Eye Games
Eyesight is not the only visual skill a child needs to succeed in school. Some of the many other necessary skills include eye teaming and focusing, eye movements and tracking, visual perception, and visual integration skills. These skills are required to succeed in reading, learning, sports, and daily life skills.
However, schools do not test for any of these skills. Schools have exclusively used the Snellen Acuity Test (the eye-chart test) to screen children’s vision in school, but the test screens only for eyesight, leaving many children’s vision disorders undetected. “Eyesight and vision are not synonymous,” writes vision expert Patricia Lemer. Eyesight is the sharpness and clarity of the images seen by the eye, while vision is the ability to focus on and interpret the pictures seen. Research has shown that most children with special needs do not have eyesight problems, but many have visual dysfunction.1 According to Jean Roberts, chief of the Medical Statistics Branch of the US Department of Health, Education, and Welfare, approximately one out of four children have an undiagnosed vision disorder, and these vision problems interfere with their ability to learn in school, play sports, and succeed socially.
The standard (or) distance Snellen test is inadequate as a solitary measure of vision because it only measures the clearness and sharpness of eyesight at a distance of twenty feet using a stationary target. Unfortunately, the ability to see a stationary object at twenty feet has little to do with how a child’s vision will function in school activities. He must be able to do reading, writing, and math assignments placed approximately eleven to sixteen inches from his face. His visual efficiency in following moving objects or landscapes affects all sports, such as physical education, ball games, or riding a bicycle. The ability to accurately judge distances and depth affects his balance, large motor coordination, and perception of his environment. Therefore, a child can pass the Snellen test with 20/20 vision and have vision problems that impact his learning, participation in sports, and social interactions.
Symptoms of visual impairment vary from child to child. Children with vision impairments often demonstrate the same symptoms as children with ADD/ADHD as evidenced by recent studies.2 As a result many children are misdiagnosed every year with ADD/ADHD. If you are told that your child has or might have ADD/ADHD, it would be wise to first seek a vision evaluation from a developmental optometrist.
Other children with visual impairment exhibit no symptoms for a long time, as many vision problems have no obvious signs or symptoms. These children devise compensatory strategies that they use successfully for several years. For example, these children may exhibit task avoidance frequently. Or a child with poor visual memory may compensate by relying on her strong auditory skills. Children with high IQs are notorious for utilizing compensatory strategies and will be successful with these strategies until they reach higher grade levels. These children may be able to demonstrate age-appropriate reading ability in the lower grades, when books help them follow stories through themes and pictures. In the higher grade levels there are no pictures and books become more fact-based and less theme-based. This is when these children may demonstrate trouble reading or read less efficiently and struggle to keep pace with peers.
Children with undetected and untreated vision problems may face significant barriers in life that interfere with their ability to succeed. Quality vision care can break down these barriers and enable children to reach their highest potential. Because symptoms do not always manifest immediately and vary between children, it is imperative to have all aspects of your child’s vision evaluated as soon as possible. This evaluation should be conducted regardless of whether your child has other existing diagnoses. Take your child to an eye doctor who measures efficiency of vision, as not all eye doctors do. The earlier a vision problem is diagnosed and treated, the less it will negatively impact a child’s development.
Vision problems are the fourth most prevalent disability in the United States. Considering that 80 percent of what children learn comes through visual information processing, this is some vital data.3 Vision examination recommendations are provided by the American Optometric Association. The AOA recommends that infants and young children have comprehensive eye exams at ages six months, three years, and five years, and every two years thereafter unless specific problems and risk factors exist, or as recommended by your child’s pediatrician.4
Choosing a Doctor
What type of doctor do you need for a comprehensive visual evaluation? Two types of doctors evaluate pediatric vision: pediatric developmental optometrists and pediatric ophthalmologists. Both will conduct examinations, prescribe glasses, diagnose and treat eye disease, and evaluate how well people use their eyes together. However, they have different areas of expertise.
Ophthalmologists are medical doctors who followed college with eight years of medical training and provide the following services.5
1. Vision services including eye exams, eyeglasses or contacts.
2. Diagnosis and treatment of eye diseases.
3. Eye surgery.
Board-certified developmental optometrists attend four years of optometry school after college and complete an additional two to three years of postgraduate training. They are required to complete clinical training and submit case studies before they can sit for their national boards. Once developmental optometrists complete their additional education and successfully pass the written and oral examinations, they are credentialed as fellows in the College of Optometrists in Vision Development, with the certification of FCOVD added to their professional title.6 Choose an optometrist for your child who is board certified.
Developmental optometrists are sometimes called behavioral optometrists because of their role in evaluating how vision affects behavior and performance. They are also referred to as pediatric optometrists because of their frequent work with children. Developmental optometrists do not perform eye surgery but are well educated in the functional and developmental aspects of vision. The Optometrist Network advises parents to ensure that the doctor evaluate their child for the following visual skills:
Acuity. An acuity test measures the clearness and sharpness of eyesight at a distance of twenty feet using a stationary target and near distance of sixteen inches from his face. This is the standard eye screening with the big “E” on the chart.
Eye Teaming. Eye teaming, or binocular vision, is a visual efficiency skill that allows both eyes to work together in a precise and coordinated way. Eye teaming allows sustained and single vision and is the basis for depth perception. The two most common eye-teaming problems are convergence insufficiency and convergence excess.
Oculomotility or tracking. Oculomotility is the patients’ ability to control where they aim their eyes, which is a skill required for reading. Also measured is the ability to follow a moving target smoothly (“pursuits”) and make eye jumps from one point to another (“saccades”).
Accommodation or focusing. The optometrist evaluates the patient’s ability to change focus rapidly and smoothly when looking from distance to near objects and back again, such as from the front of the classroom to the desk. In addition, the patient will be tested for the ability to maintain clear focus at near ranges for extended periods of time without blur or fatigue, which is required for reading small print.
Stereopsis: Stereopsis is depth perception. Good depth perception is largely dependent upon binocular vision which is the ability to use both eyes together in a precise and coordinated way.
Visual perception. Patients are analyzed to determine if they have developed the perceptual skills they need to understand and analyze what they see, including skills such as visual memory, form discrimination, visual closure, spatial relations, figure-ground relationships, and color vision.
Visual-motor integration or eye-hand-body coordination. The optometrist tests whether the patient’s visual systems are efficiently transmitting information to the body’s motor centers for good balance and coordination. The ability to transform images from a vertical to a horizontal plane (such as from the blackboard to the desk surface) is also tested.
Of the items listed above, just two—binocularity and acuity—are tested during a visit to an ophthalmologist; the others will be tested only at the developmental optometrist’s office. If dysfunction is found in any of the remaining areas above, developmental optometrists will utilize lenses, prisms, and vision therapy to enhance and improve visual function.
Developmental optometrists treat the majority of learning-related vision problems, and their interventions often improve children’s academic abilities. If your child’s developmental optometrist diagnoses eye disease, he or she will refer you to an ophthalmologist in your area for treatment. Sometimes, an ophthalmologist and an optometrist will comanage a patient’s condition. The ophthalmologist may operate on a patient’s eyes and then rely on the optometrist for rehabilitation.
Questions to ask your potential optometrist:
Do you conduct standardized tests of tracking and visual processing?
Do you conduct a series of near-point tests? Are they all conducted with dilation drops? According to the Optometric Professional Association, eye examinations conducted entirely with the eyes dilated will seriously inhibit the capacity to diagnose visually-related focusing problems as the drugs used to dilate will temporarily paralyze the focusing muscles. 7
Do you provide a customized vision report with individualized accommodations for the classroom?
Do you provide one-on-one, office-based vision therapy when necessary?
Is the vision therapy based primarily on activity or on computer programs? (You want a doctor who provides activity-based therapy in addition to any computer programs.)
Will you call me back before the exam if I have questions?
Finding a Doctor
When choosing an optometrist, ensure the doctor is board-certified in vision therapy. You will see the initials FCOVD after his or her name.
You can search for a local eye doctor a number of ways. The College of Optometrists in Vision Development provides a list of doctors who have passed oral and written exams, demonstrating competence in vision therapy; you can contact the COVD at 1-888-268-3770 or at http://www.covd.org. You can also call 1-800-PAVE-988 to reach Parents Active in Vision Education (PAVE®). A national group of parent’s staff this number and will give you a list of developmental optometrists in your area, as well as information about symptoms. You can also locate a developmental optometrist at http://www.optometrists.org.
Lemer, Patricia. “Choosing an Eye Doctor.” New Developments 3 no.4 (1998): 1.
DeCarlo, Dawn K., Ellen Bowman, Cara Monroe, Robert Kline, Gerald McGwin, Jr., and Cynthia Owsley. “Prevalence of attention-defict/hyperactivity disorder among children with vision impairment.” Journal of American Association for Pediatric Ophthalmology and Strabismus 18 No. 1 (2014):10-4. (b) Granet, David B. December 2005. "The Relationship between Convergence Insufficiency and ADHD." Strabismus 13 no.4 (2005): 163-68.
College of Optometrists in Vision Development. “Vision and Learning.” Accessed April 10, 2014. http://www.covd.org/?page=Vision_Learning
American Optometric Association. “Recommended Eye Examination Frequency for Pediatric Patients and Adults.” Accessed January 8, 2015. http://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-and-vision-examination/recommended-examination-frequency-for-pediatric-patients-and-adults?sso=y
EyeSmart. “What is an Opthamologist?” Accessed January 10, 2015. http://www.geteyesmart.org/eyesmart/living/what-is-an-ophthalmologist.cfm
College of Optometrists in Vision Development. “Certification.” Accessed September 2009. http://www.covd.org/?page=Certification