“Is it a vision problem?”

Does this child have a visually-based problem?

Our children present with a vast array of problems affecting their development and academics. Sensory problems, trauma, autism, behavior, ADHD and the list goes on. Our children get assessed by OTs, and PTs, neurologists, neuropsychologists, and pediatricians. But did they have an eye-exam? A complete eye exam? Only 40% of children have had their eyes examined by an eye doctor. (1) That leaves all of those children potentially walking around with vision problems affecting their academic and developmental development. Meanwhile, we attempt to teach them catch a ball or write the alphabet or button a button.

“Does he need an eye exam?”

YES!!! Every child, regardless of academic performance or other diagnosis, needs a complete eye exam with a binocular vision assessment and cycloplegic dilation, even if the child has never complained about their vision.  Many times, when a child is assessed with the Convergence Insufficiency Symptom Survey, they learn that they are not supposed to see “words moving” on the page or see double when they read. They had symptoms and were not even aware. Most children with ocular motor or near vision problems will read letters on a chart without difficulty. 20/20 means only that each eye has good acuity. It does not tell us how well the eyes are working together or how hard the eyes are working to make a 20/20 acuity. Only a complete eye exam with binocular assessment and cycloplegic dilation can give the whole picture.

“Is this is visually-based problem?”

There are many signs a child is having a visual-based problem.

  • Eye rubbing
  • unexplained headaches
  • poor handwriting
  • poor reading skills that do not improve with tutoring
  • head turning or tilting when reading
  • closing one eye while reading
  • poor visual motor integration that does not improve practice
  • poor balance or motion sensitivity
  • Diagnosed ADHD that does not respond to medication
  • unable to catch a ball
  • letter reversals
  • visual perceptual problems
  • spacing and size problems during handwriting tasks
  • fine motor delays
  • poor depth perception

These problems maybe mis-diagnosed as things like dyslexia or ADHD and even be treated as such without success for many years.

“Who do I send them to, to make sure they a complete eye exam?”

A good place to start is College of Optometrists in Visual Development. These doctor specialize in the assessment and treatment of eye movement disorders and near vision focusing problems that could be affecting academic performance. You can your local COVD doctor with the search tool on the site. One might also look for an optometrist that specializes in pediatrics or binocular vision.

When an appointment is made, be specific about symptoms and ask for a “binocular vision assessment”.

Every child

Every child needs a complete eye exam. Parents may have many reasons to not get this dome, but you cannot teach a child read or write, or catch a ball that cannot see.

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1.Children’s Vision Screening and Intervention. (n.d.). Retrieved from https://nationalcenter.preventblindness.org/childrens-vision-screening-and-intervention

“Can eye movement problems be related to torticollis?”

Ocular Torticollis

Torticollis can be caused by several things. Delays or problems in the integral development of muscle tone, the vestibular system and propreioception can all be causes.  Eye alignment, nystagmus and acuity problems can also affect head position.  When vision is the primary cause for torticollis, it is referred to as ocular torticollis.  One study found 20% of torticollis related to ocular problems. (1)

Eye alignment

Head tilts and head turns are common signs of eye alignment problems. Deviations between eyes in the horizontal plane (hyper- or hypo- tropia) can cause head tilts in the brains attempt to see a single, fused image. Head turns (rotation) to right or left can be caused by strabismus (eso- or exo- tropia). Again, the brain turns the head in attempt to not see double. Other more complex movement patterns can also cause head position and posture problems.

Nystagmus

Nystagmus is an involuntary movement of the eyes. This is generally associated with a neurological problem. They can be congenital or acquired. Many times, patients with a nystagmus will turn their head to find the point at which the nystagmus stops. This point, called the “null point” allows for improved vision for the patient.

Acuity problems

Astigmatism, a condition in which the eyeball is not perfecting round but more football shaped, can also cause visual acuity problems that might facilitate a head tilt in order to improve vision.

Eye Exam

Every child should have their first eye exam at 6 months (per AOA recommendations). A through eye exam that includes a binocular vision exam would find eye alignment problems most likely to cause ocular torticollis.  If treating a patient with torticollis of unknown cause, a binocular vision exam could be helpful in identify the problem. Frequently, prisms and lens can be prescribed that can help reduce the torticollis.

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“When should we see no head movement during visual tracking?”

When should they hold their head still…

The development  of the visual system in children is much discussed. The AOA offers time lines which have development of eye movement continuing to improve at 36 months. This development is dependent upon many factors including the development of the brain as whole and the vestibular, and proprioceptive systems. The development of these systems is inter-dependent. Problems in the visual system will affect development of the vestibular and other systems and impact the developmental movement sequence. This is why the first eye exam is recommended at 6 months of age.

In the birth to 3 three year old, developmental delays would most likely include tracking and saccades problems, particularly when neurological problems (seizures, anoxia, CP, etc) are present. As therapists, our treatments should should stimulate as many sensory systems at possible, including vision.

Eye Movement norms

The best information on the development of eye movement accuracy comes from the NSUCO Ocular motor norms. The NSUCO protocol looks at ability to perform the movement, accuracy of the movement, amount of head movement present and the amount of body movement present during the testing of tracking and saccades. Each of these skills is rated 1-5 with each score defined in the above referenced article. This is the standard way saccades and tracking are quantified by ODs. Each movement would include 4 numbers describing the child ability to perform the movement. This is a somewhat subjective test, much as our manual muscle testing is somewhat subjective. It is most important for the therapist to recognize the errors and refer to the doctor for scoring, then be able to interpret the score as provided by the doctor.

The norms begin at age 5 and support the idea of a constantly improving ocular motor system until full maturity at the age of the 10. The paper further references minimal standards from age 5 to 10 to help identify less than age appropriate eye movement accuracy.

The Therapist’s job

We should be screening these eye movement on all of our patients. Children with developmental delays have a high incidence of ocular motor problems which affect balance, reading, spatial awareness, fine motor and visual motor integration development. These ocular motor problems are influencing the outcomes of our interventions so being testing them should be a part of every OT and PTs evaluation process.

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Motion sickness and the eyes

Motion Sickness

As part of my vision rehab evaluation with patient I always ask about motion sensitivity (or car sickness). The answer can give cues to the functioning of the ambient (magnocellular)visual system.

What is motion sickness?

The semicircular canals within the ears (vestibular system) tell the body that it is motion. The magnocellular visual pathway also “confirms” this motion as movement is observed. But when the system is less aware of magnocellular output (such when one is reading or playing a game in the car) then the vestibular and the magnocellular system get different information. When this happens nausea and rest follow.

The magnocellular system

The magnocellular system is responsible for visual input that affects gait, posture and balance. It also helps us track during reading as it gives the brain the ability to see the line peripherally as the eyes focus on the words being read. There was some discussion that magnocellular problems were associated with dyslexia as well.

Treating the Magnocellular system

To improve magnocellular input, we do activities on a balance board while performing visual scanning tasks that emphasize keeping the head still and maintaining balance as targets are toughed. I will have patient do this while wearing glasses with binasal occlusion or base up or down prism depending on posture. This can also be helpful with idiopathic toe walking.

More recently, motion coherence tests have been developed which help to quantify magnocellular function. In these computer based tests, dot move randomly and the patient must decide which direction most of the dots are moving. Devices like the Neuro-tracker also work on magnocellular function.

Using the system as tool

The magnocellular system can be a powerful tool in improving posture and balance. The altered visual input quickly re-aligns posture without cueing and makes use of the brain natural ability.

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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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