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Seeing Eye to Eye with Vision and Learning
By Sharon Berger, O.D., FCOVD
Vision therapy is often used for children who are having difficulty in school because of deficiencies in one or more areas of vision. Similar to other therapeutic interventions, vision therapy seeks to improve skills in the area of vision to enhance a childís academic success.
 Your child just passed his vision screening, yet his teachers reported to you that they suspect there is something wrong with his eyes. According to the 2003 Journal of Optometry, up to 11 percent of the children who had vision screenings passed the screening yet still have a vision problem that needed treatment. You may have also noted on your own that your child has symptoms that make you suspect a vision problem. (See sidebar) His frustration in school is taking its toll and you need answers.
Although they may seem the same, sight and vision are different. Sight is the ability to see a certain size letter at a certain distance. When you see 20/20, it means you see a specific size letter at 20 feet that you would be expected to see at 20 feet. If you saw 20/100, it means you saw a specific size letter at 20 feet that you should have seen at 100 feet away. However, there is more to vision than reading the 20/20 size letter on an eye chart. The Journal of Optometric Vision Development states that ìvision is a multifaceted process and its relationships to reading and learning are complex. Subtle visual defects influence learning to different degrees.î Vision implies the ability to interpret and gather meaning and information from what is seen.
In order to understand the relationship between vision and learning, a basic understanding of vision terminology is also important. (See sidebar) It is also important to understand that vision does not take place in the eye, but rather in the brain. Essentially, all the visual prerequisites function to bring clear and accurate information to the visual portions of the brain. When this is accomplished the following additional perquisites can be attained:
- Visual motor and visual auditory integration – Vision is integrated with other senses such as fine motor and gross motor skills and auditory skills. A student taking notes when a teacher orally presents a topic and writes the major points on the blackboard is an example of integrating vision with fine motor and auditory skills.
- Visual Perception or Visual Information Processing – Visual perception allows us to identify the person or object at which we are looking. In the early grades children learn p, q, b and d are all letters of the alphabet. At this point, they may fail to identify them correctly or use the letters appropriately when reading and writing. With time and further learning, most children begin to process the visual information in a more sophisticated manner. They learn to visually discriminate subtle differences. In the next step of visual processing, the child is able to form a combination of letters in a particular sequence into a word. This type of processing generally proceeds from the recognition of individual letters to the overall shape of the word; only then can the word become part of the childís sight vocabulary. These are then stored in visual memory and are correctly understood and used in the interest of increased reading comprehension and fluency.
Who should be evaluated?
 When children have problems with visual motor and visual auditory integration or visual perception/visual information processing, their deficiencies will be reflected in their academic performance. Initially, many children with difficulty in performing academically are evaluated by occupational therapists, psychologists and/or neuropsychologists. Another evaluation that should be considered is one for possible vision problems. Children with learning-related vision problems may show a higher verbal IQ (usually 10 points or more) than performance IQ. Even gifted children may suffer in their school performance when they have difficulty transcribing information to paper or completing timed tests. Scantron tests can be particularly difficult for some children who often make careless errors when they are required to color in small little bubbles on their answer sheet and move their eyes back and forth from the test booklet to the answer sheet. The Journal of Optometric Vision Development agrees stating that ìa significant body of literature has shown a positive relationship between eye movement and/or visual perceptual skills and academic performance.î
Where to start?
The American Optometric Association recommends an initial well-baby eye assessment between 6 and 12 months of age. The InfantSee program offers vision assessments at no charge by participating doctors of optometry. The goal of InfantSee is to find vision problems early and to educate parents on vision care. Additionally, childrenís vision should be examined at 3 and 5 years of age and then annually once they begin school. When a vision problem is suspected, the first step is a comprehensive eye examination instead of simply having a vision screening. It is important that a professional evaluation of all the areas of vision takes place. Not all eye care practitioners are prepared to provide this type of examination. In order to be sure your child is being evaluated in all areas of vision, you will need to find a developmental behavioral optometrist that is familiar with these problems. (See sidebar) These specialized doctors of optometry have additional certifications in developmental optometry and vision therapy. They may also have received a Fellowship certification involving post-graduate education and certification testing of the optometrists and vision therapists from The College of Optometrists in Vision Development (COVD). Once a qualified developmental behavioral optometrist has discovered what the problem may be, treatment may include glasses, orthoptic vision therapy and/or occupational therapy. Although vision therapy may not start formally in an office until the age of four, early intervention can begin with home activities for vision development with infants and toddlers when needed.
What is vision therapy?
Vision therapy uses activities and procedures in order to enhance development and improve skills in the area of vision. Vision therapy is performed by licensed doctors of optometry and a vision therapist who works under the doctorís supervision. Vision develops and is learned; vision therapy helps this process. The activities are specific for your child based on his particular vision problems.
Vision therapy is:
- Specifically directed toward resolving visual problems which interfere with reading, learning and educational instruction;
- A progressive program of vision "exercises" or procedures;
- Performed under doctor supervision;
- Individualized to fit the visual needs of each patient;
- Generally conducted in-office, once or twice weekly, for thirty minutes to one hour;
- Sometimes supplemented with procedures done at home between office visits (homework);
- Prescribed to help patients develop or to improve fundamental visual skills and abilities;
- Prescribed to improve visual comfort, ease, and efficiency;
- A method which can change how a patient processes or interprets visual information.
Vision therapy is not:
- A direct treatment for learning disabilities;
- Used to strengthen eye muscles because eye muscles are already incredibly strong.
Vision therapy utilizes:
- Prescription lenses (regulated medical devices);
- Therapeutic lenses (regulated medical devices);
- Prisms (regulated medical devices);
- Optical filters;
- Eye patches or occluders;
- Electronic targets with timing mechanisms;
- Computer software;
- Vestibular (balance) equipment;
- Structured games and toys that enhance visual perception.
Vision therapy activities
The activities can be in any of the areas mentioned previously including pursuit movements, saccadic eye movements, focusing, binocular vision, visual motor integration, visual auditory integration and visual perception. There are thousands of activities used in vision therapy. Some examples are:
For a child working in the areas of ocular motor (eye movement) skills and visual auditory integration, one activity may be to have the child walk forward then backward on a walking rail or balance beam. A metronome would be added and then the child would walk forward and backward taking one step with every beat of the metronome. A ball, hanging from the ceiling in front of the balance board, could then be added and the child maintains fixation on the ball and continues to walk and keep time with the metronome. While the therapist swings the ball, the child would be asked to maintain walking with the metronome as he accurately follows the swinging ball with his eyes.
- To enhance binocular vision, special glasses are given to the child which allow him to see in 3-D. By using these 3-D glasses, the therapist is able to increase the ranges that the two eyes work together.
- For a child that has great difficulty with fixation and tracking of his eyes, a simple activity is often used where the child has to move his eyes from left to right and press a lighted button and keep his place.
- Therapy activities to work on visual spatial processing and visual perception include using colors.
- Many activities in a variety of areas are also done with vision therapy computer programs.
In order for the vision therapy program to progress steadily, the parent and child will need to complete homework outside of therapy. These activities may include a hidden picture search, various sequencing activities using a metronome or practicing walking in a straight line using alternating arm movements.
Vision therapy timeline
Vision therapy programs could vary in time required depending on the problems being addressed. The average program consists of weekly or biweekly visits for six months to one year depending on the therapist. Progress evaluations are performed usually after twelve sessions. Measurements are taken to determine when goals have been met in vision therapy. Goals that are measurable by parent and therapist include smoother and more accurate eye movements, better visual motor integration resulting in the discontinuation of blurry and double vision and neater handwriting. Parents and teachers will often see changes as the therapy continues and many note the child is improving in handwriting, getting homework done more quickly and more independently, picking up books and reading for pleasure, improving in grades in school, improving in sports and experiencing better self-esteem.
Studies on vision and learning
When a child has learning issues, parents are faced with so many questions. Who do I turn to? What is the best solution for my child? How can I get more information? Studies supporting the need for and success of a possible therapy help parents in decision making. The following information is available from research on vision therapy and learning problems:
- Research from an Optometry, 2000 issue indicates that among the 20 percent of school age children who have a learning disability in reading, 70 percent of them have some form of visual impairment, such as ocular motor, perceptual or binocular dysfunction, that may be interfering with their reading skills.
- In the article ìHidden Eye Problems Can Block Learningî Learning, July/August 1991, it is reported that 10 to 15 percent of school-aged children have a visual disorder significant enough to cause a decrease in academic performance. Another report by Vision and Learning, estimates this type of relationship to be as high as 25 percent.
- In children already diagnosed as having learning disorders, the incidence of vision disorders reaches from 30 to 85 percent as stated by the Journal of Behavioral Optometry.
- Over 200 references on the effectiveness of vision therapy can be found at www.childrensvision.com/Efficacy.htm.
There are many studies that support the importance of vision related to learning. It is known that approximately twenty percent of the children have some type of vision problem and children with learning problems have a higher incidence of vision problems than the average child. When a child has passed a vision screening and there are still issues with reading and writing, a parent may want to rule out all possible causes of a learning problem. Obtaining a comprehensive vision examination from a qualified behavioral development optometrist is one avenue a parent can pursue to understand the underlying problem. After this is confirmed, the parent has the option of addressing the visual issues by seeing a qualified vision therapist.
Dr. Sharon Berger has been practicing pediatric optometry since 1980. She is a fellow in COVD and served as its state director for 5 years. She is presently the state chairperson for the InfantSee program and a member of the Georgia Optometric Association and American Optometric Association. Dr. Berger can be reached at 770-992-7620 or drsharonberger@hotmail.com.
Visual Prerequisites
Important for Vision and Learning
Eye Health: The inner and outer portions of the eyes should be free of disease.
Visual Acuity: The clarity of sight should be adequate for both distance and near visual tasks.
Refractive Status: This area is closely related to visual acuity. Glasses are prescribed to compensate for myopia, hyperopia, and astigmatism.
- Myopia, or nearsightedness, generally means that the individual has difficulty with sight at distance,
- Hyperopia, or farsightedness, generally means that the individual has difficulty with sight at near or difficulty in maintaining sight at near,
- Astigmatism is caused when the eye is of irregular shape. It can impair both distance and near sight and can occur in combination with myopia or hyperopia.
Ocular Motor Skills: There are three basic components to this area and they are important in viewing at distance and near.
- Fixation is the ability to direct the eyes to the object of regard be it a baseball in flight or a word on a page.
- Pursuit movements entail the ability of the two eyes to track a moving object be it a car or a baseball.
- Saccadic movements entail the ability to move from one point of interest to another. Accurate and efficient saccadic movements are particularly important in proceeding from fixated word to the next in reading.
Binocular Vision: This requires that the two eyes coordinate in a precise and efficient manner in order to send a unified message to visual areas of the brain. When this is not accomplished, double vision results. This, in turn, has a negative effect on depth perception in addition to negatively impacting oneís ability to read and line up columns for math exercises. Further, when the individual exerts excessive effort to attain or maintain binocular vision, headaches and fatigue are often a byproduct.
Focusing: This aspect of the visual system involves a tiny lens that is located behind the front external surface of the eye. It is able to change shape in order to produce a clear image on the back of the eye of the object one is looking at. Focus changes according to the distance of the object from the person. The major tasks of the focusing system are to maintain clarity, particularly when performing near tasks such as reading, near to far and from far to near, as a child does when copying material from the black board. If these tasks are not done accurately and efficiently, blurred vision ensues resulting in inefficient visual performance.
Members of College of Optometrists in Vision Development (COVD)*
Sharon Berger, O.D., FCOVD
1190 Grimes Bridge Road Roswell, GA 30075
Office: (770) 992-7620
www.roswelleyeclinic.com
David L. Cook, O.D., FCOVD 1395
South Marietta Parkway Ste 116 Building 400 Marietta, GA 30067
Office: (770) 419-0400
www.cookvisiontherapy.com
Daniel D. Gottlieb, O.D., FCOVD
10700 Medlock Bridge Rd Ste 103 Duluth, GA 30097
Office: (678) 417-9778
www.gottliebvisiongroup.com
Wallis E. Reagin, O.D., FCOVD
104 Church Street Decatur, GA 30030
Office: (404) 378-3694
Email: wreagin105@earthlink.net
Dylan Reach, O.D.
6507 Roswell Rd Ste J Sandy Springs, GA 30328
Office: (404) 256-7911
www.southerneyegroup.com
Jennifer Dattolo, O.D.
1190 Grimes Bridge Road Roswell, GA 30075
Office: (770) 992-7620
www.roswelleyeclinic.com
Nancy Truong, O.D.
1786 Oak Rd Ste A Snellville, GA 30078
Office: (770) 979-3456
www.mountainvieweyedocs.com
Kimberley Linert, O.D.
101 Pilgrim Village Dr Ste 400 Cumming, GA 30040
Office: (678) 455-7506
Email: kalinert@earthlink.net
Kimberly Becker, O.D.
390 Windermere CircleNewnan, GA 30265
Office: (770) 330-0925
Email: kimberlybecker@hotmail.com
*Taken from www.covd.org
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