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The summer is winding down, and back-to-school is on almost every parent’s thoughts. As a “doctor in training”, I’ve been thinking about my amazing summer internship at The Michigan College of Optometry externship site, Wow Vision Therapy in St. Joseph, Michigan. What especially amazed me was the number of children that we see in this clinic that have learning-related component to their vision problem. At the beginning of each child’s treatment plan, we ask the parent what they expect vision therapy will do to help their child. Almost every patient has school-related goals. In optometry school, we talk about the fact that 1 in 4 children suffers from an undiagnosed vision problem and that 1 in 8 children suffers from a binocular vision problem known as Convergence Insufficiency, but until I came to this practice, I didn’t realize just how many families are affected by this. When a child struggles in school, it’s not just a problem for them; the entire family is affected.
Seeing so many children with vision problems causing them to struggle in school made me start thinking about how these children even began to realize that they had a vision problem. I have had the opportunity to speak with a number of our patients’ parents. It’s amazing how often I hear that the visual system was the last thing on their minds when their child started to have problems in school. Vision-related learning problems can often manifest in ways that don’t always suggest that the visual system is at the root of the problem. Common symptoms include problems with reading comprehension or fluency, avoidance of reading, headaches or eyestrain after near work, poor handwriting, or attention problems. It’s easy to think that these problems could be academic or behavioral, but a visual dysfunction can be all-too-often to blame. Imagine how hard it would be to pay attention or to be interested in reading if the words were doubled on the page or looked like they were moving around! It would be hard to read efficiently or have neat hand writing if everything you see up close is blurry!
Detecting vision-related learning problems can be a difficult task for parents. I often hear that the child had a school vision screening, but they passed with 20/20 vision! Now I’m starting to remind parents that 20/20 vision is only a small piece of the puzzle. Most people think of 20/20 as “perfect vision,” but there are a whopping 17 skills that are necessary for efficient learning! A list of these skills can be found at the COVD website on Children's Vision and Learning Month. Children who struggle with these skills may not realize that they have a problem. They don’t know how other people see, so they may not realize that they should not have to struggle to keep their vision clear, comfortable, and single.
The best way to make sure that you child does not have a learning-related vision problem is to have a comprehensive eye exam from an optometrist who is trained to identify and recommend the necessary treatment for vision-related learning problems. The American Optometric Association has outlined the best practices for this in a Clinical Practice Guideline (CPG) entitled Care of the Patient with Learning Related Vision Problems. In this CPG, under Early Detection (pg 8-9) it says, “because the evidence that learning related vision problems can be prevented to any substantial degree is inconclusive, the emphasis is on early detection. It is recommended that vision examinations be scheduled at 6 months, 3 years of age and at the entry into school…” Too often, parents rely on school vision screenings to tell them if their child has a vision problem. These, however, may not be enough. School screenings usually test for only distance visual acuity and possibly any overt eye muscle problem. This leaves out the vast majority of the 17 necessary skills. Even with the screenings in place, 1 in 4 children suffer from undiagnosed vision problems! A comprehensive vision examination with a focus on the vision problems that can affect learning will detect these problems before your child begins to struggle in school. It is with these insights that I hope will lead to fewer parent oversights. For those parents who read this story, make sure your child is seen by an optometrist who knows how to recognize the 17 vision skills! Make a comprehensive vision exam a priority to your back-to-school checklist this year!
To find out if your optometrist will recognize a vision-related learning problem simply use the 17 skills checklist and ask before making your appointment. You can also contact the American Optometric Association at www.aoa.orgor
April A. Jones
Now wait a minute, that’s hard to believe right!? We all know that is illogical. Doing simple finger exercises will not teach anyone how to become a skilled piano player! His fingers are strong enough to move the keys on the piano, his brain just does not know how to coordinate his fingers to play the music. The answer to his problem is found when you locate a good piano “coach” who can guide him along a process of learning the skills for playing the piano. Then with practice he will improve. So, you dismiss the internet offer as another example of someone trying to promote an unproven and implausible self-help program.
Now let’s consider another scenario. This time it is your 10-year-old son who is struggling to read and keep up in school. He loses his place easily when reading. He is having trouble concentrating on a reading task and become very frustrated. He says his eyes hurt and sometimes he gets a headache when he reads. It sounds like he could be having a vision problem.
So you seek professional help and schedule him to have his eyes examined by your family optometrist, Dr. A. Your son has his eye exam with Dr. A. and what you learn from the doctor is that his eyes are healthy and he has normal 20/20 eye sight. But, he is having difficulty with coordinating his eyes together as a team when he tries to look at a book to read. Specifically he has trouble with his binocular vision (eye teaming). The doctor called it Convergence Insufficiency(CI). As it turns out, Convergence Insufficiency occurs in about 8-12% of children; affecting about 21.5 million people in the US (adults included). Often times a person with CI (especially children) will experience symptoms involving stress and strain around the eyes and have occasional double vision and avoidance behaviors. Often these symptoms look like ADD (Attention Deficit Disorder) too.
Doctor A. turns to you and says your child has a problem with proper eye coordination. His visual brain has not developed the correct neuromotor coordination abilities resulting in poor eye teaming when he attempts to do near vision work. This condition is treatable with 25-30 hours of office-based, doctor supervised, optometric vision therapy. While Dr. A. does not provide this service in his office, he recommends another doctor whose practice is dedicated to treating patients with office-based optometric vision therapy and makes the referral.
Gosh, you were hoping for an easy fix like a new pair of glasses! But what you are hearing is that it is much more complicated and will take several trips to another doctor over an extended period of time.
In the mean time, you think about it and decide to check around on your own and take your son to another doctor, Dr. B. for a second eye examination. Dr. B. completes his eye exam of your son and agrees with the diagnosis…yes, he has CI. But this doctor’s approach is entirely different. Dr. B. describes the problem with your son’s eyes is that he just has “weak eye muscles” which need to be strengthened. He advises you that your child’s problem can be solved with some simple “eye exercises”! All you have to do is make his eye muscles stronger by asking him to look at the tip of a pencil as you move it closer to his nose. In addition you are given some “work books” that have your son doing “tracking exercises”. You are puzzled by the lack of consistent treatment recommendations between the two doctors but since the recommendation is coming from a doctor, it must be true…right? Besides he accepts the minimal payment by your insurance and the treatment plan sounds a lot easier than what Dr. A was recommending.
So…who do you believe? Why if both doctors agree on the diagnosis, don’t they agree on the method of treatment? Who has got it right, Dr. A or Dr. B?
First, let’s remember the first example of the 10-year-old boy who was having trouble playing the piano. Is it logical to think that doing simple finger exercises will help him learn how to successfully play the piano? The answer seems pretty obvious right?
Surely the coordination of a person’s eyes is equally as complex as coordinating ones fingers to play a piano. So it would seem illogical that doing simple eye exercises would be effective at treating a problem with both eyes coordinating when attempting to read. However, over 50 years ago, many doctors were taught that Convergence Insufficiency (CI) was a problem with eye muscle strength. While techniques in the area of visual rehabilitation were also beginning to emerge about that time, there were still some text books that the had the old-fashioned remedy for CI as just a “series of simple eye exercises”. The problem was that the eye-exercise model of treatment was based on an assumption and not based on research. Therefore, many doctors to this day still hang on to an old outdated model of treatment that was never based on proven research.
Therefore the answer to the question, “Who has got it right, Dr. A. or Dr. B”, can only be answered based on double-blind multicenter research. What’s more, the research on the best methods to treat CI was completed in 2008. It is a landmark study called the Convergence Insufficiency Treatment Trial (CITT). The CITT was funded with a $6.1 million grant by the National Institute of Health and conducted through the National Eye Institute along with several sites around the country including Mayo Clinic and Bascom Palmer plus 6 Colleges of Optometry.
What this double-blind, multicenter research did was to compare office-based doctor supervised vision therapy (OBVT) to home based eye exercises called “pencil push-up therapy” as well as compared to a placebo, called “placebo therapy”
What did the research prove? It found that the “eye exercise therapy” had about the same effectiveness as the placebo. In fact the research proved that both the “eye exercise therapy” and the placebo therapy were found to be ineffective in treating Convergence Insufficiency.
However, office-based vision therapy was found to be effective and in subsequent research found to be the cure for convergence insufficiency. Dr A was correct!
The research is clear. So why do some doctors persist to advise patients about old-fashioned and ineffective treatment for Convergence Insufficiency? This can be difficult to answer in each case, but certainly when this condition, Convergence Insufficiency (CI) is accepted by the entire optometric and medical community as an important public health issue, then and only then will the majority of doctors get it right.
To address this fundamental public health problem and its realitive importance in the eye-care community, I wrote an article that was published in the Journal of Behavioral Optometry (Vol 21/2010/#2) entitled: "Does Convergence Insufficiency Really Matter"(download)
Dan L. Fortenbacher, O.D.,FCOVD
