In Search of Hyperopes

Last week I brought a group of 1st year optometry students to an elementary school in Brooklyn .  We performed a vision screening on roughly 80 pre-kindergarten, kindergarten and 1st grade students.  I really enjoy taking 1st year students on vision screenings.  It’s their first real clinical experiences.  They get to practice what they have been taught on patients other than their classmates.  There are so many “teachable moments.”  It never takes more than 5 minutes before one of them notices something worthy of a referral for a comprehensive vision examination.  They begin to see the connections between various measurements and visual function in a classroom (and beyond!).  And who can resist smiling when you watch a 5 year old try to take apart a student’s  ophthalmoscope.

The purpose of a vision screening is to identify children with vision problems requiring intervention.  Sometimes these vision problems are easily overlooked.  A classic example is hyperopia (farsightedness).

When children are farsighted, they are able to compensate for the hyperopia by focusing their eyes.  They have to focus even more when reading or performing other near vision tasks.  The greater the hyperopia, the greater the focusing effort.  All that focusing can cause eye fatigue, intermittent blur, headaches, and inefficiency when using the eyes to gather information.  But it also allows the young hyperope to avoid blurry vision.  These children will pass the vision screening unless you search for the hyperopes.  That is one of the tests that we perform during a vision screening.  We include a certain procedure to look specifically for hyperopes with good visual acuity.

But a little bit of hyperopia is expected in children…….. so when do you refer?  How much hyperopia warrants a comprehensive eye exam and the possibility of an eyeglass prescription?

When discussing referring or prescribing for uncorrected hyperopia, I often point to an article written by Dr. Jerome Rosner in 1997:  The relationship between moderate hyperopia and academic achievement.  Rosner looked at the correlations between refractive error and performance on reading tests in a group of 782 elementary school children.  He found that the children with uncorrected hyperopia greater than +1.25 diopters were more likely to have lower reading scores.

Dr. Rosner drew a line in the sand — for children with hyperopia greater than +1.25, a comprehensive vision examination is indicated to determine if that child would benefit from lenses.  That was the number we used at the vision screening.  We referred many children for a variety of reasons;  that included several children who were able to read the letters on the chart 10 feet away, despite uncorrected hyperopia of greater than +1.25.

But identifying these children is only the first step in the battle against learning related vision problems.  These children need comprehensive vision examinations.  Hopefully that will happen and these children will be well on their way to successful performance in and out of the classroom.

Read more about vision screenings here and here.

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I’m the Data

Today Jillian and Robin Benoit visited with students at SUNY Optometry via Skype.  Together they told Jillian’s story…… how it was discovered that she had severe amblyopia; how an ophthalmologist treated her amblyopia; how her vision problems persisted even when the ophthalmologists said there was nothing more that could be done to help her; and ultimately how optometric vision therapy changed her life.

There were a few moments in their presentation today that I found particularly thought-provoking:

1.  Vision therapy changed, not only Jillian’s life, but the lives of her family and friends.  If Jillian had never learned to read music and play the clarinet, she and her family would not have traveled to see her play with her school band.  They never would have experienced the myriad of opportunities associated with writing and marketing, not 1 book, but soon to be 2 books!  And they will never have to wonder, what if I had taken her to see an optometrist when she was a baby.

2.  Jillian received an email from an ophthalmologist who seemed intent on using the never-changing defensive strategy to bash optometric vision therapy:  where is the evidence, where is the data to prove that vision therapy works.  Jillian took on the ophthalmologist by telling him, “I’m the data!  VT is for people and the people can tell if it works.”  Bravo, Jillian!

Jillian, I would like to give you another perspective on “show me the evidence, show me the data.”  The results of the Amblyopia Treatment Study 2-A were published in the journal Ophthalmology in 2003.  In that study, children between 3 and 7 years of age with severe amblyopia were randomized to 2 treatment groups: full-time or 6 hours/day of patching.  The results: visual acuity in the amblyopic eye improved a similar amount in both groups.  The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hr group and 4.7 lines in the full-time group.

Despite this evidence that was published in an ophthalmological journal, Jillian was patched for 11 hours/day for 3 years.  What good is the evidence if you don’t put it into practice!

Thanks Jillian  and Robin Benoit for encouraging my students to be Superheroes.  You are developmental optometry’s Rock Stars…… Rock On!  

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Malingering?

Over the last week or so, I have examined 3 children, all referred,  with a tentative diagnosis of malingering.  The medical dictionary defines malingering as “the act of intentionally feigning or exaggerating physical or psychological symptoms for personal gain.”  When adults do this, it is usually an attempt to obtain a status of visually disabled in order to collect monetary benefits.  With children, it is more likely because they want a pair of glasses.  Perhaps a sibling or a best friend has recently gotten a pair of incredibly chic eyeglasses and a heavy dose of positive feedback!  This is not an uncommon scenario in a busy pediatric service, and I have a bunch of different techniques to “trick” my young patients into reading the littlest letters without any lenses.  Here is how it worked out for me with these 3 patients.

JB is a 9 year old boy, brought in by his foster mother.  He has had a traumatic childhood and is being treated for a bipolar disorder.  He is in a special education program but still struggling academically.  He was referred by another doctor who suspected malingering but JB kept insisting he could not see any letters of any size at any distance.  But when I questioned him and his mother, he did not behave like a child with such reduced vision.  He watches TV, plays video games and runs around during recess without getting hurt.  Objective measurements made it very clear that he does not require any lenses, and there was no obvious pathology that might account for his vision loss.  After multiple “malingering busting” tricks, JB finally read the 20/20 line without any lenses.   I believe that JB’s “malingering” is much more than an exaggeration of his symptoms for personal gain.  This is a desperate cry for help, from a young boy with some serious problems.   It took so much time to determine that he does not have any ocular pathology or  a need for a  distance correction, that I was unable to assess him for the presence of a learning related vision problem.  I discussed this with his mother, and we both agreed that JB needs further evaluation.   She accepted a referral to the Vision Therapy Service.

DD is an 8 year old girl.  She was very quick to point out to me that she is, in fact, almost 9 years old.  She was referred by her school because her teacher felt that she was faking a vision problem so she would not have to complete her schoolwork….. she’s lazy!  DD had a pair of glasses and all our measurements indicated that making her glasses a little stronger should have done the trick, but she consistently stopped reading the letters at the 20/80 line.  Now, it was a busy evening, I had several patients still waiting to be seen, this was taking too long and I was getting cranky.  I reached all the way to the bottom of my bag of “malingering busting” tricks but she was stuck at 20/80.  I kept insisting that she could read smaller letters and she kept stopping at 20/80.  I finally looked at her retinas with my ophthalmoscope and felt like a fool.  Indeed 2 weeks later she was diagnosed with a retinal dystrophy that is causing her poor vision.  Her vision will probably get worse, it certainly isn’t going to get better.  DD has an appointment with my colleagues in our Low Vision Service.  It is time to help her make the most of her remaining vision and prepare her to function with progressive vision loss.  I also began the process of obtaining appropriate services and accommodations from her school.

BT is a 10 year old girl referred by the school after failing a vision screening.  She was also seen by another optometrist who couldn’t figure it out.  Once again, she does not behave like a child with reduced vision, but she could only read the biggest letters on the chart.  After trying several lens combinations, and getting minimal improvements, I finally told her that I ran out of lenses.  If this last set of lenses didn’t improve her vision, then she wasn’t going to be getting any glasses.  Bingo.  She read the 20/20 line with a combination of lenses that added up to zero power.  Finally, a malingering malingerer.  Mom was not surprised.  She agreed to purchase an inexpensive pair of sunglasses for BT.

What’s the lesson here?  If your child is complaining about poor vision, or the school suspects a vision problem, please make sure your child has a comprehensive vision examination.  If something doesn’t seem right, get a 2nd opinion.  Yes, sometimes they really are “exaggerating.”  But sometimes its evidence of a much more serious problem that needs serious intervention.

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The Need (part 2)

Dr. Eric Borsting and colleagues are still investigating the diagnosis, treatment and consequences of convergence insufficiency.  The most current research from the Convergence Insufficiency Treatment Trial (CITT) which was presented at COVD’s annual meeting considers the behavioral and emotional problems associated with convergence insufficiency (CI).

Fifty-three children with symptomatic CI were enrolled in the study.  For each child, the parents completed the Child Behavior Checklist (CBCL) and the teachers completed the Connors 3 ADHD Index.  The children were then enrolled in office-based vision therapy programs, and 44 of them completed 16 weeks of treatment.  The parents and teachers then completed the surveys again.

When scores at baseline (pre-therapy) were compared to normative data, the children with CI had more symptoms on both surveys.  On the Connors 3 ADHD Index, the symptoms most frequently reported by teachers were inattentiveness, distractability and giving up easily.  On the CBCL, the symptoms most frequently reported by parents were somatic, such as headaches and eye discomfort.  Children with CI exhibited more symptoms and behaviors associated with ADHD than children with no visual problems.  Following vision therapy, the children showed significant improvement on both scales.  Treatment of convergence insufficiency resulted in a reduction in the behavioral and emotional problems reported by both parents and teachers.

Here’s the take-home message:  if your child has been diagnosed with ADHD or exhibits many of the behaviors associated with ADHD, your child needs a comprehensive vision examination.  If vision deficits are revealed, then vision therapy might be the most appropriate treatment option.  This study is another contribution to evidence documenting the power of vision therapy in the treatment of learning-related vision problems.

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The Need (part 1)

Research presented this morning at COVD’s annual meeting had an uber important message:  we need more vision therapy!  Drs. Lisa Christian, Angela Peddle, and 4th year students Shannon Pennifeod and Beth Schellenberg presented the preliminary results of a very important study.

The doctors and students from Waterloo School of Optometry reviewed the records of young patients, all of whom  had been identified as learning disabled by the district school board.  Before writing an individual education plan (IEP) for each, the school board advised that each student have a comprehensive vision examination performed by the pediatric service of Waterloo School of Optometry.

The records of 68 students ranging in age from 6-12 years were reviewed.  None of them had ever had a previous eye exam.  Children requiring spectacles were not included in the study.  The number of vision problems discovered in this population was astounding.

• 43% had reduced stereo vision
• 67% had binocular dysfunction at near
• 36% had signs of convergence insufficiency
• 38% had deficient accommodative skills

Six measurements of binocularity were obtained; 60% of patients failed two or more of those tests.

Children with reading problems who require individual education plans are at high risk for vision problems. What would have happened if these children were not referred for a comprehensive vision examination?  They would have continued to struggle with undiagnosed vision problems.  We need comprehensive vision examinations for ALL children entering school.  Many of theses children will also require vision therapy.

Does your child have a reading or learning disability?  Please make sure that child has a comprehensive vision examination.  Make it happen.

Find a doctor in your area.

Read more about comprehensive eye examinations here.

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The Splash – From Ripples to Waves

Check out this video highlighting a child that has been helped with vision therapy.  In the feature story, the child says he went from C’s and D’s to A’s and B’s in a matter of months.  To me it is another great example of how these developmental life altering vision problems can impact school performance and beyond.

This child’s developmental optometrist is Dr. Carol Scott.  She is the reason I am a developmental optometrist today.  During my first year of optometry school, Dr. Scott came and lectured about children she was working with.  She talked with passion about how so many of these smart, intelligent children were struggling in school due to treatable vision problems.  She talked about the profound impact treating these vision problems had on these children – in many instances, completely altering the trajectory of their lives.  Unfortunately, in our society,  if you cannot read well and therefore cannot perform well in school, so many doors quickly close to your future.  I knew during that lecture that this was the part of my profession I wanted to practice for the rest of my life.

In thinking about that moment, it is amazing how Dr. Carol’s seemingly small act of lecturing to a group of first year optometry students had such a profound impact on my life.  Before attending her lecture, I had considered vision therapy to be one of the last things I wanted to do in my future practice.  Now as a developmental optometrist I see the lives of children change everyday.

And so it is with vision therapy.  The way we will reach the many people who can benefit from developmental optometry  will be the accumulation of many little ripples.  The ever-growing number of lives affected and the ever-mounting body of evidence supporting vision therapy are becoming the waves that will bring our brand of optometry to the mainland.

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Moms Need to Know

I participated in my first Twitter party last week.  As children go back to school, the party focused on children’s vision.  The Twitter Party was sponsored by 5 Minutes for Mom, an online community for moms (and people who love kids) and Eye Smart (American Academy of Ophthalmology). The party was 1 hour long, and every 10 minutes or so, the party host would pose a question for all the participants to consider.  Links were also provided to answer the questions and win prizes!  All the party-goers were tweeting questions and answers…. it was chaotic and very organized at the same time.  It was fun to read and respond to all the ideas that were being tweeted.  My keyboarding skills (and my synapses) got quite a workout in that hour!

Here are some of the ideas and questions that were presented during the party:

• Good vision is important to a child’s’ ability to succeed in school.
• What do you think is the most important thing you can do to keep your child’s eyes healthy?
• It is essential to check vision & eye health through their childhood, including school years.
• As your children head back to school, make sure they have the visual skills to be successful in the classroom.
• There are several important times for children to have eye exams: as newborns, during infancy, preschool age, and when entering school.
• The 3 most common “refractive” vision problems in children: hyperopia, myopia and astigmatism.
• As we head back to the classroom, it’s a great time to teach kids about eye health and the science of vision.
• Every year, a whopping 3 MILLION school days are missed because of Pink Eye.
• 90% of sport-related eye injuries could be prevented by wearing protective eyewear.
• If your child’s eyes are strained from too much screen time, practice the “20-20-20” rule: Every 20 minutes, shift your eyes to look at an object at least 20 feet away, for at least 20 seconds.

Don’t forget, good vision and eye health are key to your kids success in the classroom and safety on the playground.

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The Science: Performance-Related Symptoms

Convergence insufficiency (CI) is a common visual disorder that is characterized by great difficulty maintaining binocular eye alignment when looking at something close up (such as a book or a writing assignment).  This landmark study, funded by the National Eye Institute, provides strong evidence that office-based vision therapy is the most effective treatment for CI.  Treatment success can and should be measured 2 ways: objectively (looking at changes in measurements used in the diagnosis of CI) and subjectively (looking at changes in symptomology associated with CI).

The Convergence Insufficiency Symptom Survey (CISS) was developed to quantify the frequency and severity of symptoms reported by patients with CI.  The 15 symptoms on the CISS can be divided into 2 categories: performance- related and eye-related.  There are 6 performance-related symptoms evaluating visual efficiency when reading and/or performing near work:

• Loss of place
• Loss of concentration
• Having to re-read
• Reading slowly
• Trouble remembering what you read
• Getting sleepy when reading

The 9 eye-related symptoms include blur, headaches, double vision, tired, sore, uncomfortable eyes, words that move and jump, and pulling sensations around the eyes.

This study evaluated the symptomology of children with Convergence Insufficiency before and after optometric vision therapy.   Before vision therapy, the six most frequently reported symptoms were the six performance -related items. Fifty percent of all the children in the study responded “fairly often or always” when asked if they lose their place when reading.  Similarly, 45% of the children reported loss of concentration and having to re-read; 40% read slowly; 38% have trouble remembering what they read; and 37% get sleepy when they read.

Children with parent-reported ADHD (attention-deficit hyperactivity disorder) had significantly higher symptom scores on the CISS and the higher score was almost entirely attributed to an increase in the frequency and severity of these performance-related symptoms.

The good news is that ALL the children who responded to treatment reported a decrease in ALL their symptoms.  And while this study did not look at academic performance, the authors do note this relationship when they state: “the treatment of symptomatic CI may have a positive impact on reading performance and attention.”

What is the take home message?  If your child has a convergence insufficiency, it is important to consider both eye-related and performance-related symptoms.  Your child may not be complaining of blurred or double vision, but they still might have performance-related symptoms.  Loss of place, re-reading, poor reading comprehension, slow reading, sleepiness, poor concentration….. am I describing your child’s symptoms?  Have you considered a vision problem as a possible explanation?

Read more about convergence insufficiency here.

Reading more about vision and ADHD here.

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Success Stories for Children’s Vision and Learning Month

Children’s Vision and Learning Month is coming to a close today.  Have you seen the success stories that were posted on Facebook?  So inspiring!

Developmental optometrists are helping children succeed by treating their learning related vision problems.  Here are just a few of them:

Ryed  from Kansas

Nick from Pennsylvania

Kyle   from Massachusetts

Morgan  from Michigan

Ytzel  from Oklahoma

Autistic children from Barbados in Michigan

Jacob  from  Utah

August may be over, but these success stories are being written every day all over the world.  Give your children the gift of a comprehensive vision examination as they head back to school.  Start writing your child’s success story today!

Find a doctor here.

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The Splash – Persistent Parents

Our guest blogger this month, Carrie Hall,  is one of the very talented vision therapists at my practice. She brings a unique perspective to the blog since she works with patients every week often times for many months.  Because of this,  she often gets to know the patients and their families on a very personal level and truly gets to know the struggles, trials, and triumphs patients go through.  At the conclusion of COVD’s National Vision and Learning month, I think her perspective into one of our patients is a perfect addition to what has been a great highlight of many inspiring vision therapy success stories.

As a vision therapist, I often see a theme among the parents that I encounter. Though they are of various ages, personalities, beliefs and styles, they often share one certain characteristic that sets them apart as vision therapy parents. They are incredibly persistent. They have been told many times in their lives that their children may not be capable of certain things. Perhaps by a doctor intending to give them a realistic expectation of the future, or perhaps by a teacher who is frustrated by a lack of success in their child. Whatever the source, I encounter parent after parent who has been informed that their child will not be capable of a certain level of ability, be it athletic,  academic, or just general life skill development.

Lynn was one such parent. Her daughter Shelby was simply not blooming in school like her older sister had. Reading was inexplicably difficult for this 8 year-old. Always a fight, often involving tears, Shelby simply would not take to reading. Lynn was baffled. Shelby was obviously bright and determined, a spunky and enthusiastic girl. It just didn’t add up. The pieces did not fit. Her eye doctors confirmed that Shelby’s vision was fine. She had 20/20 acuity, so the only reason why she shouldn’t be learning to read was if she simply wasn’t as smart as Lynn thought.
Perhaps some parents are more inclined to take the words of professionals at face value than others. Perhaps some parents simply refuse to be satisfied with an underwhelming determination of their children’s potential. Whatever is the mitigating factor, Lynn could not and would not be satisfied with this evaluation of her daughter. She persisted in her search. When she eventually found Washington Vision Therapy Center whose symptom checklist of vision-related learning problems read like a specific description of Shelby’s struggles, Lynn knew she had found her answer. When confronted with the financial strain that therapy would mean for her family, her persistence did not waiver. She would make whatever sacrifices were necessary: she would ensure her daughter’s chances for success in school and life no matter what.
Maybe persistence is a genetic trait as well. I certainly saw the same attributes in little Shelby that her mother demonstrated. Months after beginning therapy, after countless lifesaver cards and hart charts, Shelby was burnt out with it all. Who can blame her though? When the goal of all the work is just to get better at doing homework, it hardly seems a fair thing to ask of a girl of 8 who would rather be playing outside than getting better at reading any day of the week.
But like I said, maybe persistence is a genetic trait. Or perhaps it’s more nurture than nature. Whatever the case, Shelby persevered. Not only did she make it through therapy, she did great at it. She learned to be able to coordinate the use her two eyes like the best of them by the time it was all said and done. She and her mother developed a balanced working relationship in regards to this specific area in order to attack vision therapy head-on and accomplish every last bit of what Dr. Winters wanted to see from her clinically. Neither one of them would quit. Lynn pushed Shelby, and Shelby pushed right back in order to finish well. That little girl was the definition of persistence.
It’s the characteristic that marks out the parents, and the patients as well, for success. They are all up against diagnoses and school evaluations that make the future look bleak. They have been told repeatedly that they can’t, that they won’t. But they refuse to listen. Little fighters, they are, coming in and out of our offices defying the odds stacked up against them.
The other day, Shelby came up to her mother after doing some reading and said, “You know Mom, I think I like this reading thing.”  She is now at grade level in reading.  That is the payoff for any persistent mother.  Lynn has continue to fight to get Shelby’s story of hard work and persistence out to the public and she is now being featured on COVD for National Children’s Vision and Learning month. http://www.cisionwire.com/college-of-optometrists-in-vision-development/r/mom-of-struggling-reader-finds-help-and-speaks-out-for-college-of-optometrists-in-vision-development,c9283372 Imagine that. A homeshooling mom from Yakima, Washington who believed her child’s struggles with reading were more than a resistant attitude or just that her daughter wasn’t smart enough. Persistence is a powerful thing.

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