Over the last 3 decades I have worked with thousands of children and adults with binocular vision dysfunction and other visual brain related problems. Some of the most common conditions I have treated are the visual problems that involve poor eye coordination and visual processing ability. The impact of these visual conditions on a patients life can be significant. The overall impact of poor visual abilities in some of the key areas of visual acquisitions skills such as binocular vision, accommodation and oculomotor function can be very stressful causing reduced individual performance and even emotional side effects.
I wrote about one such syndrome coined BAOD and published it on The VisionHelp Blog entitled: A new visual syndrome- BAOD...it's more than a feeling.
The emotional fallout of these visual conditions can take a significant toll on the child and the family. The following video by P.A.V.E. (Parents Active for Vision Education) describes the impact of an unaddressed vision related learning problem as well as the positive changes that occur when visual problems are identified and properly treated.
As a regional referral practice that specializing in developmental vision and therapy, most of our patients find their way to us through a doctor, occupational therapist, teacher, other professional or proactive parents who recognize and recommend us.
In the video below our patient Matthew was referred by his family primary care Optometrist with a binocular vision problem known as Convergence Insufficiency. Prior to treatment he was seeing double when trying to read or view anything within 20 inches. This caused Matthew, a bright boy, to struggle to keep-up in school. It was also beginning to have emotional side-effects on his self esteem.
This video shows how much better Matthew is doing within only 10 sessions of office-based optometric vision therapy in conjunction with home oriented activities...the evidenced-based proven standard of care for this diagnosis. Not only is Matthew no longer seeing double, his confidence is growing. Matthews response below sums it up!
Progress in vision therapy is not only about improving symptoms...it's about improving lives!
Dan L. Fortenbacher, O.D. FCOVD
Have you ever wondered if what you see is really the right way of visually seeing the world? If you find all of your visual tasks to be pretty easy to accomplish, then you may never have thought that there is anything besides just being able to "see clearly". Now, imagine being a child who in fact sees print overlap or move while reading and yet not knowing that "doubling letters" is not the right way of seeing. A child wouldn't know that overlapping print is a sign of a problem since they have no reference to what is actually normal vision.
My name is Amanda Hodge, 4th Optometry Student at Michigan's College of Optometry at Ferris State University and I have just completed my 2nd rotation with Dr. Dan Fortenbacher and the team at at Wow Vision Therapy. As a doctor in training, this experience has opened my eyes to many aspects optometric care that I was literally not aware of until I saw the vision therapy patient in action. For example, I have heard several children say, "I didn't know I wasn't suppose to see like that." What occurred to me is that this may be the main reason why younger children often do not have complaints about their vision. What I've learned is that a child can have a significant visual problem but never announce anything to their parents because they don't know any different.
This is true for doctors too! Doctors who work with children's vision must be aware of the behaviors which can be signs and symptoms of a problem that requires the necessary testing to make the right diagnosis. Often a parent may see a behavior in their child and just assume that it is something else, but in fact be a sign of a significant vision problem.
Some examples of questions parents can ask their children or themselves are:
Other symptoms can be found on the College of Optometrists in Vision Development (COVD) website Vision and Learning Symptoms checklist. Another good resource for children and vision is the American Optometric Association (AOA) Good Vision Throughout Life. This section breaks down what to be aware of for different age groups.
If you as the parent or your child answered "yes" to any of the above questions (or those on the COVD or AOA website) it is important to make the time to schedule your child for a comprehensive vision examination. Make sure you tell the doctor what your concerns are and specifically ask the doctor if he/she offers vision therapy or has a referral protocol with a vision therapy provider if your child requires VT care. Simply ask, "Do you ever recommend vision therapy for your patients?" If the answer is no, then your doctor may also overlook the vision problems that are only detected by running the correct vision tests.
Now you might be saying to yourself, I don't have a doctor and don't know where to begin? Well a good place to get started would be to visit the Doctor Locator via the COVD website and/or the AOA website by locating an optometrist who works in pediatrics.
Don't let your child fall through the cracks of having to deal with an undiagnosed vision related learning problem. Schedule a comprehensive vision examination for your child if you are concerned that vision may be playing a part in your child's struggles. But, most importantly be sure that you ask the right questions.
Amanda Hodge
4th Year Intern, Michigan College of Optometry
What an amazing year it has been for Connor Caple. The Doctors and Staff at Wow Vision Therapy would like to congratulate Connor for all of his accomplishments and to his parents for staying strong throughout Connors years of frustration as a result of his reading and learning difficulties. Especially we would like to recognize Connor's mother, Michelle who expressed her story of sadness in a letter to musical artist Matthew West who in turn composed a song entitled: To Me
About 1 year ago, at age 15, Connor presented for care to Wow Vision Therapy as a recommendation from his reading teacher who recognized many of the visual symptoms that Connor was experiencing. Connor's symptoms were significant for poor concentration for reading, letter reversals, difficulty keeping his place when reading and avoidance of reading. On the COVD Quality of Life Symptom Checklist he scored 47!
Connor was identified with delays in visual development particularly in eye movement skill, visual processing and visual imagery ability.
Connor completed his vision therapy treatment plan with us at Wow Vision Therapy in July 2010. He was reading everyday, but because it was the middle of the summer it was not known how well we was actually going to do in school.
Connor came in for his 3 month progress evaluation this week and is reporting 3 grade levels improvment in reading and doing much better in spelling. His Quality of Life Symptom Checklist is nearly all "0's" ...only a few "1's" (total score 7).
We are thrilled with Connor's success and thankful to have had the opportunity to play a role in the progress of his life's journey. Connor's next stop is New York City on the weekend of November 13-14, 2010 where he and his parents will be interviewed on the Fox and Friends Sunday Morning Show. This should be a wonderful interview where his story of struggle that lead to his mother's letter that lead to...To Me
To Me by Matthew West (The Story Behind The Song) from emicmg on Vimeo.
*Thank you to Steve and Michelle Caple who gave us permission to share Connor's story*
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
In my practice that specializes in vision therapy, the majority (about 70%) of our patients find their way to my care from a direct referral from another doctor or rehabilitation professional. Yet there are a significant number of patients, (often children) who are referred by a parent of a past patient who recognizes behaviors in a child that looks like what their own child struggled with before coming to see us for vision therapy.
This represents about a third of our practice that come to us directly because of a parent, teacher or friend who saw behaviors or recognized the problems described by the other parent. That means many children somewhat serendipitously find their way to our care because of a thoughtful "goodwill ambassador" past patient or friend.
This group of patients are typically the kids with vision related learning problems. There can be a variety of clinically presenting conditions but some of the more common diagnoses are convergence insufficiency, accommodative dysfunction or oculomotor dysfunction or a combination of all three.They may also have a visual processing problem resulting in letter reversals, difficulty with visual memory and/or hand-eye coordination.
When a child has a vision related learning problem, it is also interesting to note that the diagnosis is typically very obvious as I will demonstrate to the parent directly their child's trouble with the sample visual test and then let the parent see for themselves usually how effortless the test is if they have normal abilities. Once we establish the diagnosis and determine that this child has a vision problem that can be effectively treated, there is typically a three part response by the child's parents.
First there is a sense of relief that finally a visual explanation has been found that answers why their child has struggled and it is not because their child was "not smart enough" or "not trying hard enough" and they are not "bad parents".
Second there is a feeling of hope for their child's future because the solution I present just makes sense. We provide the "best practice" delivery of care, doctor supervised office-based vision therapy that is a proven and effective treatment and I have a solid track record of 30 years experience in this specialty.
Thirdly the parents then experience a momentary feeling of regret and disappointment (sometimes anger) that their previous eye care professional who saw their child did not not recognize the problem in the first place. As a result of overlooking their child's vision problem their child had to deal with often years of frustration and emotional side effects. It is this group of parents who will ask me, "Dr. Fortenbacher, why did our child's previous eye doctor not tell us about this problem with our child's vision?" Often I can not honestly say why with certainty, but try to emphasize the positive, we can leave the past behind and move forward now to solve the problem.
However now I'm pleased to have a better response to this question. Thanks to my friend and colleague, Dr. Leonard Press who has written 3 wonderful articles on The VisionHelp Blog there is now an answer to the proverbial question, "Why did our other eye doctor not tell us about this problem?" The answer can be found in CATS WHO SUCCEED.
Dan L. Fortenbacher, O.D., FCOVD
{Authors note: Coincidently today, just before I was about to publish this blog article, I examined a 5th grade (11 year old) girl who has been struggling to concentrate in school for the last 3 years. Her teachers thought she had ADHD since she could not concentrate on reading or paper pencil activities for more than a couple minutes. When asked about her interest in the new 3-D movies her mother reported that they just give her a headache and she shuts her eyes! Until recently, her mother never suspect a vision problem since she had always passed the school vision screening with 20/20 eye sight. But, the frustration and headaches with reading prompted her to make an appointment for her daughter to see an optometrist. The primary care optometrist recognized this little girl's poor attention and concentration was due to a binocular vision problem called convergence insufficiency and referred her to see me for a specific diagnosis and treatment. This article was written for her and the millions of other children who continue to struggle with treatable binocular vision problems (like convergence insufficiency) that causes poor attention, concentration and reduced ability for near-centered visual tasks, such as reading and paper pencil activities. These kids also typically do not enjoy the new 3-D movies because of a condition known as 3-D Vision Syndrome... dizziness, discomfort and poor depth perception while watching a 3-D movie.}
A link between 3-D Vision Syndrome and a treatable binocular vision problems associated with "ADD-like" behaviors in children is being recognized. Not only has the advent of 3-D technology hit the bit screen, but soon will become common place in the home as the next wave of 3-D televisions. However, for children to enjoy the 3-D visual experience requires that they have developed an essential visual function called binocular vision. Binocular vision involves the ability to effectively coordinate, focus and move the eyes effortlessly. This eye coordination function develops normally in early childhood for most kids however, research shows that as many as 10-15% of children will have difficulty in binocular function. Some children (3-5%) will have a total lack of binocular ability due to a complete failure of binocular vision known as strabismus. These children will have no appreciation for 3-D movies or 3-D television because these children are completely stereo blind.
On the other hand, another more common form of binocular vision failure affects 7-10% of the population and has more serious symptoms. Stereo blindness is less severe in these cases because these children have the general ability to coordinate their two eyes, however they just do it very poorly! As a result, instead of having fun with the three dimensional entertainment experience, these children will often experience dizziness, visual discomfort and reduced depth perception while watching the 3-D movie; what is now being called the 3-D Vision Syndrome. A look into the cause of this "visual stress", optometrists will often find that the patient who complains of 3-D Vision Syndrome will have a diagnosis of a binocular vision problem called convergence insufficiency (CI).
It is no strange coincidence that convergence insufficiency (CI) which has been linked with 3-D Vision Syndrome is also associated with "ADD-like" behaviors in children due to the inability for the CI individual to sustain binocular alignment and focus of the two eyes for near-centered visual tasks such as reading. As a result parents whose children experience dizziness or discomfort associated with a 3-D movie or TV should seek a Doctor of Optometry for a comprehensive vision examination. Don't forget to mention your child's symptoms to the doctor as routine eye health and eye sight testing will not identify a child with convergence insufficiency (CI). Rather a battery of specialized tests are necessary to properly diagnose problems with binocular vision such as convergence insufficiency.
When diagnosed with CI a patient can be effectively treated with office-based vision therapy which has been found, though double-blind research, as the only effective treatment yielding an effective "cure" in most individuals. While outcomes can vary, the usual result of office-based vision therapy for CI is complete remediation of the binocular vision dysfunction and improved ability to visually attend and participate in near centered visually demanding tasks. That translates to better concentration and ability to stay on task improving competency for completing reading and homework...and enjoyment of the 3-D movie or TV experience!
Dan L. Fortenbacher, O.D., FCOVD
"Eye movement is a predictor of academic success". This month marks the 10 year anniversary when the Harvard University Graduate School of Education made this announcement. The research clearly shows that there is important association between effective eye movement control and academic success.
Ever since this breaking news a decade ago, further evidence of the association between eye movement and academic success continues to be recognized. For example, in Volume 27 Issue 8 of the Journal of Brain Development in 2005 the titled research is, the Voluntary Control of Saccadic and Smooth-Pursuit Eye Movement in Children with Learning Disorders.
While the testing of eye movement is relatively easy, the clinical presentation of poor eye movement control can often be missed and misunderstood. For example the testing of smooth-pursuit eye movement control can be easily performed with a bead on a stick or the tip of a pencil or pen. The examiner simply asks the child to look at the target (held about 10 inches from the nose) and follow it with their eyes as the target is slowly moved horizontally, vertically (on the midline) and in a rotation. The child should be able watch the moving target with minimal head movement. Furthermore, the child who is years and older, should be able to "visually track" the target with a minimal amount of distraction such as asking simple questions (cognitive loading).
With the advent of web-based professional networking sites, like Sovoto, a platform now exists to help doctors and other professionals who work with children to see an example of a child with oculomotor dysfunction. To see an example of a child with oculomotor difficulty that was associated with his reading difficulty click here.
The American Optometric Association has published the symptoms of eye movement disorders in the Optometric Clinical Practice Guideline (CPG) Care of the Patient with Learning Related Vision Problems. They are:
More importantly, once identified, the child who is diagnosed with a problem in eye movement, such as smooth-pursuits, can be treated with vision therapy. Specifically office-based optometric vision therapy provided by a vision therapist (supervised by the doctor), can effectively treat disorders of voluntary eye movement. The results can often be a dramatic improvement in the child's reading efficiency.
To see the same patient after 24 sessions of office-based vision therapy click here. His reading efficiency and fluency has improved and he is enjoying reading!
To learn more about optometric vision therapy and find a doctor who provides office-based vision therapy visit the COVD website at www.covd.org
Dan L. Fortenbacher, O.D.,FCOVD
