“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

Common Birth to 3 Vision Conditions

Vision Birth to Three

The visual system at birth has a lot of development to do. The early eye exam (6 months to one year) should find anything that may impede this development.

Common Birth to 3 vision problems

Common Birth to 3 Eye problems Pathology Acuity Prognosis Functional Problems Modification
Coloboma failure of the halves of the eye to join completely inutreo, may affect pupil, retina or lid varies depending of retinal damage stable condition glare problems if pupil is affected and retina is functional, reduced bincular depth percpetion sunglasses, motor practice
Optic Nerve Hypoplasia decreased evelopment of the optic nerve, usually assocaied with midbrain/endocrine problems varies from minimal affect to near blindness, possbile field cut, possble nystagmus stable condition Delayed motor development due to reduced visual input.   Refer to TVI at 3 yrs old. vestibular and motor facilitation tasks.
Retinopathy of Pre-Maturity scarring related to excessive blood vessel growth during prolonged O2 exposure in premature infants varies by amount of scarring stable condition depends on level of scarring, may be no delays related to vision based on acuity
Corticol Visual Impairment lack of vision due to visual pathway damage/failure to develop Usually not 100% blind stable condition near blindness, refer to TVI, use contrasting colors, movment and work peripheral to central to investigate amount of vision. Referal to TVI is important for school readiness.
Accommodative Esotropia medial eye turn due to extreme farsightedness 20/20 with glasses in place, eye turn also corrects with glasses improves, but child will remain in glasses throughout life none with early correction, amblypoia without correction glasses should be comfortable and worn at all times.
Infantile Esotropia medial eye turn not related to generally reduced due to amblyopia, may improve with correction varies, tx by surgery vs VT vs Botox reduced motor development per doctors order concerning patching, facillitate motor improvement
Amblyopia reduced acuity due decreased visual pathway development  due to prolonged suppression or lack of stimulation to visual pathway varies, 20/200 or worse to 20/50 depending on patching complaince and glasses wear compliance. may improve with compliance of tx and glasses wear, binocular vision therapy reduced motor dev., head turns, decrease binocular depth perception. Brain with compensate in time motor dev facilitation, exercise amblyopic eye if currently patching, binocular vision activities
Strabismus eye mis-alignment at rest, corrected with surgery vs VT vs Botox varies, generally reduced due to amblyopia varies greatly. Long term, brain adapts to suppression of the turned eye reduced motor dev, self-esteem, self conscious of turned eye, reduced binocular depth perception eye exercises per doctors order, facilitate motor development

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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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