Letter Reversals

Letter Reversals

Letter reversals are frequently an area of concern for parents as their child begins to learn writing and reading. Reversals are often viewed as a sign of dyslexia and are surrounded by myth. Here are the facts on letter reversals

  • Letter reversals are common and appropriate until a child reaches 7 or 8 years old (second grade).
  • After the age of 7-8, the children who continue to have reversals are the children that are having difficulty with reading(1)
  • Learning letters is the first time a child learns that an item becomes a different thing based on the way it is facing. A cup from seen from one side or the other is still a cup but a “b” seen the other way (“d”) is not the same thing.
  • Visual spatial and left/right body awareness correlated with children having letter reversal problems suggesting that addressing left/right awareness would improve letter reversals (2)
  • Working memory deficits, also found in dyslexia, were found in children with letter reversals, so addressing working memory may improve letter reversals. (3)
  • Children with ADHD tend to have more reversals, possibly related to difficulty in an inability to to suppress the more natural left-right flow of making most letters.

Treatment Ideas

Having the child the pull letters from a bag and identify the letters without looking at them has been a great activity (suggested by Dr. Charles Boulet) and correlated well with children having difficulty with this task that have reversal problems.

Dr. Kenneth Lane OD, FCOVD’s book , Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook, has an excellent discussion of letter reversals as well as treatment techniques. Presenting p-q-d-b chart and having the child touch “p” and “b”  with right and q and d with the left has proven to be very challenging. This activity include a component of eye0hand cooridnation and saccade accuracy that will further improve binocular vision and saccade accuracy.

The Optomteric Extension Program offers Recognition of Reversals Workbook, also by Dr, Lane (a great bookstore!!). This workbook has more activities for reversals and its only $20.

Calm the panic!!

In a few cases, letter reversals after the age of 7-8 can indicate dyslexia, but there are many other reasons a child may have reversals.

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References

  1. Terepocki, M., Kruk, R. S., & Willows, D. M. (n.d.). The incidence and nature of letter orientation errors in reading disability. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15493319
  2. McMonnies, C. W. (1992, October). Visuo-spatial discrimination and mirror image letter reversals in reading. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/1430744
  3. Brooks, A. D., Berninger, V. W., & Abbott, R. D. (n.d.). Letter naming and letter writing reversals in children with dyslexia: momentary inefficiency in the phonological and orthographic loops of working memory. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/21978009
  4. Levy, F., & Young, D. (n.d.). Letter Reversals, Default Mode, and Childhood ADHD. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26794673

Convergence Tasks for Therapists

The Z axis

As therapists, we recognize the importance of mid-line crossing to help with primitive reflexes.  Reaching lateral outside of the base of support challenges balance and posture.

But to exercise convergence, the therapist must turn their favorite activity into the “Z axis”. This axis is the near-far axis, (referred to as the Z axis in vision) and challenges the convergence and accommodation system.  Many of our favorite activities can be modified just by turning them, to help strengthen the near vision system.

Simple convergence strengthening activities

Clothespins are great therapy tool, strengthening pinch for writing and other tasks. Having a child reach to a distance to retrieve the clothespin then hanging the clothespin on a near string can can help with convergence and divergence. The proprioceptive input of the hand hanging the clothespin on the string will cue the eyes to converge to a point.

The swing adds vestibular and proprioception to the convergence and divergence in this video.

In my clinic, I also use a cup with a straw that patients then put toothpicks in. This task can be graded by moving the cup closer to the child’s face.  This is task also made more difficult by not allowing the kiddo to touch the straw, removing the proprioceptive input,  forcing the eyes to guide the hand more accurately.

Amazing creative therapists

Cheerios on a Straw

In the task, the patient puts cheerios on a small coffee stirrer. The hand working at the end of the straw does a great job cuing the eyes to converge. Just make sure the straw stays in at mid-line.

Ball in a Tube

In this task, a 4 ft florescent bulb protector ($4 at Home Depot) is cut in half with a ping pong ball put inside. I then placed stickers on top of the tube. The patient has to align the ping pong ball under the the sticker. In standing? Even better. Balancing on a balance board? Even better!!!

As a bonus, the scrap end of the tube become a great “light saber” for popping bubbles to work on tracking and eye hand coordination.

Thanks to therapists that I have met

The weeks I spend traveling are exhausting but the energy of the people I met help me stay motivated. Thank you to all the therapists and teachers and others, that I have met.

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The Binocular Vision Exam

The Child’s Special Visual System

Children’s eyes are amazing. They bring the world to an eager child and facilitate development of many skills.  The visual world influences posture and gait, fine motor development, letter recognition on to reading skills and many other areas.  The importance of good vision cannot be over stated.

The Pediatric vision exam

The vision exam for a child should include assessments not generally not performed on adults. Check out this post first to understand how we see up close. 

  • Cyclopelgic Dilation and Refraction- This allows for the doctor to completely exam the retina of a child for optic nerve problems and other congenital problems that child may have. The cyclopelgic dilation also relaxes the ciliary muscles which control accommodation (focusing of the lens within the eye). This allows the doctor to exam the true refractive error of the eye which can frequently be corrected by the accommodation of the lens.  This should be considered mandatory once a year.
  • Near Point of Convergence – This brief assessment allows for the doctor to assess how how well the eyes are working together when seeing up close.
  • Measured cover test- A cover test reveals the amount of effort needed for the eyes to maintain their position. It also shows subtle eye movement problems like strabismus.
  • Retinoscopy – in this assessment, the doctor can get an objective measurement of refractive error. This eliminates communication problems some children may have and makes for the most accurate solution for a child;s visual acuity.

Better or Worse

General optometrists and opthamologists may or may not perform these tests.  Without them, an important part of the assessment of a child’s vision has been left out. Eye movements can cause delays in gross and fine motor development and decreased reading performance and difficulty in sports, like hitting or catching a baseball.

Look for doctors that advertise being pediatric or binocular vision specialist. Look for doctors that members of the College of Visual Development or the Neuro – Optometric Vision Association.  These are doctors that specialized in the assessment of binocular vision skills.

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Hemispatial Neglect or Field cut?

Field cut vs. Neglect following Stroke

Patients frequently present with a reduced awareness of their affected side following a stroke or brain injury.  This decreased awareness can be a visual field cut or a hemi-spatial neglect or both. Here are some ways to tell just why your patient cannot find half of the world.

Anatomy of field cut vs. neglect

A stroke with neurological neglect is generally associated with middle cerebral artery strokes. These are the most common strokes. The temporal/parietal lobes tend to be affected in these strokes with hemiplegia also occurring.

Generally, a true field cut is associated with a posterior cerebral artery stroke with the occipital lobe being affected. This is stroke is less common. The patient may not have any other symptoms from the stroke.

Functional differences between field cut and neglect

There are many difference functional in patients that have neglect vs field cut.

Patients with a field cuts:

  • show awareness of the field cut, they will tell you “I can see on my right side”
  • They begin compensations quickly
  • Show organized search patterns during cancellations tasks. This mean left to right, top to bottom pattern

Patients with neglect present differently

  • They may not be aware of the field loss and may not be aware of any of the stroke related deficits. This lack of insight to their condition is a big hurdle to treatment
  • They do not compensate well. This is probably related to the lack of insight.
  • Problems with attention in general. Perseveration (unable to shift attention) and distractibility are common.
  • Patient with neglect have difficulty with crossing midline. The eyes may not track across midline to affected side.  Slow saccades to affected side.
  • Poor search patterns on cancellation tests.  These patients randomly search for targets. It is important to watch how a patient completes cancellation assessments as a patient with a field cut and neglect will have similar looking cancellation tests when completed.
  • These patients tend to be oriented (posture and head position) away from the affected side.

Treatment differences of field cut vs neglect

Early resolution of neglect is vital to improving functional status following stroke.  Here are some of my favorite activities for treating neglect:

Field cuts tend to be a bit easier and are discussed here.

Neglect and filed cuts are common consequences to stroke and confusion about just what the patient is experiencing can make treatment difficult. I hope the helps!!!

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Dyslexia and Vision Rehabilitation

Dyslexia and Vision Therapy

Dyslexia is word frequently tossed about when children have problems reading or learning. Commons complaints that lead to the use of the word include letter reversals, poor reading comprehension and decreased reading fluency. These symptoms are also recognized as possible vision related problems cause by poor eye movement accuracy.

Is dyslexia a vision problem or a language problem?

Attempting to define dyslexia can be confusing. The origin of the word is vague: “dys” meaning difficulty with and “lexia”  meaning reading lends itself to broad interpretation.  The best definition for dyslexia, from the International Dyslexia Association says:

“Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.”

The research shows that the root cause of dyslexia is phonological processing, or how the brain processes sounds in language. Additionally, the prevalence of dyslexia is estimated to be between 5-20% of the population, according to the National Institute of Health: http://www.ninds.nih.gov/disorders/dyslexia/dyslexia.htm. *

Reading is a complex process involving language, speech, memory and other processes, but all of these processes assume that the collection of the information to be processed is accurate, ie that the eyes work correctly and move accurately. We do know that poor eye movements lead to poor processing skills because the data to be processed was not collected accurately.

Does vision therapy treat dyslexia?

This is also a very interesting question. In our vision rehab practice, we frequently get children referred to us that have common symptoms of dyslexia and visual processing difficulties like reversals and poor reading skills. Following the interventions, the children have reduced symptoms and most have improved reading fluency.

Some of patients do continue to have problems in reading although they show improved eye movements. At this point, we may further assess the patient using a dyslexia screening tool that can identify specific errors related to the processing parts of reading such as the decoding and encoding of words. When results indicate, we refer those children to specialists like our friends at Read-Write Learning Center at  that specialize in the treatment of dyslexia.

 

Does vision therapy treat dyslexia????

NO. Vision therapy cannot treat dyslexia. But it does improve the accuracy of eye movements eliminating many of the symptoms generally associated with dyslexia. With these eye movement problems gone, an accurate assessment of the visual processing skills and reading fluency is now possible, allowing for an accurate diagnosis of a visual processing or other reading and learning problems.

Here is a video case study describing the process.


*Special thanks to Hunter Oswalt, Director of the Read-Write Learning Center for her input on editing this post.

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Assessing visual fields

Assessing visual field in the OD office

Heres is how visual fields are assessed in the optometry office.

humphery

This is Humphery visual field tester. The test is generally done monocularly first. The patient places their face on the chin rest and clicks a switch when they see a light in the field. The device monitors fixation during the test and lets the tester know if the patient “cheated” by moving their eyes. Binocular testing may be done separately if needed. During this, the patient is allowed to move their eyes.

The results are very precise with even small peripheral reductions in field picked up. But there are some limitations. The patient must be able to respond in a timely manner by clicking a button, so motor response time and even posture can affect the ability to perform testing on this device.

Confrontation Field Testing

Visual field testing by confrontation is a way to perform visual field testing in clinic without the computerized tester.

In the test, the therapist sits in front of the patient presenting fingers in each field with patient reporting the number of fingers up. This is done for each eye.

It is important to present stimulus in all four quadrants of the visual field. Results of this can be correlated with other visual cancellation tests.

There is also campimetry which uses a specialized disk with different fixation points.

photo (15)

With the campimetry device shown above, the patient fixates on numbers on the disk and reports if they can see the middle spot.

There is also a web-based Damato Multifixation Campimeter test for visual fields that is  free.

Types of visual field cuts

Homonymous hemianopia is the most common visual field loss following a neurological event. This is lose of half of the visual field in each eye . These can affect right or left visual field (generally contralateral to the affected side of the brain, left brain right field cut). These tend to be associated with tempro-parieital lobe or occipital lobe damage. Left side field cuts tend to have a neglect aspect associated with them. The patient may not even be aware of the left sided vision loss making treatment of the field cut more difficult. Right sided field cuts tend to be more occipital lobe related with the patient showing improved awareness of the loss and improved recovery. Here is what it would like using a Goldman 30-2 test. This test looks at each eye separately and requires fixation.  The similar patterns in each eye tells us this a visual pathway problem, not and orbit problems.

visualfields-page-003 visualfields-page-002

 

Here is what it looks like on the Easterman Binocular Test. This test uses both eyes, allows for eye movements and is a more functional look at patient useful visual field.

visualfields-page-001

Quadrantanopia is loss of vision in a quadrant of the visual filed (upper right, lower right, upper left, lower left). It can also be homonymous (in both eyes) and may be described a superior right homonymous quadrantanopia.

quad

This is what that might look like.  They might also be bitemporal ( in the lateral fields of both eyes) or binasal (in the medial fields of both eyes)

A central scotoma is is loss of the central visual field and is associated with age-related macular degeneration.

visualfields-page-005 visualfields-page-004

 

 

Visual field treatment

Their are two common strategies behind improving functional status for patients with a field cut. We tend to use a combination of both at the optometry office.

The most common technique is to improve scanning strategies by having the patient perform scanning tasks into the area of the field cut. This can be done with any number of devices such as a Dynavision or a Sanet Vision Integrator. Both of these devices, and others, present random targets in a field with the patients ability to find these targets being timed. With either of these, patient practice scanning strategies which improves their awareness of the field and improves their time locating targets in the missing field.

In optometry, we have other tools available. We can use field expansion systems such as the Peli-lens or Gottlieb Field awareness system. Both of these involve the application of small pieces of prism to the lens of the patients glasses. These small strips move visual stimuli into the patient’s existing field “reminding” them to look to the affect side.  They cue the patient to scan into the missing field, something like a warning system.

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Balance and Vision

 

Two Visual Pathways

The focal, central or Parvocelluar visual system is called the “What” vision system. It is responsible for object identification. It allows us to focus on a specific object in the visual field. This information is interpreted in the occipital lobe.

The ambient/peripheral or Magnocellular visual system is the “Where” system responsible for spatial information, balance, coordination and peripheral awareness. This information is shared with the occipital lobe, in addition to links to the cerebellum and balance areas of the brain. Functional MRI shows this information actually reaching 99% of the cortex. Using ambient vision, we can automatically change our posture and gait to walk uphill or protect ourselves from falling over as someone bumps into us.

Functionally, these two systems allow use to look at the road ahead of us (focal vision) and be aware of the car to our left(ambient). It also allows us look at the TV but be aware of where the door in the room is. It allows us to be focused on a word in reading, but still make accurate saccades to the next word.

Notice what happens to the people attempting to walk through the tunnel.

Notice how the people in the tunnel are leaning to one side. The tunnel walls have confused their ambient vision system and affected the gait and balance.

A tool for rehabilitation…

Frequently this system can become faulty following a neurological event. In a condition called Post Trauma Vision Syndrome”, patients become over-centrally focused. This is seen clinically as decreased balance, decreased reading accuracy and poor spatial awareness a midline shift or toe/heel walking.  The patients also report becoming “over-stimulated” by visual information.   A visual field done a patient with this condition might look like this

peripheral loss

This is one eye, but the other may look the same. Notice the reduced periphery that might not show up in typical in-clinic screening of visual fields.  This visual field test is called a Goldman 30-2 and is done on each eye.  It  should be a standard part of the assessment of all of the post-TBI/CVA patients.

Improving Ambient Visual Function

To improve function of the ambient system, binasal occlusion may be added to a patients glasses with or without mild base in prisms.  How does this help?

A person that is over-centrally focused has a difficult time seeing the entire word. They tend to see letters rather than the whole word which greatly reduces reading fluency and comprehension. Saccades also become less accurate due to the decreased awareness of the line of text  making the person lose their place frequently.

This can also improve posture and gait. As the brain becomes more aware of the ambient visual system, it is better able to correctly adjust gait and posture. Remember the tunnel?

Optometrists that offer this type of service are involved in neuro-optometry. The organization is called the Neuro-Optometric Rehabilitation Association. This is a multi-disciplinary organization that was started by ODs who wanted to understand brain injury better and exchange information with other providers of care in the  TBI community like OTs and PTs. There is a provider list on their website to help you find a NORA optometrist in your area.

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