louis, a seven year study. Percept Mot Skills 1967;25:101-10.
MO: Mosby-Elsevier, 2006.
55. Solan HA, Mozlin R. The correlations of perceptual-motor
45. Solan HA. Learning disabilities. In: Rosenbloom AA, Morgan maturation to readiness and reading in kindergarten and the
MM, eds. Principles and practice of pediatric optometry. primary grades. J Am Optom Assoc 1986;57:28-35.
Philadelphia, PA: J.B. Lippincott, 1990.
56. Willows DM, Kruk R, Corcos E. Are there differences between
46. Solan HA, Ciner EB. Visual perception and learning: issues and disabled and normal readers in their processing of visual
answers. J Am Optom Assoc 1989;60:457-60. information? In: Willows DM, Kruk R, Corcos E, eds. Visual
processes in reading and reading disabilities. Hillsdale, NJ:
Lawrence Erlbaum, 1993.
References 45 46 Learning Related Vision Problems
57. Santiago HC, Matos I. Visual recognition memory in specific 67. Grigorenko EL. The biological foundations of developmental
learning disabled children. J Am Optom Assoc 1994;65:690-700. dyslexia. In: Sternberg RJ, Spear-Swerling L, eds. Perspectives
on Learning Disabilities: Biological, Cognitive, Contextual.
58. Kulp MT. Relationship between visual motor integration skill and Boulder, CO: Westview Press, 2000.
academic performance in kindergarten through third grade. Optom
Vis Sci 1999; 76:159-63. 68. Mattis S, French JH, Rapin I. Dyslexia in children and adults:
three independent neuropsychological syndromes. Dev Med Child
59. Flax N. The relationship between vision and learning: general Neurol 1975;17:150-63.
issues. In: Scheiman MM, Rouse MW, eds. Optometric
management of learning-related vision problems, 2nd ed. St. Louis, 69. Boder E. Developmental dyslexia: a diagnostic approach based
MO: Mosby-Elsevier, 2006. on three atypical reading-spelling patterns. Dev Med Child Neurol
1973;15:663-87.
60. Lyon GR. The Future of Children. Learn Disabil 1996;6:54-76.
70. Lyon GR, Watson B. Empirically derived subgroups of learning
61. Altarac M, Saroha E. Lifetime prevalence of learning disability disabled readers: diagnostic characteristics. J Learn Disabil 1981;
among US children. Pediatrics 2007;119 Suppl:S77-S83. 14:256-61.
62. Shaywitz SE, Shaywitz BA, Fletcher JM, et al. Prevalence of 71. Bender WN, Golden LB. Subtypes of students with learning
reading disability in boys and girls: results of the Connecticut disabilities as derived from cognitive, academic, behavioral, and
Longitudinal Study. JAMA 1990;264:998-1002. self-concept measures. Learn Disabil Q 1990;13:183-94.
63. Wadsworth SJ, DeFries JC, Stevenson J, et al. Gender ratios 72. Watson BU, Goldgar DE. Subtypes of learning disability. J Clin
among reading disabled children and their siblings as a function of Neuropsychol 1983;5:377-99.
parental impairment. J Child Psychol Psychiat 1992;33:1229-39.
73. Scheiman M, Gallaway M, Coulter R. Prevalence of vision and
64. Flynn JM, Rahbar MH. Prevalence of reading failure in boys ocular disorders in a clinical pediatric population. J Am Optom
compared with girls. Psychol School 1994;31:66-72. Assoc 1996;67:193-202.
65. Thomson JB, Raskind WB. Genetic influences on reading and 74. Hokoda SC. General binocular dysfunctions in an urban
writing disabilities. In: Swanson HL, Graham S, Harris KR, eds. optometry clinic. J Am Optom Assoc 1985;56:560-2.
Handbook of Learning Disabilities. New York: Guilford Press,
2005. 75. Hoffman LG. Incidence of vision difficulties in children with
learning disabilities. J Am Optom Assoc 1980;51:447-51.
66. Nopola-Hemmi J, Myllyluoma B, Voutilainen A. Familial
dyslexia: neurocognitive and genetic correlation in a large Finnish 76. Bennett GR, Blondin M, Ruskiewicz J. Incidence and prevalence
family. Devel Med Child Neurol 2002;44:580–586. of selected visual conditions. J Am Optom Assoc 1982;53:647-56.
References 47 48 Learning Related Vision Problems
77. Montes-Mico R. Prevalence of general dysfunctions in binocular Developmental lag versus deficit models of reading disability: A
vision. Ann Ophthalmol 2001;33:205-8. longitudinal, individual growth curves analysis. J Educ Psychol.
1996:88:3-17.
78. Rouse MW, Hyman L, Hussein M, et al. Frequency of
convergence insufficiency in optometry clinic settings. Optom Vis 88. Swanson HL, Saez L. Memory difficulties in children and adults
Sci 1998;75:88-96. with learning disabilities. In: Swanson HL, Graham S, Harris KR,
eds. Handbook of Learning Disabilities. New York: Guilford
79. Rouse MW, Borsting E, Hyman L, et al. Frequency of convergence Press, 2005.
insufficiency among fifth and sixth graders. Optom Vis Sci
1999;76:643-9. 89. Optometric clinical practice guideline: pediatric eye and vision
examination. St. Louis, MO: American Optometric Association,
80. Borsting E, Rouse MW, Deland PN, et al. Association of 2002.
symptoms and convergence and accommodative insufficiency in
school-aged children. Optometry 2003;74:25-34. 90. Cotter SA, Barnhardt C. Optometric assessment: case history. In:
Scheiman MM, Rouse MW, eds. Optometric management of
81. Borsting E, Rouse MW, Deland PN, et al. Prospective comparison learning-related vision problems, 2nd ed. St. Louis, MO: Mosby-
of convergence insufficiency and normal binocular children on Elsevier, 2006.
CIRS symptom surveys. Optom Vis Sci 1999;76:221-8.
91. Cron M. Overview of normal child development. In: Scheiman
82. Pennington BF, Lefly D. Early reading development in children at MM, Rouse MW, eds. Optometric management of learning-
family risk for dyslexia. Child Dev 2001;72:816-833. related vision problems, 2nd ed. St. Louis, MO: Mosby-Elsevier,
2006.
83. Gallagher A, Uta Frith U, Snowling MJ. Precursors of literacy
delay among children at genetic risk of dyslexia. J Child Psychol 92. Borsting E. Overview of vision efficiency and visual processing
Psychiat 2000;41:203-213. development. In: Scheiman MM, Rouse MW, eds. Optometric
management of learning-related vision problems, 2nd ed. St. Louis:
84. Elbro C, Borstrøm, I, Petersen D. Predicting dyslexia from Mosby-Elsevier, 2006.
kindergarten: the importance of distinctness of phonological
representations of lexical items. Read Res Q, 1998;33:36–60. 93. Simons HD, Grisham JD. Binocular anomalies and reading
problems. J Am Optom Assoc 1987;58:578-87.
85. Wender PH, Wolf LE, Wasserstein J. Adults with ADHD. Ann
NY Acad Sci 2001;931:1-6. 94. Grisham JD, Simons HD. Refractive error and the reading
process. J Am Optom Assoc 1986;57:44-55.
86. Shaywitz SE, Fletcher JM, Holahan JM, et al. Persistence of
dyslexia: the Connecticut Longitudinal Study at adolescence. 95. Simons HD, Gassler PA. Vision anomalies and reading skill: a
Pediatrics 1999;104:1351-9. meta-analysis of the literature. Am J Optom Physiol Opt 1988;
65:893-904.
87. Francis DJ, Shaywitz SE, Stuebing KK, et al.
References 49 50 Learning Related Vision Problems
96. Eames TH. The influence of hypermetropia and myopia on 106. Richman JE, Garzia RP. Eye movements and reading. In: Garzia
reading achievement. Am J Ophthalmol 1955; 39:375-7. RP, ed. Vision and reading. St. Louis, MO: Mosby-Year Book,
1996.
97. Eames TH. Comparison of eye conditions among 1,000 reading
failures, 500 ophthalmic patients, and 150 unselected children. 107. Ciuffreda KJ, Kenyon RV, Stark L. Saccadic intrusions
Am J Ophthalmol 1948;31:713-7. contributing to reading disability. Am J Optom Physiol Opt
1983;60:242-9.
98. Rosner J, Rosner J. Comparison of visual characteristics in
children with and without learning difficulties. Am J Optom 108. Ciuffreda KJ, Kenyon RV, Stark L. Eye movements during
Physiol Opt 1987;64:531-3. reading: further case reports. Am J Optom Physiol Opt
1985;62:844-52.
99. Rosner J, Rosner J. Some observations of the relationship between
the visual perceptual skills development of young hyperopes and 109. Ciuffreda KJ, Bahill AT, Kenyon RV, Stark L. Eye movements
age of first lens correction. Clin Exp Optom 1986;69:166-8. during reading: case reports. Am J Optom Physiol Opt
1976;53:389-95.
100. Hoffman LG. The effect of accommodative deficiencies on the
developmental level of perceptual skills. Am J Optom Physiol Opt 110. Biscaldi M, Fischer B, Aiple F. Saccadic eye movements of
1982;59:524-9. dyslexic and normal reading children. Perception 1994;23:45-64.
101. Stein JF, Riddell PM, Fowler S. Disordered vergence control in 111. Biscaldi M, Gezeck S, Stuhr V. Poor saccadic control correlates
dyslexic children. Br J Ophthalmol 1988;72:162-6. with dyslexia. Neuropsychologia 1998;36:1189-1202.
102. Evans JW, Drasdo N, Richards I. Investigation of accommodative 112. Biscaldi M, Fischer B, Hartnegg K. Voluntary saccadic control in
and binocular function in dyslexia. Ophthal Physiol Opt dyslexia. Perception 2000;29:509–21.
1994;14:5-19.
113. Maples WC, Ficklin TW. Interrater and test-retest reliability of
103. Maples WC. Visual factors that significantly impact academic pursuits and saccades. J Am Optom Assoc 1988;59:549-52.
performance. Optometry 2003;74:35-43.
114. Hoffman LG, Rouse MW. Referral recommendations for
104. Kedzia B, Tondel G, Pieczyrak D, et al. Accommodative facility binocular function and/or developmental perceptual deficiencies. J
test results and academic success in Polish second graders. J Am Am Optom Assoc 1980;51:119-26.
Optom Assoc 1999;70:110-6.
115. SG, Morris EJ, Tychsen L. Visual motion processing and sensory-
105. Garzia RP, Peck CK. Vision and reading II: eye movements. J motor integration for smooth pursuit eye movements. Annual
Optom Vis Dev 1993;25:4-37. Review of Neuroscience 1987;10:97-129.
References 51 52 Learning Related Vision Problems
116. Solan HA, Hansen PC, Shelley-Tremblay J, et al. Coherent motion 126. Solan HA, Usprich C, Mozlin R, et al. The auditory-visual
threshold measurements for M-cell deficit differ for above and integration test: intersensory or temporal-spatial. J Am Optom
below average readers. J Am Optom Assoc 2003;74:727-34. Assoc 1983;54:607-16.
117. Van Donkelaar P, Drew AS. The allocation of attention during 127. Groffman S, Solan HA. Developmental and perceptual assessment
smooth pursuit eye movements. Prog Brain Res 2002;140:267-77. of learning-disabled children: theoretical concepts and diagnostic
testing. Santa Ana, CA: Optometric Extension Program
118. Chen Y, Holzman PS, Nakayama K. Visual and cognitive control Foundation, 1994.
of attention in smooth pursuit. Prog Brain Res 2002;140:255-65.
128. Denckla MB, Rudel RG. Rapid automatized naming of pictured
119. Surburg PR. Midline-crossing inhibition: an indicator of objects, colors, letters and numbers by normal children. Cortex
developmental delay. Laterality 1999;4:333-43. 1974;10:186-202.
120. Fischer B, Hartnegg K. Stability of gaze control in dyslexia. 129. Fawcett AJ, Nicolson RI. Naming speed in children with dyslexia.
Strabismus 2000;8:119-22. J Learn Disabil 1994;27:641-6.
121. Garzia RP, Richman JE, Nicholson SB, Gaines CS. A new visual- 130. Meyer MS, Wood FB, Hart LA, et al. Selective predictive value of
verbal saccades test: the Developmental Eye Movement Test rapid automatized naming in poor readers. J Learn Disabil
(DEM). J Am Optom Assoc 1990;61:124-35. 1998;31:106-17.
122. Lieberman S, Cohen AH, Rubin J. NYSOA K-D Test. J Am 131. Denckla MB, Rudel RG. Rapid "automatized" naming (R.A.N.):
Optom Assoc 1983;54:631-7. dyslexia differentiated from other learning disabilities.
Neuropsychologia 1976;14:471-9.
123. Bosse ML, Tainturier MJ, Valdois S. Developmental dyslexia: the
visual attention span deficit hypothesis. Cognition 2007;104:198- 132. Badian NA. Phonemic awareness, naming, visual symbol
230. processing, and reading. Read Writ 1993;5:87-100.
124. Optometric clinical practice guideline: care of the patient with 133. Wolf M, Obregon M. Early naming deficits, developmental
strabismus: esotropia and exotropia. St. Louis, MO: American dyslexia and a specific deficit hypothesis. Brain Lang
Optometric Association, 2004. 1992;42:217-47.
125. Scheiman MM, Gallaway M. Visual information processing: 134. Wolf M, Bowers, PG. The double-deficit hypothesis for the
assessment and diagnosis. In: Scheiman MM, Rouse MW, eds. developmental dyslexias. J Educ Psychol 1999;91:415-38.
Optometric management of learning-related vision problems, 2nd
ed. St. Louis, MO: Mosby-Elsevier, 2006. 135. Wolf M, Goldberg O’Rourke A, Gidney C, et al. The second
deficit: An investigation of the independence of phonological and
naming-speed deficits in developmental dyslexia. Read Writ
2002;15:43-72.
References 53 54 Learning Related Vision Problems
140. Borsting E, Ridder WH, Dudeck K, et al. The presence of a 149. Williams M, Molinet K, LeCluyse K. Visual masking as a
magnocellular defect depends on the type of dyslexia. Vision Res measure of temporal processing in normal and disabled readers.
1996;36:1047-53. Clin Vis Sci 1989;4:137-44.
141. Nicolson RI, Fawcett AJ, Dean P. Developmental dyslexia: the 150. Lehmkuhle S, Garzia RP, Turner L, et al. A defective visual
cerebellar deficit hypothesis. Trends Neurosci 2001;24:508-511. pathway in reading disabled children. N Engl J Med 1993;
328:989-96.
142. Fawcett AJ, Nicolson RI, Dean P. Impaired performance of
children with dyslexia on a range of cerebellar tasks. Ann 151. Livingstone MS, Rosen GD, Drislane FW, Galaburda AM.
Dyslexia 1996;46:259-83. Physiological and anatomical evidence for a magnocellular defect
in developmental dyslexia. Proc Natl Acad Sci 1991;88:7943-7.
143. Fawcett AJ, Nicolson RI, Maclagan F. Cerebellar tests differentiate
between groups of poor readers with and without IQ discrepancy. J 152. Eden GF, VanMeter JW, Rumsey JM, Misog JM, et al. Abnormal
Learn Disabil 2001;34:119-35. processing of visual motion in dyslexia revealed by functional
brain imaging. Nature 1996;382:66-9.
144. Georgiewa P, Rzanny R, Gaserc C, et al. Phonological processing
in dyslexic children: a study combining functional imaging and 153. Demb JB, Boynton GM, Heeger DJ. Functional magnetic
event related potentials. Neurosci Letters 2002;318:5-8. resonance imaging of early visual pathways in dyslexia. J
Neurosci 1998;18:6939-51.
References 55 56 Learning Related Vision Problems
154. Demb JB, Boynton GM, Heeger DJ. Brain activity in visual cortex 163. Facoetti A, Paganoni P, Lorusso ML. The spatial distribution of
predicts individual differences in reading performance. Proc Natl visual attention in developmental dyslexia. Exp Brain Res
Acad Sci 1997;94:13363-6. 2000;132:531-8.
155. Talcott JB, Hansen PC, Assoku EL, et al. Visual motion sensitivity 164. Facoetti A, Molteni M. Gradient of visual attention in
in dyslexia: evidence for temporal and energy integration deficits. developmental dyslexia. Neuropsychologia 2001;39:352-7.
Neuropsychologia 2000;38:935-43.
165. Facoetti A, Paganoni P, Turato M, et al. Visual-spatial attention in
156. Talcott JB, Witton C, McLean M, et al. Dynamic sensory developmental dyslexia. Cortex 2000;36:109-23.
sensitivity and children’s word decoding skills. Proc. Natl Acad
Sci USA 2000;97:2952-7. 166. Facoetti A, Lorusso ML, Paganoni P, et al. Auditory and visual
automatic attention deficits in developmental dyslexia. Cognitive
157. Steinman SB, Steinman BA, Garzia, RP. Vision and attention II: Brain Res 2003;16:185-91.
is visual attention a mechanism through which a deficient
magnocellular pathway might cause reading disability? Optom 167. Facoetti A, Lorusso ML, Paganoni P, et al. The time course of
Vis Sci 1998; 75:674-81. attentional focusing in dyslexic and normally reading children.
Brain Cognition 2003;53:181-4.
158. Cheng A, Eysel UT, Vidyasagar TR. The role of the
magnocellular pathway in serial deployment of visual attention. 168. Vidyasagar TR. Neural underpinnings of dyslexia as a disorder of
Eur J Neurosci 2004;20:2188–292. visuo-spatial attention. Clin Exp Optom 2004;87:4-10.
159. Breitmeyer BG, Ganz L. Implications of sustained and transient 169. Vidyasagar TR. A neuronal model of attentional spotlight: parietal
channels for theories of visual pattern masking, saccadic guiding the temporal. Brain Research Reviews 1999;30:66-76.
suppression, and information processing. Psychol Rev 1976;83:1-
36. 170. Cornelissen PL, Hansen PC, Hutton JL, et al. Magnocellular
visual function and children's single word reading. Vision Res
160. Williams MC, Lovegrove W. Sensory and perceptual processing in 1998;38:471-82.
reading disability. In: Brannan JR, ed. Applications of parallel
processing in vision. Amsterdam: North-Holland, 1992. 171. Helenius P, Tarkiainen A, Cornelissen P, et al. Dissociation of
normal feature analysis and deficient processing of letter-strings in
161. Solan HA, Ficarra A, Brannan J. Eye movement efficiency in dyslexic adults. Cerebral Cortex 1999;9:476-83.
normal and disabled elementary school children: effects of varying
luminance and wavelength. J Am Optom Assoc 1998;69:455-64. 172. Cornelissen P, Richardson A, Mason A, Fowler S, et al. Contrast
sensitivity and coherent motion detection measured at photopic
162. Solan HA, Larson S, Shelley-Tremblay, et al. Role of visual luminance levels in dyslexics and controls. Vision Sci 1995;
attention in cognitive control of coulomotor readiness in students 35:1483-94.
with reading disabilities. J Learn Disabil 2001;34:107-18.
References 57 58 Learning Related Vision Problems
173. Cornelissen PL, Hansen PC, Gilchrist I, et al. Coherent motion 182. Solan HA, Suchoff IB. Tests and measurements for behavioral
detection and letter position encoding. Vision Res 1998;38:2181- optometrists. Santa Ana, CA: Optometric Extension Program
91. Foundation, 1991.
174. Iles J, Walsh V, Richardson A. Visual search performance in 183. Rouse MW, Borsting E. Management of visual information
dyslexia. Dyslexia 2000;6:163-77. processing problems. In: Scheiman MM, Rouse MW, eds.
Optometric management of learning-related vision problems, 2nd
175. Solan HA. Brannan JR, Ficarra AP, et al. Transient and sustained ed. St. Louis, MO: Mosby-Elsevier, 2006.
processing: effects of varying luminance and wavelength on
reading comprehension. J Am Optom Assoc 1997;68:503-10. 184. Farr J, Leibowitz HW. An experimental study of the efficacy of
perceptual-motor training. Am J Optom Physiol Opt 1976;53:451-
176. Brannan JR, Solan HA, Ficarra AP, et al. Effect of luminance on 5.
visual evoked potential amplitudes in normal and disabled readers.
Optom Vis Sci 1998;75:279-83. 185. Seiderman AS. Optometric vision therapy results of a
demonstration project with a learning disabled population. J Am
177. Williams MC, LeCluyse K, Rock-Faucheux A. Effective Optom Assoc 1980;51:489-93.
interventions for reading disability. J Am Optom Assoc
1992;63:411-7. 186. Hendrickson LN, Muehl S. The effect of attention and motor
response pretraining on learning to discriminate b and d in
178. Scott L, McWhinnie H, Taylor L, et al. Coloured overlays in kindergarten children. J Educ Psychol 1962;53:236-41.
schools: orthoptic and optometric findings. Ophthal Physiol Opt
2002;22:156-65. 187. Greenspan SB. Effectiveness of therapy for children's reversal
confusion. Acad Ther 1975-76;11:169-78.
179. Evans BJ, Joseph F. The effect of coloured filters on the rate of
reading in an adult students population. Ophthal Physiol Opt 188. Rosner J. The development of a perceptual skills program. J Am
2002;22:535-45. Optom Assoc 1973;44:698-707.
180. Richman JE. Overview of visual attention and learning. In: 189. Weisz CL. Clinical therapy for accommodative responses:
Scheiman MM, Rouse MW, eds. Optometric management of transfer effects upon performance. J Am Optom Assoc
learning-related vision problems, 2nd ed. St. Louis, MO: Mosby- 1980;50:209-15.
Elsevier, 2006.
190. Hoffman LG. The effect of accommodative deficiencies on the
181. Schute-Körne G, Bartling J, Deimel W, et al. Visual evoked developmental level of perceptual skills. Amer J Optom Physiol
potentials elicited by coherently moving dots in dyslexic children. Opt 1982;59:254-62.
Neurosci Letters 2004;357:207-10.
191. Tassinari JD, Eastland RQ. Vision therapy for deficient visual-
motor integration. J Optom Vis Devel 1997;28:214-26.
References 59 60 Learning Related Vision Problems
192. Solan HA, Ciner EB. Visual perception and learning: issues and
answers. J Am Optom Assoc 1989;60:457-60. 203. Rouse MW, Borsting E. Vision therapy procedures for
developmental visual information processing problems. In:
193. Solan HA. Intrinsic motivation vs. extrinsic rewards in vision Scheiman MM, Rouse MW, eds. Optometric management of
therapy and learning. J Behav Optom 1995; 6:143,144,165. learning-related vision problems, 2nd ed. St. Louis: Mosby-
Elsevier, 2006.
194. Press LJ. Visual information processing therapy. In: Press LJ, ed.
Applied concepts in vision therapy. St. Louis, MO: Mosby-Year 204. Computer aided vision therapy (CAVT). Mishawaka, IN: Bernell
Book, 1997. VTP, 2007.
195. Kirshner AJ. Training that makes sense. Novato, CA: Academic 205. Computerized perceptual therapy (PTS II). Mishawaka, IN:
Therapy, 1972. Bernell VTP, 2007.
199. Lane KE. Developing ocular motor & visual perceptual skills: an
activity workbook. Santa Ana, CA: Optometric Extension
Program Foundation, 2005.
200. Swartwout JB. Manual of techniques and record forms for in-
office and out-of-office optometric vision training programs..
Santa Ana, CA: Optometric Extension Program Foundation, 1991.
This position statement addresses these issues, which are important to To identify learning-related vision problems, each of these interrelated
individuals who have learning-related vision problems, their families, areas must be fully evaluated.
their teachers, the educational system, and society.
Educational, neuropsychological, and medical research has suggested
POLICY STATEMENT distinct subtypes of learning difficulties.9,10 Current research indicates
People at risk for learning-related vision problems should receive a that some people with reading difficulties have co-existing visual and
comprehensive optometric evaluation. This evaluation should be language processing deficits.11 For this reason, no single treatment,
conducted as part of a multidisciplinary approach in which all profession, or discipline can be expected to adequately address all of
appropriate areas of function are evaluated and managed.4 their needs.
The role of the optometrist when evaluating people for learning-related Unresolved visual deficits can impair the ability to respond fully to
vision problems is to conduct a thorough assessment of eye health and educational instruction.12,13 Management may require optical correction,
visual functions and communicate the results and recommendations.5 The vision therapy, or a combination of both. Vision therapy, the art and
management plan may include treatment, guidance and appropriate science of developing and enhancing visual abilities and remediating
referral. vision dysfunctions, has a firm foundation in vision science, and both its
application and efficacy have been established in the scientific
literature.14-17 Some sources have erroneously associated optometric
Appendix 63 64 Learning Related Vision Problems
vision therapy with controversial and unfounded therapies, and equate This Policy Statement was formulated by a Task Force representing the
eye defects with visual dysfunctions.18-21 College of Optometrists in Vision Development, the American
Optometric Association, and the American Academy of Optometry. The
The eyes, visual pathways, and brain comprise the visual system. following individuals are acknowledged for their contributions:
Therefore, to understand the complexities of visual function, one must
look at the total visual system. Recent research has demonstrated that Ronald Bateman, O.D. Stephen Miller, O.D
some people with reading disabilities have deficits in the transmission of Eric Borsting, O.D., M.S. Leonard Press, O.D.
information to the brain through a defective visual pathway.22-25 This Susan Cotter, O.D. Michael Rouse, O.D., M.S.Ed.
creates confusion and disrupts the normal visual timing functions in Kelly Frantz, O.D. Julie Ryan, O.D., M.S
reading. Ralph Garzia, O.D. Glen Steele, O.D.
Louis Hoffman, O.D., M.S. Gary Williams, O.D.
Visual defects, such as a restriction in the visual field, can have a
substantial impact on reading performance.26 Eye strain and double
vision resulting from convergence insufficiency can also be a significant
handicap to learning.27 There are more subtle visual defects that influence Approved by:
learning, affecting different people to different degrees. Vision is a College of Optometrists in Vision Development, October 1996
multifaceted process and its relationships to reading and learning are American Academy of Optometry, January 1997
complex.28-29 Each area of visual function must be considered in the American Foundation for Vision Awareness, February 1997
evaluation of people who are experiencing reading or other learning American Optometric Association, March 1997
problems. Likewise, treatment programs for learning-related vision Optometric Extension Program Foundation, April 1997
problems must be designed individually to meet each person's unique
needs. 5/9/97
SUMMARY
1. Vision problems can and often do interfere with learning.
2. People at risk for learning-related vision problems should be
evaluated by an optometrist who provides diagnostic and
management services in this area.
3. The goal of optometric intervention is to improve visual function
and alleviate associated signs and symptoms.
4. Prompt remediation of learning-related vision problems
enhances the ability of children and adults to perform to their full
potential.
5. People with learning problems require help from many
disciplines to meet the learning challenges they face. Optometric
involvement constitutes one aspect of the multidisciplinary
management approach required to prepare the individual for
lifelong learning.
Appendix 65 66 Learning Related Vision Problems
315.00 Specific reading disorder CIRS Convergence Insufficiency and Reading Study Group
379.57 Deficiencies of saccadic eye movements NSUCO Northeastern State University College of Optometry
379.58 Deficiencies of smooth pursuit movements SCCO Southern California College of Optometry
Other ICD-9-CM codes for accommodative and vergence dysfunctions TVPS Test of Visual Perceptual Skills
can be found in the Optometric Clinical Practice Guideline for Care of
the Patient with Accommodative and Vergence Dysfunction.21 VIP Visual Information Processing
Executive functions A set of cognitive abilities that control and regulate Vision related learning problems Deficits in visual efficiency and
other abilities and behaviors. visual information --processing skills that affect learning.
Grapheme The visual representation of letters or words; single letters or Vision therapy A sequence of activities individually prescribed and
letter pairs associated with a particular sound. monitored to develop efficient visual skills and information processing.
Laterality The internal representation and sensory awareness of both Visual closure The capacity to identify an object accurately when
sides of one’s own body. incomplete details are available for analysis.
Learning disabilities Disorders in one or more of the basic Visual discrimination The awareness of the distinctive features of
psychological processes involved in understanding spoken or written objects and the symbols of written language.
language including unexpected difficulties in learning in individuals who
otherwise possess the intelligence, experience, and opportunity for Visual efficiency A term referring to the basic neurophysiological
normal achievement. processes that include visual acuity, refractive error, accommodation,
vergence, and ocular motility.
Appendix 69