Vision, Learning & Perception
Our practice is one of a few in the Bay Area that offers services for children who have vision related learning problems. We use techniques developed for training children and adults having visual tracking problems, tired eyes due to eye teaming dysfunction, and near focusing difficulties. Research has shown that nearly 70 percent of children experiencing reading difficulties have these visual efficiency dysfunctions that limit their progress. With home vision training of only 20 minutes per day for two to three months, most children can overcome their vision dysfunction and make faster progress in reading.
Some children also have visual information processing or perceptual immaturities that can also severely limit classroom success. We conduct a thorough battery of perceptual and memory tests to identify weak areas of information processing. When visual processing difficulties are found, perceptual training can be done to improve the deficient area. Techniques are available for training word memory, visual-motor integration, vision perception, letter and word reversal confusion, and eye-hand coordination.
Dr. Nguyen's research thesis dealt with "Prism Correction for Eye Coordination Disorders." Because of this experience she has developed expertise in binocular vision. And, over the years, she has gained great experience and knowledge in testing children's vision, visual and perceptual skill assessment, and providing vision therapy when there is a problem. She practices a full scope of optometry, believing that when someone comes for an eye exam, she needs to focus on the whole in order to make a diagnosis.
The First Eye & Vision Examination
One of the questions most commonly asked by many concerned parents is, "At what age should my child have their first eye exam?". In some cases, the answer is as young as a newborn baby! Premature babies often have their eyes examined and corrected with contact lenses during the first few months of life to ensure normal development of their vision and brain pathways supporting good vision.
In most cases, Dr. Nguyen and Dr. Hong recommend having the first eye exam during the first year of life to rule out misalignment or crossing of an infant's eyes, amblyopia or lazy eye, and rare disorders such as cataracts or glaucoma.
The second eye exam should be between the ages of four and six years to ensure good tracking eye movement and vision and perception development. Early successful learning in reading, writing, and arithmetic requires a certain level of development in visual, perceptual, and integrated skills.
Does Your Child Have a Vision Problem?
According to Dr. Byron Demorest, MD, a former president of the American Academy of Ophthalmology, you should schedule a consultation with the eye doctor if your infant has:
- Poor focus on objects after 3 months of age.
- Eyes that are not straight.
- An eyelid that is droopy.
- A family history of serious eye problems.
- A watery eye with overflow tearing.
You or your children should have an eye examination if you have one or more of the following common visual symptoms and behaviors:
- Having a red eye with or without discharge.
- Squinting eyes to read or see small objects.
- Complaining of blurred distant vision.
- Blinking eyes excessively.
- Complaining of headaches or double vision at near distances.
- Tired eyes when reading.
- Intermittent blurring of print.
- Blurred distance vision for a while after reading.
- Print moving, jumping, pulsating, or floating.
- Frequent loss of place.
- Rereading same line.
- Skipping letters, words, or lines.
- Covering one eye or tilts head when reading.
- Becoming distracted, restless, or inattentive when reading.
- Avoidance or dislike of reading.
- Feel sleepy with reading during the day.
- When you have systemic diseases such as high blood pressure, diabetes, high cholesterol, thyroid disorders.
- And when you have not had an eye exam within the last two years.
Finding The Right Vision Specialty
An excerpt from an article by David Grisham, OD, MS, FAAO
International Dyslexia Association Newsletter, December 1997
International Dyslexia Association Newsletter, December 1997
Scott impressed his teacher as an energetic 7-year-old boy who wanted to do well, but he just couldn't concentrate on his reading lessons. He skipped over words, lost his place in print, and seemed to have a lot of reversal confusion with b's and d's. He fatigued quickly with a book in hand, but his mother said he could watch movies and play video games for hours. Scott was sent to the school nurse for vision screening. She found Scott to have 20/20 visual acuity with each eye when tested on a chart ten feet away and sent him back to class with the report that a vision problem was not indicated. Just to be sure, the parents sent Scott to an ophthalmologist, a medical eye doctor, who confirmed the nurse's report of good vision. He found no significant refractive error, no strabismus and normal eye health. The resource specialist at the school still suspected a visual tracking problem so she recommended another vision exam with an optometrist specializing in children's vision. This eye doctor reported that Scott not only had a tracking problem, i.e., couldn't move his eye accurately from one point to another, but also had a convergence insufficiency where print would double if he held the book within 8 inches of his face, which he often did. Three months of vision therapy was recommended along with weekly office visits. Now the parents were really confused. Did Scott have a vision problem or not that affected his reading performance? They sought a third opinion at our University Eye Clinic. We examined Scott for visual acuity, (he has 20/20), refractive error (normal), eye health (normal), eye tracking (immature), eye coordination or teaming (convergence deficiency), near focusing skills (deficient) and screened for a visual perceptual dysfunction (immature visual-motor integration). We had to admit that both previous doctors were correct as far as they went with their examinations. Many parents find themselves in this situation where eye doctors seemingly disagree and the difference is often due to the depth and extent of the vision examination. Parents and teachers need to know what type of vision examination to ask for, to demand if necessary, from eye doctors.
There are three levels of vision examination that are offered by vision care practitioners. The first level is called a Primary Care or Visual Pathway Examination. This involves testing the optical performance of the eyes and establishing the health status of the visual system. All eye doctors, ophthalmologists and optometrists, measure visual acuity, check for refractive error and investigate for eye disease. Myopia ,or nearsightedness, reduces vision at distance, but usually does not affect reading performance. In fact, superior reading is often found in nearsighted people compared to the farsighted or even those having no refractive error. Paradoxically, school vision screening is designed to find the myopes who need glasses for distant viewing, but who happen to be the best readers in class. Poor reading is associated with excessive farsightedness. Farsighted children must use their focusing power to clear up the image at distance and since they can usually do this, they do not flunk the visual acuity chart located 10 feet away. In the classroom, however, these farsighted children must constantly use excessive focusing power to read books clearly and this neuromuscular system can fatigue quickly. The eye doctor utilizes refractive techniques or drops to identify the student who has significant farsightedness, but the school nurse will usually miss this important condition. Eye health is not usually an issue with children, except for minor infections of the lids and pink eye. I believe current school screening procedures are inadequate. Even a Primary Care Examination is insufficient and should not be considered a thorough vision examination for the child experiencing reading difficulties.
It is at the second level of investigation of the visual system that most vision problems occur which affect reading performance and comfort. Optometrists refer to this level of testing as a Visual Efficiency Examination. Besides testing for pathway integrity (first level), the optometrist also measures visual performance over time in tracking skills (smooth tracking and eye movements used in reading), convergence and divergence skills (board to book and back), near focusing amplitude and facility, and binocular fusion and depth perception. In the last ten years, the research literature has shown the visual efficiency conditions listed in Section 1, Do You or Your Child Have a Vision Problem? on to be much more prevalent in children having reading difficulties. Our studies at UC Berkeley have found that over half the children in remedial reading classes or special education have some visual efficiency dysfunctions that can affect reading and comfort. These tracking and eye teaming conditions do not cause dyslexia, a neurologic problem, but they make reading more difficult and unpleasant than it needs to be. Common symptoms and behaviors of visual efficiency dysfunction are listed in Section 2, Do You or Your Child Have a Vision Problem? Most ophthalmologists and optometrists in commercial settings do not offer this second level of testing. Ophthalmologists are simply not trained in these testing and analysis techniques since these are not directed toward diagnosing eye disease. Commercial optometrists restrict their testing to the basics to keep costs down. Visual efficiency dysfunction results from a mismatch between the maturity of child's visual skills and the visual accuracy and stamina required by school work, e.g., careful and accurate decoding of print, rapid copying of material from the board to paper, sustained convergence and near focusing of the eyes for a reading assignment. Our cultural requirement of at least 12 years of education has outstripped normal visual physiology for many, and these kids are left behind with a sense of discomfort or dislike for sustained reading and class work. Many adult computer operators experience the same problems. Once these visual deficiencies are found, they can be easily managed with specially designed reading glasses or a short program of vision training that can improve eye tracking, teaming, and focusing. The optometrist who specializes in children's vision or developmental vision is probably the best professional to complete a Visual Efficiency Examination and to deliver follow up care, but most recently graduated optometrists can perform this examination on request.
A third level of vision examination looks at the meaning that children extract from visual images, a perceptual Skills Assessment. Is a child's visual perception automatic, organized, age appropriate, and can perceptual information be easily remembered? Extraordinary reversal difficulty with letters and words can indicate perceptual immaturity. Difficulties with sight word identification, or late acquisition of math concepts, and poor copying skills can all be indicators of visual perceptual immaturity. School psychologists and resource specialists do some visual perceptual testing, but they rarely make recommendations for improving deficient perceptual skills. Most optometrists, however, who specialize in children's vision do offer both testing and perceptual therapy services. Reading disabilities result from a multiplicity of factors, some of which are visual and perceptual in nature, so it is imperative that these visual factors be taken into account in the total management of the reading disabled child. When parents and teachers want to rule out visual factors that need to seek levels two and three of vision testing-first, a Visual Efficiency Evaluation and possibly, a Perceptual Skills Assessment. Scott's parents did and after three months of vision therapy (30 minutes per day) but his attitude and reading performance shot up beyond expectations.