Signs of Autism: April is Autism Awareness Month

Lack of eye contact, staring at spinning objects or light, fleeting peripheral glances, side viewing, and difficulty attending visually are behaviors typically associated with autism.  Yet these can also be signs that there is a visual component to your child’s challenges.  This April, the College of Optometrists in Vision Development (COVD) is participating in Autism Awareness Month and releasing a Public Service Announcement to help educate parents on the visual component to Autism.

As COVD President, Dr. David Damari notes, “Visual problems are very common in individuals with autism. Children on the autism spectrum often have eye coordination and eye movement disorders. For example, when asked to follow an object with their eyes, they usually do not look directly at the object. Instead, they will scan or look off to the side of the object. They might also have difficulty maintaining visual attention. At least one study suggests that more than 20% of those with autism have strabismus (eye turn) and 10% have amblyopia (lazy eye). Other studies support this high incidence of functional vision problems as well.”

Most people don’t realize our eyes are actually part of the brain. So it stands to reason that if someone has a neurological disorder that impacts the brain, their vision would be compromised in some way.  Children with ASD and other neurological disorders don’t complain verbally when their world doesn’t look right; they show us with their behavior.  When vision disorders are treated, one can see improvement in the child’s behavior and how he interacts with the world.

Here is one example of how a child’s behavior changed dramatically once the vision problem was treated.  As a pediatrician, Zach’s mother was aware of the symptoms of autism. While he had many symptoms of autism, he did not meet enough criteria for that diagnosis.  It wasn’t until she took him to a developmental optometrist that she understood how an undiagnosed vision problem could impact his quality of life.

Dr. Janna Jennings shares, “Zach begged me to bring him a loaded gun so he could shoot himself in the head … Since he started wearing the bifocals prescribed by the developmental optometrist a little over two years ago, he has never said another suicidal thing again. After a few months of vision therapy, he stopped saying he was stupid.”  While it took more than bifocals and vision therapy to help Zach fully recover, you can see the impact bifocals and vision therapy can make when there is a visual component to a child’s challenges.

To learn more about how vision disorders can impact a child with ASD or to find a developmental optometrist near you, visit COVD’s website:  www.covd.org.

“For this April’s observance of Autism Awareness month,” Damari continues, “we invite everyone to take a few minutes to view our Public Service Announcements and share them with your friends and relatives.”  The Autism and Vision PSA is airing on Insider Exclusive and can also be seen on COVD’s YouTube channel.

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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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It Takes Two

Today I examined a 9 year old boy with autism.  He had been examined 2 years ago and glasses were prescribed for full-time wear.  But his parents never had the glasses made.  They sought a second opinion and were told he only needed the glasses for reading.  Mom would often read with him and never noticed any difficulties and so decided that he probably didn’t need the glasses at all.  Now, two years later, his teacher called home because he was having difficulty seeing anything written on the board unless he walked to the front of the classroom.  So mom brought him back.

This child is VERY hyperopic and astigmatic.  Without lenses, his visual acuity at both distance and near is significantly reduced.  He also has an exotropia (his eye is turned outward) which is much worse when he does not have appropriate lenses.  When I put the lenses on, his vision improved. But he is amblyopic.  Because he has always had blurry vision, he has not developed the ability to see the smaller letters or use his vision effectively.  I expect his vision to improve as he wears the lenses.

I wanted to laugh and cry.  I was happy that I will have a positive impact on this young child’s vision and his life!  He will be able to participate much more actively in all his activities.  His autism surely poses other difficulties in his daily life and I am thrilled to eliminate (or at least mitigate) any visual deficiencies.  I am giving him a chance to interact with his world in a much more meaningful way.  But 2 years lost……… what if he had received those glasses 2 years ago?  What opportunities to learn and grow have been lost because he could not see?

It takes two.  I can do my part but I need help!  I need parents too.  I need parents to bring their children in for comprehensive eye examinations.  I need parents to ask questions if they don’t understand.  I need parents to comply with treatment plans (even if their children are not happy), I need them to return for follow-up care.

Parents, please help me help your child.  Schedule that exam.   Make sure your child wears the glasses in school.  Call me if you have questions or concerns.  Together we can accomplish so much, but I can’t do it alone.

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Case Report: Double Vision to Monovision

Today’s guest blogger is Ms. Annie Hao.  Annie was born and raised in China until her family moved to Japan in 1997 where she attended elementary school. In 2000, she came to America and finished her schooling in Pittsburgh, PA.  She attended  Michigan State University in Ann Arbor and received her Bachelor of Science in Physiology. She is currently a 3rd year student at Southern College of Optometry in Memphis, TN.  Upon graduation, Annie intends to complete a private practice residency in vision therapy and eventually practice vision therapy in a group practice setting. In her free time she likes to run, read. and cook.

A 61-year-old white male presented with a chief complaint of double vision and a history of having difficulty with glasses. He reported being uncomfortable with driving and said he could not see road signs well enough.  The history revealed that he had worn vertical prism for the past 25 years. For the past 6 years his glasses “haven’t been right” and he presumed that it was due to the change in his eye doctor and moving away from New York.  He reported being involved in a car accident when he was a teenager which may have affected the muscles of his right eye.  He also has a history of Meniere’s disease, an inner ear disease that affects balance and hearing.

Upon examination he was found to have a moderate vertical deviation, with a tendency of the right eye to turn upward.   While trying to determine his spectacle prescription, he reported double vision and vertical prism was required to help move the images from each eye closer together.   He saw two lines of letters and the lines were almost level, but one of the lines was tilted.  Further testing demonstrated that, in addition to the vertical deviation, he also had a cyclo deviation which was causing the images to be rotated or tilted away from each other.

Among all causes of double vision, the prevalence of a cyclorotation or torsional deviation is very low; however symptoms, when noticed, can have a major negative impact on a patient’s quality of life.  These symptoms include but are not limited to double vision, dizziness, and difficulties in negotiating stairways, steps, and street curbs. Simple horizontal or vertical spectacle prisms used to treat other causes of double vision are insufficient to relieve these symptoms because they do not address the rotational aspect of the deviation.   Surgical intervention for cyclodeviations is an option; however surgery for cyclodeviations is more complex, and many patients wish to avoid surgery if possible. Dr. Paul Harris suggested another treatment option for this patient: monovision.  This involves modifying the patient’s spectacle prescription so one eye sees clearly at distance and the other eye sees clearly at near.  Whether the patient is looking at something far away or close up, the non-preferred eye is slightly blurred.  This makes it easier to ignore this 2^nd image and thus eliminates the double vision.  Dr. Harris has worked with many patients with similar diagnoses and has found that monovision therapy is an effective treatment option to relieve double vision for patients who are unable to attain fusion (eye alignment) through traditional methods.

After these treatment options were discussed, the patient chose monovision as the preferred treatment option. When he received his glasses, the patient reported significantly improved comfort when driving and double vision was no longer an issue.

A careful history and examination are the important keys to uncovering a cyclovertical deviation and improving the patient’s quality of life.  Sometimes thinking “outside the box” can help determine an effective treatment option for a particular patient.  In this case, blurring the image from one eye made it much easier to avoid binocular vision and eliminate the double vision.  Although cyclovertical deviations are fairly rare, their detection and treatment with monovision spectacles can give great relief to the patient and satisfaction to the doctor.

The vertical deviation and cyclorotation deviation can be seen in this cheiroscopic tracing.  The patient looks through the instrument with both eyes open and copies the pattern, first with the right eye and the right hand, then with the left eye and the left hand.  The vertical displacement and the outward tilt of the 2 drawings represents the vertical and cyclorotational components of the misalignment.

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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 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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The Science – Vision problem or ADHD?

I have just spent sometime venturing through the blogosphere of mothers with children with ADHD.  I was so impressed with these brave women that write about their experiences, triumphs, and challenges in raising their children with ADHD.  Many of their accounts truly broke my heart.  This is an excerpt from Penny Williams blog “A Mom’s View of ADHD” where she describes her experience of trying to find a good fit for educating her son with ADHD:

“I live in search mode these days, ever since my son Luke, age nine, was diagnosed with ADHD in 2008. I am searching for the medication, therapy, classroom accommodation, product that will make his life with learning disabilities a little easier. I guess you could say I’m searching for the magic bullet, but I don’t think that’s really accurate anymore. It was true the first year or two — I was looking for an “answer,” something to erase his ADHD symptoms. Then I realized that that “something” doesn’t exist. I didn’t think I was looking for a cure for ADHD because I knew that’s not possible, but that’s exactly what I was searching for nonetheless.

My focus in my search now is different, more refined. I am searching for tools to help him compensate for his differences, for environments where he can learn and prosper, parenting methods best suited to his needs, treatments that teach him the skills necessary to have a happy, successful life despite ADHD (and dysgraphia, SPD, Executive Functioning Deficits, and a gifted intelligence). This search is intense and stressful for me, his parent. There’s a lot of {self-inflicted} pressure to be diligent to find all opportunities and to make choices that will only have positive outcomes. In the area of making appropriate choices that lead to positive outcomes, I have failed miserably this year.Luke has struggled in school since the day he walked into kindergarten. Yes, the very first day. While it should improve each year with treatment, maturity, growing self-awareness and a diligent advocacy for accommodations and resources in school, it has not improved for Luke. I feel like we have been standing in the same place for three years, paralyzed, while the world continues to move on all around us. In our minds, we’re moving and working, but we’re getting nowhere.

That feeling of helplessness became overwhelming to me earlier this year. I fought hard with the school but mostly we just received lip service. I watched Luke struggle to fit in an environment that was clearly the opposite of what he needed. I knew he needed more help. I had to find that for him. ”

I think Penny encapsulates the very real struggle that many parents go through that have children with ADHD.  As a developmental optometrist I work everyday with children that have been diagnosed with ADHD.  I see in their parents’ eyes the same sentiments shared by Penny.  While I do not claim to have a magic bullet, I do have tools that have helped many of of my patients that have vision problems that can often mimic or complicate ADHD.

Dr. David Damari, Developmental Optometrist and Fellow of the College of Optometrists in Vision Development wrote a great research article, “Visual Disorders Misdiagnosed as ADHD,” that gives several great case studies of patients with ADHD  who had developmental vision problems. He speaks in the article of how similar the symptoms are for children with common developmental vision problems and those of children with ADHD.  He also describes in detail case studies of children that were misdiagnosed with ADHD and instead suffered from vision problems that affected their ability to perform well in school, learn, read, and maintain their attention.  He also references other research that shows the correlation between ADHD and Convergence Insufficiency, one of the leading developmental vision problems in children.

Probably, though most compelling are the stories from parents whose children were misdiagnosed with ADHD.  Here is a story from the parent of a child from the website, “Vision Therapy Success Stories”:

“Recently, “Sarah” came into the office just to talk to Dr. X. She was so excited .she was no longer struggling with reading and schoolwork and couldn’t wait to thank him. She is no longer taking Ritalin and is doing well in school.

Prior to seeing Dr. X, Sarah struggled to do the work required of her in high school. She found reading burdensome, was unable to finish her homework in a reasonable amount of time, and was unable to keep up with all her assignments. She was feeling frustrated and discouraged. Sarah had been put on Ritalin in order to help her focus on her work, but she continued to struggle.”

Bottom line, if your child is stuggling with attention in school, check to be sure there is not a vision problem.  To find a Developmental Optometrist near you that can diagnose and treat these types of vision problems, please follow this link.

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The Splash – Success after Long Academic Struggle Highlighted on CBS Boston

This is a great article and video done by CBS Boston.  It beautifully highlights some children similar to the ones I see in my office everyday – children that struggle in school due to undiagnosed treatable vision problems.  Dr. John Abondanzza, a Fellow of the College of Optometrists in Vision Development (COVD), does a great job of describing the types of vision problems with which these children are struggling.  The story highlights a child named Jacob, whose mother is a school teacher, and who has struggled in school and with reading.  I especially love the part at the end of the video with little Jacob saying that he now “loves to read.”  Check it out at http://boston.cbslocal.com/2011/10/18/unusual-therapy-helps-kids-struggling-in-school/.  If you feel that you or your child may struggle with a learning-related vision problem and would like to find a developmental optometrist near you, please follow this link.

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The Science – A Glimpse into our Children’s Vision

As I go out and speak with parents, teachers, and doctors, I am almost invariably asked one question.  How can we do a better job of detecting vision problems in our children?  It really is a great question when you consider the following grim statistics:

• One in four children have a vision problem that can affect learning¹
• 60% of students identified as problem learners have undetected vision problems²
• 64% of children ages five and younger have never had their vision screened by a healthcare professional³
• 32-63% of vision problems identified by comprehensive eye examinations were missed in school screenings⁴

Looking at the scope of the problem, anyone can see that this issue is not going to be solved overnight.  Enhanced vision screenings in our schools, more children receiving comprehensive vision exams before entering school, and educating the public on how vision can affect school performance; these are large-scale efforts currently underway by many of COVD’s members throughout the country.  However, there are things each of us can do to help those children we work with everyday.

One great tool we have is the Convergence Insufficiency Treatment Trial (CITT) Symptom Survey.  Other than being a mouthful, this checklist represents one of the great accomplishments of evidence-based medicine.  In 2008, the Archives of Ophthalmology published the results of research sponsored by the National Institute of Health on the treatment of  Convergence Insufficiency, one of the leading vision problems in children.  This condition is often associated with headaches, double vision, and eyestrain.  The study concluded that for an overwhelming majority of these children, the condition is very treatable.

From that study, we have gleaned the CITT Symptom Survey.  In a matter of a few minutes we can now screen children with a tool that is highly predictive for both convergence insufficiency and other functional vision problems⁵.  This one-page symptom survey can easily be filled out as part of the intake process in any office or can be sent home with parents.  It is quick, easy to score, and communicates to parents the types of vision struggles their child is having.   Here is a copy of the CITT Symptom Survey.

Unfortunately, we can’t see through a child’s eyes.  The CITT symptom survey at least gives us a glimpse.

1. Comprehensive Eye Exams Particularly Important for Classroom Success. (2008, August 4). American Optometric Association.

2. ADD/ADHD and Vision. (2011).  College of Optometrists in Vision Development

3. Cotch, M. (2002). Visual Impairment and Use of Eyecare Services and Protective Eyewear Among Children. USA Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 425-429.

4. Danahuse, S. P., Johnson, T. M., & Leonard-Martin, T. C. (2000). Screening for Amblyogenic Factors Using a Volunteer Lay Network and the MTI Photoscreener: Initial results from 15,000 Preschool Children in a Statwide Effort. Ophthalmology, 1637-1644.

5. Rouse, M., Borsting, E., Mitchell, G., Cotter, S., Kulp, M., Scheiman, M., et al. (2009). Validity of the Convergence Insufficiency Symptom Survey: A Confirmatory Study. Optometry and Vision Science, 357-363.

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