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An Ophthalmologist’S Approach To Visual Processing Learning Differences Harold Paul Koller



American Academy of |Ophthalmology says there is no involvement of vision in dyslexia. Should ophthalmologists get involved with dyslexia? Is dyslexia an eye or vision problem? ...

American Academy of |Ophthalmology says there is no involvement of vision in dyslexia. Should ophthalmologists get involved with dyslexia? Is dyslexia an eye or vision problem?

In the past, most ophthalmologists read or
were told that treatment of the disorders
affecting children with dyslexia and other
learning disabilities fell outside the field of
ophthalmology because the brain, and not the
eyes, is the main organ active in the process
of thinking and learning



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    An Ophthalmologist’S Approach To Visual Processing Learning Differences Harold Paul Koller An Ophthalmologist’S Approach To Visual Processing Learning Differences Harold Paul Koller Document Transcript

    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 243 11 An Ophthalmologist’s Approach to Visual Processing/Learning Differences Harold Paul Koller, M.D., F.A.A.P., F.A.A.O. In the past, most ophthalmologists read or The first step in educating ophthalmolo- were told that treatment of the disorders gists is to introduce psychiatry, educational affecting children with dyslexia and other and neuropsychology, physical and occupa- learning disabilities fell outside the field of tional therapy, and educational science in all ophthalmology because the brain, and not the its forms relating to learning differences in eyes, is the main organ active in the process children and adults to the ophthalmology of thinking and learning (Hartstein, 1971; community (Koller & Goldberg, 1999). (An Hartstein & Gable, 1984; Miller, 1988). appendix to this chapter outlines briefly what Because dyslexia, for example, implied an an ophthalmologist in general practice should inability to understand the written word, the know about learning disorders.) The second definitive diagnosis and therapy was in the is to make the diagnosis and treatment of hands of the educators and clinical psycholo- children more efficient by developing a sys- gists, not the ophthalmologist. The role of an tem for classifying disorders that is oriented ophthalmologist, thus, was to rule out disease toward ophthalmologists. This chapter as the first step in determining the reason for describes such a classification system for a learning difference before referring the learning disorders. It then goes on to describe child back to the pediatrician or family doc- causes and treatment of medically based oph- tor for further evaluation and referral. thalmic problems affecting learning, as well This limited role for ophthalmologists in as other conditions affecting learning that are treating children with learning disorders is not purely ophthalmic but which ophthalmol- now being displaced by a move toward an ogists can help diagnose (Koller, 1999a). interdisciplinary approach. The ophthalmolo- gist is often the first expert to whom the pedi- AN OPHTHALMOLOGIST’S atrician refers a child suspected of having a CLASSIFICATION APPROACH TO learning disorder. Educating ophthalmolo- LEARNING DISORDERS gists in the medical and nonmedical condi- tions and situations that could affect learning Children with learning disabilities can be in a child or older individual will help ensure classified into two main groups: (1) those that a patient receives appropriate, effective, with purely medically and surgically treated and timely remedial treatment. ophthalmic disorders that temporarily or
    • 244 ICDL Clinical Practice Guidelines chronically affect learning efficiency in focusing structures of the eyeball (globe) school (DSM-IV: Axis III – general medical itself. Refractive status is inherited, with the conditions), and (2) those with conditions not eyeballs of children shaped like the eyeballs of purely ophthalmic that traditionally have fall- their parents. A nearsighted eye (myopia) is en into the243 fields of the cognitive sciences longer, and the light is focused in front of the and education (DSM-IV: Axis I). The second retina. A farsighted (hyperopia) eye is shorter, group of conditions can be subdivided into the and the light is abnormally focused in back of four traditional types of learning differences: the retina, not on it. An astigmatic eye is one in (1) developmental speech and language disor- which the cornea in front or the lens in the ders, (2) nonverbal learning disorders, (3) middle of the eye is misshapen microscopical- attention disorders, and (4) pervasive develop- ly like a lemon or football, more curved in one mental disorders (PDD). Many of these have direction than the other, 90 degrees away. A observable ophthalmologic findings. The blurry image results from all three refractive social reasons for deficient learning in school, abnormalities (Reinecke, 1965). A corrective such as dysfunctional family environment, spectacle lens is necessary to refocus the light poor instruction, foreign first language, and rays coming from the objects observed to cre- severe psychiatric disease are not directly ate a sharp focused image on the retina, which associated with eye abnormalities (DSM-II is then transmitted to the brain so a person can and IV). The next section discusses the causes interpret what is seen clearly. and treatment of disorders within the first Strabismus is the condition of misaligned main group; that is, medical conditions that eyes in which the eyes are not aimed in the temporarily or chronically affect learning. same visual direction. The eyes may be diver- gent (exotropia or walleyes), convergent Ophthalmic Causes of (esotropia or crossed eyes), or vertically apart Learning Difficulties (hypertropia). They also can be cyclotropic, or misaligned around an anterior-posterior axis There are several purely ophthalmic caus- through the pupil, which can cause significant es of temporary or chronic learning difficul- visual confusion and image “tilt” or torsion. ties. Many times these conditions cause Most acquired strabismus can cause double intermittent blurry vision in school and at vision (diplopia), which is most annoying to home, itchy eyes, redness, foreign body sen- school-aged children. Less frequently, the sation, various visual phenomena, double sudden onset of strabismus with diplopia in a vision, tearing, light sensitivity (photopho- school-aged child or younger may be of para- bia), and ocular pain and headache. All of lytic etiology as a result of a virus infection, these symptoms can affect children’s concen- or even a brain tumor. The paralysis in the lat- tration in the classroom and at home and their ter case is due to one of the three cranial ability to learn efficiently (Koller, 1997). The nerves innervating the six extra-ocular mus- main categories of ophthalmic causes affect- cles in each eye being affected. A thorough ing learning are refractive errors, strabismus medical evaluation is mandatory (Parks, and amblyopia, nystagmus, systemic diseases 1975). affecting the eyes, local ocular diseases, and Treatment for exotropia is usually surgi- neuro-ophthalmic disorders. cal, although for small deviations and those Refractive errors are optical refractive less severe cases in which the eyes go out imperfections due to the size and shape of the more at near (convergence insufficiency) than
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 245 in the distance (divergence excess), eye “A” and “V” syndromes in which the eyes go exercises in the form of classic orthoptics or “in” or “out” more in one gaze than in anoth- optometric vision training is quite acceptable. er. For example, a “V”-pattern esotropia is The idea is to train diplopia awareness to one in which the eyes go in more when look- improve fusional convergence amplitudes. ing down than when looking up, which could This enables the individual to see and focus cause double vision when reading. Treatment singly over a broader area of viewing and for a is either with bifocal eyeglasses or surgery if longer duration (Bedrossian, 1969). Treatment spectacles are ineffective. for nonparalytic esotropia (the eyes are Amblyopia is the term applied to dimin- crossed in but move normally in all directions ished vision without an obvious physical or and to the extreme gaze positions) is usually structural abnormality present to account for surgical or optical (eyeglasses) if there is the vision loss (Simon & Calhoun, 1998). It excessive farsightedness. In such a case, the is called “organic amblyopia” when the eyes over-focus and turn in too much. The vision loss is due to a structural defect such hyperopic power of the glasses assumes the as an abnormal optic nerve. The lay term for focusing function and, when the lenses are amblyopia is “lazy eye,” which people often worn, the eyes do not have to focus to see confuse with strabismus or “a weak eye mus- clearly and the eyes remain straight. If the cle.” A more appropriate term for amblyopia eyes turn in more at near than in the distance, would be “lazy vision.” There are three types bifocal eyeglasses are required to cause more of amblyopia: (1) refractive, due to the eyes focusing relaxation close up. There are cases, having different refractive errors and focus- however, involving both esotropia mecha- ing ability; (2) strabismic, in which the eyes nisms that require both glasses and, for the are not aimed at the same object, causing portion of deviation not controlled by the eye- diplopia to occur; and (3) occlusion ambly- glasses alone, surgery. If left untreated, the opia, in which one eye has unclear or opaque weaker eye may develop suppression in order media inhibiting light from being clearly to avoid double vision and become ambly- transmitted from the environment to the reti- opic. Paralytic as well as restrictive esotropia na, such as a cataract. patients often present with face turns to pre- For vision to develop normally, both eyes serve use of their eyes together away from the must be in focus, see clearly, be aligned side of the paralyzed eye muscle. This can straight ahead, and maintain coordinated eye sometimes interfere with efficient reading. movements in all fields of gaze. If this does Treatment is often surgical. not take place, the lateral geniculate body in Hypertropia or vertical strabismus comes the brain develops ganglion cell degeneration in a variety of forms but often it presents to and a subsequent decrease in visual acuity. the pediatrician or ophthalmologist as a head The cause of this in the refractive type is one tilt, chin depression, elevation or face turn, or blurred retinal image in the affected eye and combinations of these abnormal head pos- one clear image in the more normal eye. The tures. These can all interfere with normal brain automatically shuts off the blurry navigation as well as with reading and learn- image and the cells in the lateral geniculate ing. The treatment is usually surgical. One body atrophy. Giving these patients the cor- common such condition is congenital fourth rect eyeglasses and covering the better eye nerve palsy; head tilt is the presenting sign. with a patch to cause the cells to regenerate is One should also be aware of the so-called the best therapy. The earlier this is done, the
    • 246 ICDL Clinical Practice Guidelines easier it is for the cells to regenerate and the Occlusion amblyopia can cause deprivation better the results. The brain becomes less nystagmus, which decreases or is entirely plastic after age six and often does not eliminated when the obstacle to normal respond to occlusion therapy after puberty. In focusing is removed. Many types of nystag- the strabismic type, eyeglasses or surgery to mus are associated with less than normal eliminate the malalignment of the eyes, pre- vision and often a null point exists in one ceded and followed by occlusion therapy over field of gaze, causing a head tilt or face turn the better eye, is the best treatment. In occlu- in order to achieve optimal visual acuity that sion amblyopia, surgical therapy to remove exists in the field of least nystagmus activity. the cause of the obstruction is performed Treatment in some cases is surgical in order first, followed by appropriate optical correc- to move both eyes and the null point away tion. A contact lens, or intraocular lens in the from the extreme gaze position of the null case of a unilateral cataract in a child, is cur- rently the best therapy. Amblyopia is zone and to the primary straight-ahead posi- reversible if diagnosed early. However, treat- tion. Reading can be labored for children and ing school-aged children is frequently a adults with nystagmus, and learning is there- challenge due to peer ridicule and the child’s fore sometimes compromised. lack of compliance with eye patching. Systemic disease affecting the eye and dis- Schoolwork and learning can be affected rupting normal visual learning processes most because the patch covers the better eye. commonly include (1) juvenile rheumatoid Alternatives to patching include cycloplegic arthritis; (2) metabolic and endocrine disor- eyedrops, such as atropine and cyclopento- ders, such as juvenile diabetes or pituitary late, to blur the vision in the better seeing eye disorders; (3) blood dyscrasias affecting the as well as oral levodopa. L-dopamine seems eye and brain, such as leukemia; and (4) to improve amblyopic vision in some individ- metastatic neoplastic disease to the eye and/or uals, even after adolescence, although this brain, such as neuroblastoma. All of these dis- drug is not yet in widespread use in the eases are treated medically and surgically, as United States (Leguire, Rogers et al., 1998). required. Disruption of schooling often Nystagmus is repetitive movements of occurs for significant periods of time in the the eyes, usually horizontally to-and-fro with more serious cases. Learning is thus second- a fast jerk in one direction (Reinecke, 1997). arily compromised even if no basic learning The movement may be only horizontal or disorder was present before the child became vertical and rarely torsional, but more often ill. If the brain becomes structurally involved it is a mixture. Nystagmus is typically stable in the disease process, the various learning in any specific field of gaze, which is termed the “null point.” There are many types of centers can be directly affected, causing a pos- nystagmus based on description of the pat- sible permanent learning disorder. tern and on the etiology. Examples include Local ocular causes of decreased vision vestibular nystagmus, latent and manifest include: latent nystagmus, amaurotic or “blind” nys- • Ocular media opacities, such as opaque tagmus (which is more a searching, than corneal lesions and cataracts. jerking movement), and idiopathic infantile • Congenital and infantile glaucoma (high nystagmus. The latter is seen in patients with intraocular pressure frequently causing albinism and various retinal disorders. legal or complete blindness).
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 247 • Significant unilateral and bilateral ocular normal eye evaluation may merely be experi- trauma causing moderate to severe vision encing the pediatric equivalent of adult, con- loss, such as rupture of the globe after stricting visual fields and the typical falling on a sharp object. “scintillating scotoma.” These aura are often • Ocular and adnexal neoplasms with termed “ophthalmic migraine” when headache secondary disfigurement and/or vision symptoms are minimal or absent in adults. loss, such as retinoblastoma and rhab- Children have a number of associated signs domyosarcoma of the muscles of the and symptoms of pediatric migraine. These globe or eyelids. para-migraine entities include infantile colic, • Severe chronic ocular infections, such as lactose intolerance, sleep disturbances Herpes Simplex Virus–I, with vision loss (including night terrors and nightmares), and affecting the cornea. motion sickness. They also include frequent • Congenital and degenerative retinal or febrile seizures; unexplained abdominal dis- optic nerve diseases affecting the macula comfort; allergic predisposition; unusual sen- or optic nerve, such as toxoplasmosis and sitivity to light (photophobia), noise, and optic nerve hypoplasia (small, poorly smell; and a type-A personality resistant to functioning optic nerve). change with occasional obsessive/compulsive behavior. Para-migraine entities may also be These are frequently seriously urgent characterized by various other visual phenom- conditions, often requiring surgery, chemo- ena, such as micropsia (things looking small- therapy, or other medical treatments to cure er or farther away), macropsia (things looking or control. Schooling and learning invariably larger or closer), and metamorphopsia (things suffer (Miller, 1988). looking distorted, as in a fun house mirror). Neuro-ophthalmic causes of temporary or The classic description of the latter is the so- intermittent learning impairment and ineffi- called “Alice in Wonderland” syndrome. ciency include two broad categories frequent- Children complaining of any of these ly seen in the pediatric ophthalmologist’s symptoms, either as a single symptom or in office: (1) primary brain diseases and tumors combination, sometimes are not believed or causing personality and behavior changes and are misunderstood, leading to a misdiagnosis (2) the vast variety of vascularly mediated or no diagnosis at all. A pediatric examiner pediatric migraine syndromes. must ask the parents of children with learning Classic migraine involves a vascular- differences and difficulty with schoolwork if mediated headache, often preceded by vari- these symptoms occur to ascertain whether or ous visual auras, photophobia, and nausea. It not para-migraine complaints exist. A pedi- is usually followed by the desire to sleep, atric neurologist is best for advising these after which the headache often is gone. families about acephalgic pediatric migraine Children frequently present with a variation therapy. More severe pediatric vascular termed “acephalgic migraine.” Headaches migraine can result in the syndrome of oph- are not usually a part of the presenting symp- thalmoplegic migraine, which is manifested tom complex. This fact often confuses the by paralysis of one or more extraocular mus- parents and many professional caregivers cles with resultant strabismus and diplopia. who expect migraine to always be a In these cases, a pediatric ophthalmologist headache. Children who complain of blurry should be consulted. More serious conditions vision in school but who are found to have a such as a brain tumor must be ruled out. A
    • 248 ICDL Clinical Practice Guidelines migraine predisposition must be considered bring out the inability of such children to iden- in any child with a learning problem. tify the components of “bat” as “bu,” “aah,” Migraine is definitely familial and inherited and “teh.” A history of letter reversals in school in a multi-factorial mode with various family and difficulty reading may not really point to a members having different combinations of receptive language disorder alone because non- symptoms (O’Hara & Koller, 1998). verbal learning disorders and attention disor- The following section discusses condi- ders can also cause these symptoms in certain tions that are not purely ophthalmic, but instances. Early preschool identifying charac- some of which may have ophthalmologic teristics include unusual difficulty learning findings. These include receptive language numbers, letters, and colors without evidence disorders, a nonverbal learning disorder, and of eye disease. The ophthalmologist should some pervasive developmental disorders. refer these children to a knowledgeable neu- ropsychologist or speech and language pathol- COGNITIVE AND EDUCATIONAL ogist for further testing to identify all the CLASSIFICATIONS IN specific language disorders existing in each LEARNING DISORDERS individual case and then to recommend diag- nosis-specific therapy. A licensed reading Speech and Language Disorders teacher and a homework tutor may both be required, with additional therapy and monitor- Articulation and expressive language dis- ing by the speech and language pathologist and orders (Koller, 1999b) can be grossly diag- the neuropsychologist as necessary. nosed by taking a history of the child from Auditory processing disorders are in the the parents and observing the child speaking realm of ear, nose, and throat specialists, as well or not speaking while seated in the exam as speech and language pathologists, and should chair. If the parents have not yet sought pro- be referred to those professionals for appropri- fessional help, the child can be referred back ate, specific diagnoses and therapy (Welsch, to the pediatrician, an ear, nose, and throat 1980; Welsch & Healey, 1982). A tutor is often specialist, or a speech and language patholo- helpful to teach auditory interpretation and gist for further evaluation and therapy with attention in the classroom environment. the primary care physician’s knowledge and Auditory processing disorders are receptive lan- consent. The ophthalmologist is not directly guage dysfunctions and the “hearing” equiva- involved in the specific diagnosis or treat- lent of “visual” developmental dyslexia. One ment of children with these disorders. remedial method in reading disorders is to have Receptive language disorders, in contrast, the child simultaneously listen to a recording of involve visual processing and perception and the written text while following the printed should be more thoroughly analyzed by the material in the book in the presence of a reading pediatric ophthalmologist. Realizing that instructor. This therapy is effective if only visual developmental dyslexia is now thought to be a or auditory processing is abnormal, not if the result of a genetically inherited deficiency child suffers from both disorders. (Shaywitz, 1998) in cerebral phonetic analysis, the ophthalmologist can deduce the likely pres- Nonverbal Learning Disorders ence of dyslexia from the family history and by asking the child a few questions about simple Appropriate diagnostic studies establish words, such as “cat” and “bat,” in an attempt to this all-too-often missed learning disorder.
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 249 The ophthalmologist can suspect a nonverbal children and adults. Occupational therapy is learning disorder (NVLD) by giving the the treatment path that is most efficient for young patient a simple visual memory test in individuals with NVLD. At times, therapy the office. It takes only 1 to 2 minutes to per- must be coordinated with a homework tutor, form. (See Figure 1.) NVLD is thought to be reading specialist, and/or a physical therapist associated with right hemisphere white mat- if other, more complex aspects of NVLD are ter dysfunction (Bannatyne, 1974; Foss, identified. Numerous treatment strategies 1991; Johnson & Myklebust, 1967). The frontal have been tried over the years but utilizing lobe may also be involved. The main deficits of current repetitive, standard rehabilitation sci- this disorder include visual-spatial perception, ence techniques seem, at present, to be best. visual memory, psychomotor coordination, It is in this category of learning differ- complex tactile-perceptual skills, reasoning, ences that some optometric vision training concept formation, mathematical abilities, and techniques appear to be effective. These tech- psychological/behavioral difficulties. niques are partially based on occupational Well-developed verbal and reading skills, and physical therapy principles as well as however, are frequently observed in these standard rehabilitation science. Adults, after Figure 1a Figure 1b Figure 1c Figure 1a-1e. – A Diagnostic Tool for Categorizing Nonverbal Learning Disabilities in School- aged Children 6 to 12 Years Old (A simple pattern [1a] is presented to a child for 15 seconds. The child is then asked to draw the pattern from memory. Figures 1b and 1c are examples of acceptable normal variations in children’s drawings. Figures 1d and 1e represent variations that indicate a possible nonverbal learning disorder.) Figure 1d Figure 1e
    • 250 ICDL Clinical Practice Guidelines strokes, as well as all-aged individuals after visual information processing. The first goal accidental closed head trauma, are taught to of therapy is to develop the patient’s motor- utilize the uninjured functioning parts of their awareness ability by performing isolated, brain to compensate for loss of normal use of simultaneous, and sequential movements an injured or damaged brain area, despite the involving both sides of the body. The treating fact that the area of the brain assuming the optometrist wishes to develop motor memory new function was never intended to do so. of the differences between the right and left Stroke patients thus learn to read, write, talk, sides of the body. This is typically accomplished and navigate once again despite permanent using balance activities, ball bouncing, chalk- brain damage to the area previously pro- board squares, and other gross eye-hand coordi- grammed to maintain those particular func- nation activities such as beanbag tossing or ball tions. A similar model exists for children playing. The second goal of therapy is to develop with naturally occurring brain dysfunction, the patient’s motor-planning ability. This is such as the one for nonverbal learning dis- accomplished using numerous other techniques, abled individuals. These children are born including jumping jacks, the Randolf shuffle, and with inefficient or inadequate brain program- slap-tap, among others. These strategies seem to ming and processing. Laterality training, eye work by repetitive, positive psychological rein- movement coordination strategies to help forcement and one-on-one patient-therapist inter- create smooth pursuits (saccades), and hand- action as much as by direct influence on the eye coordination exercises all help improve, cerebral academic learning process itself. Since to some extent at least, performance of those NVLD involve higher cognitive learning centers functions. To what direct extent learning in which abstract thinking, visual memory, and itself, in a classroom or at home, is enhanced spatial recognition are the main deficits, repetitive in all cases has yet to be shown via evidence- training makes it possible for a child to learn to based science using a masked or double perform certain tasks more efficiently. “Practice masked controlled study. Published studies reviewed by the author to date are anecdotal make perfect” is a commonly accepted theme. If a or retrospective/prospective reviews of meas- child with NVLD is taught by optometric urement parameters or performance, often techniques to enhance motor memory, motor while other remedial methods are carried out awareness, and motor integration—and this simultaneously (Atzmon et al., 1993). improvement can be transferred to the academic Piaget’s theory stating that “intelligence is the arena—then the claimed benefits of optometric most important instrument of learning” and that vision training can be realized. Those who profess environmental interaction is equally important benefits from vision training in cases of speech has been used as the basis for utilizing games and and language disorders, attention disorders, and play as a medium to enhance the process of think- pervasive developmental disorders (including ing and learning. This was tried in a West Virginia classic autism) are simply not reporting the other school setting by Furth and Wachs more than 25 therapies for these individuals being carried out years ago (Furth & Wachs, 1974). Developmental simultaneously by other professionals, including optometry has adopted some of Piaget’s theory pediatric neurologists, psychiatrists, psycholo- for vision training. The idea is to think before you gists, language therapists, occupational therapists, can actually learn a fact or concept. physical therapists, educators, and pediatricians. Some optometric exercises (Scheiman, NVLD account for less than 15% of all learning 1994) are designed to improve developmental disabled individuals (Koller, 1999b). Vision
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 251 therapy is but one of many interdisciplinary inter- Pervasive Developmental Disorders ventions necessary for these individuals. The ophthalmologist can frequently iden- Attention Deficit/ tify an individual with Asperger’s syndrome or Hyperactivity Disorders Rett syndrome by history and observation of the patient’s behavior in the examination chair. The diagnosis of attention deficit/hyperac- Lack of eye contact is often the initial com- tivity disorders (ADD/ADHD) is established plaint and reason for referral to the ophthal- by the criteria listed in the DSM-IV with , mologist (Koller & Goldberg, 1999). Lack of behavior repeated over time. Some controversy social relatedness and peer interaction is still exists concerning the real existence and obtained by the ophthalmologist from the definition of these two diagnoses as a separate family and patient history. The history can category of learning disorders (Carey, 1999). also provide information concerning an The pediatric neurologist, pediatric develop- intense area of interest or other behavior pecu- mental specialist, family pediatrician or physi- liar to individuals with autistic spectrum dis- cian, or psychiatrist usually provides treatment. orders. Definitive diagnosis and treatment It is necessary for the ophthalmologist to iden- should be in the hands of a qualified psychia- tify the behavior by listening and observing trist and knowledgeable pediatricians, as well while the child is in the examination chair and as occupational and physical therapists, who referring appropriately. Pharmacological thera- are well schooled in diagnosing and treating py is the treatment of choice, with ancillary children with pervasive developmental or remediation from homework tutors, certified autistic spectrum disorders (PDD/AS) reading specialists, and, occasionally, occupa- (Greenspan & Wieder, 1998). The role of the tional therapists. Teaching a child to concen- ophthalmologist is to suspect the diagnosis trate quite often appears to be easier when the and refer appropriately, noting the high index patient is on stimulant therapy such as Ritalin of suspicion. or Adderal. Nonetheless, many pediatric neu- “Vision training” techniques have yet to rologists and pediatric developmental special- be shown to directly influence the main ists now prefer to reserve drug therapy for deficits of autistic individuals. However, some more persistent cases. vision training techniques and occupational The Committee on Quality Improvement therapy are appropriate for nonverbal learning (Subcommittee on Attention Deficit/Hyper- disorders that are part of an autistic individ- activity Disorder) of the American Academy of ual’s component disabilities. Since the autistic Pediatrics (2000) recently published its clinical spectrum involves people with difficulties in practice guidelines, Diagnosis and Evaluation social relatedness and social skills, use of lan- of the Child with Attention Deficit/Hyper- guage for communicative purposes, and a lim- activity Disorder, which emphasizes to pedia- ited but intense range of interest, many tricians the DSM-IV criteria for diagnosing different professionals must become involved ADHD and observing the typical behaviors in in ongoing therapy. Any eye abnormality pres- more than one setting, location, and situation ent should be corrected by the ophthalmolo- over time. Research involving the study of aca- gist, just as an appropriate specialist should demically efficient individuals with ADHD treat any medical condition. If the patient is compared to those afflicted who are scholasti- sufficiently functioning and can concentrate cally inefficient was suggested. on occupational and/or vision therapy tasks,
    • 252 ICDL Clinical Practice Guidelines these tasks should be provided for those com- research in the area of mitochondrial (not ponent disorders the PDD/AS patient mani- nuclear) inheritance must be done to correlate fests. There is much to be learned in the future learning disabilities with these conditions. from studying these remedial methods with Familial dysautonomia may also be a partial evidence-based science. Optometrists, oph- mitochondrial disorder, as might many other thalmologists, occupational therapists, and types of learning differences and disabilities. speech and language pathologists should work together to bring about this research. CONCLUSION OTHER DISORDERS As noted previously, having the ophthal- AFFECTING LEARNING mologist aware of all of the medical and non- medical conditions and situations that could Other disorders affecting learning that an affect learning in a child or older individual ophthalmologist frequently sees include increases the potential for a child with learn- Tourette syndrome and some purely mental ing disabilities to receive appropriate, effec- disorders such as anxiety disorder, opposi- tive, and timely remedial treatment. It is tional defiant disorders, and personality dis- important for one professional to take the orders (Axis-I). Idiopathic sleep disorders responsibility of coordinating all the special- can also affect learning, as can social and ists actually involved in the care of any patient family dysfunction or poor school instruction with a learning difference. It doesn’t matter (Axis-IV). All these conditions can be what that person’s specialty is, so long as he suspected from a social and family history or she is knowledgeable in the general field taken by an ophthalmologist in the office. and has the motivation, passion, and resources Tourette syndrome is often treated by a pedi- necessary to coordinate the efforts of atric neurologist or psychiatrist, whereas a pediatric psychiatrist most effectively han- numerous physicians, psychologists, educa- dles the other conditions mentioned. tors, and allied health professionals, such as Several serious genetic disorders are fre- occupational therapists, physical therapists, quently associated with learning differences, optometrists, and speech and language thera- including familial dysautonomia (Reilly-Day pists. Social workers and attorneys often are syndrome) (Groom, Kay, & Corrent, 1997) involved, too. Given the desire, an ophthal- and mitochondrial cytopathy (Phillips & mologist can assume this task easily. The oph- Newman, 1997). Both these conditions thalmologist is often the first expert to whom involve multiple systems within the body. The the pediatrician or family physician refers the brain is a high oxygen/energy uptake organ child suspected of having a learning differ- and the mitochondria are the oxygen genera- ence. However, the pediatric psychiatrist, neu- tors of our cells. Any disease of the mito- rologist, or developmental specialist could be chondria affects most organ systems. The equally effective. True multidisciplinary sci- autonomic nervous system is almost non- ence and coordination of effort is mandatory functional in familial dysautonomia, and if optimal benefit is to be achieved for all brain processing is also affected. Much more individuals with learning disorders. s
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 253 REFERENCES American Academy of Pediatrics (2000). Johnson, D., & Myklebust, H. R. (1967). Clinical practice guideline: Diagnosis and Nonverbal disorders of learning. In Learning evaluation of the child with attention Disabilities Educational Principles and deficit/hyperactivity disorder. Pediatrics, Practices. New York: Grune and Stratton. 105(5), 1158-1170. Koller, H. P. (1997). How does vision affect Atzmon, C. O. et al. (1993). A randomized learning? Journal of Ophthalmic Nursing prospective masked and matched compar- & Technology, 16 (Vol. I), 7-11. ative study of orthoptic treatment versus Koller, H. P. (1999a). Visual perception and conventional reading and tutoring treat- learning differences: An ophthalmologist’s ment for reading disabilities in 62 children view. American Orthoptic Journal, 49. (including pro and con editorial comments Koller, H. P. (1999b). How does vision affect by Drs. Hardenbergh and Cibis Tongue). learning? Journal of Ophthalmic Nursing Binocular Vision & Eye Muscle Surgery & Technology, 18(1), 12-18. Quarterly, 8(2), 91-106. Koller, H. P., & Goldberg, K. B. (1999). A Guide Bannatyne, A. (1974). Diagnosis: A note on to visual and perceptual learning disabilities, recategorization of the WISC scaled scores. Current concepts in ophthalmology, 24-28. Journal of Learning Disabilities. 7, 272-274. Pennsylvania Academy of Ophthalmology. Bedrossian, E. H. (1969). The surgical and Leguire, L. E., Rogers, G. L., et al. (1998) nonsurgical management of strabismus. Occlusion & Levodopa-Carbidopa Treat- Springfield, IL: Charles C. Thomas. ment for Childhood Amblyopia. Journal of Carey, W. B. (1999). (in commentaries). AAPOS, 2(5), 257-264. Problems in diagnosing attention and Miller, N. R. (1998). Neuro-Ophthalmologic activity. Pediatrics, 103(3), 664-667 Topographic Diagnosis of Tumors and Foss, J. M. (1991). Nonverbal learning dis- Related Conditions. In Walsh & Hoyt abilities and remedial interventions. (Eds.), Clinical Neuro-Ophthalmology Annals of Dyslexia, 41, 129-131. (pp. 1137-1242). Furth, H. G., & Wachs, H. (1974). Thinking O’Hara, M. A., & Koller, H. P. (1998). goes to school, (Piaget’s theory in prac- Migraine in a pediatric ophthalmology tice). Toronto: Oxford University Press. practice. Journal of Pediatric Ophthal- Gable, J. L. (1984). Visual disorders in the mology & Strabismus, 35, 203-208. handicapped child. San Mateo, CA: Macel Parks, M. M. (1975). Ocular motility and stra- Dekker. bismus. Hagerstown, MD: Harper & Row. Greenspan, S. I., & Weider, S. (1998). The Phillips, P. H., & Newman, N. J. (1997). child with special needs. Reading, MA: Mitochondrial diseases in pediatric ophthal- Perseus Books. mology. Journal of AAPOS, 1(2), 115-122. Groom, M., Kay, M. D., & Corrent, G. F. Reinecke, R. D. (1965). Refraction: A pro- (1997). Optic neuropathy in familial grammed text. New York: Appleton dysautonomia, Journal of Ophthalmology, Century-Crofts. 17(2), 101-102. Reinecke, R. D. (1997). Idiopathic infantile Hartstein, J. (1971). Current concepts in nystagmus: Diagnosis & treatment. Journal dyslexia. St. Louis, MO: Mosby. of AAPOS, 1, 67-82.
    • 254 ICDL Clinical Practice Guidelines Scheiman, M. M., & Rouse, M. W. (1994). Welsh, L. W., Welsh, J. J., & Healey, M. P. Optometric management learning-related (1980). Central auditory testing and vision problems. St. Louis, MO: Mosby. dyslexia. Laryngoscope, XC(6), 972-984. Shaywitz, S. E. (1998). Dyslexia: Current Welsh, L. W. et al. (1982). Cortical, subcorti- concepts. New England Journal of cal, and brainstem dysfunction: A correla- Medicine, 338(1), 307-312. Simon, J. W., & Calhoun J. H. (1998). tion in dyslexic children. American Journal Amblyopia: A child’s eyes. Gainesville, FL: of Otolaryngology, Rhinolaryngology and Triad. Laryngology, 9(3), 310-315.
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 255 Appendix VISUAL PERCEPTION AND LEARNING DIFFERENCES IN PEDIATRIC OPHTHALMOLOGY: What the Ophthalmologist Needs to Know about Learning Disabilities in Clinical Practice I. Ophthalmic Causes of Temporary Learning Impairment and Inefficiency A. Strabismus, amblyopia, and refractive errors 1. Decompensated accommodative esotropia with secondary diplopia 2. Secondary ocular cranial nerve palsies (n. III, IV, VI) 3. Uncorrected congenital vertical strabismus with abnormal face and head positions 4. Bilateral very high ametropias, such as bilateral amblyopia of high hyperopia 5. Bilateral occlusion amblyopia, such as after congenital cataract surgery 6. Associated untreated “A” and “V” syndromes 7. Convergence insufficiency exotropia/phoria in certain individuals B. Nystragmus of moderate to severe degree causing significant vision loss C. Pediatric ocular diseases that can affect learning via visual and emotional effects 1. Severe juvenile rheumatoid arthritis and related ocular inflammations 2. Congenital glaucoma with vision loss 3. Congenital cataracts and major corneal opacities with vision loss and nystragmus 4. Significant unilateral and/or bilateral ocular trauma with vision loss 5. Ocular and adnexal neoplasms with secondary disfigurement and vision loss 6. Severe chronic ocular infections such as HSV-I with vision loss 7. Congenital and degenerative retinal diseases affecting the macula II. Neuro-ophthalmic Causes of Temporary or Intermittent Learning Impairment and Inefficiency A. Brain tumors causing a change in personality and behavior in a pediatric patient B. Migraine syndromes 1. Acephalgic pediatric migraine with visual disturbances and variable vision in school 2. Ophthalmic migraine in childhood 3. Ophthalmoplegic migraine 4. Classic migraine in the older student C. Optic nerve disease with significant visual impairment III. Systemic Diseases Associated with Vision and Neurologic Dysfunctions Potentially Affecting Learning A. Metabolic and endocrinic disorders B. Blood dyscrasias affecting the eye and brain C. Metastatic neoplastic disease to the eye and/or brain
    • 256 ICDL Clinical Practice Guidelines IV. The Ophthalmologist’s Role in Examining a Child and Advising the Family of a Defect in visual processing and/or learning is to rule out the presence of eye disease or related sys- temic disorder and to refer the pediatric patient to the proper professionals for more defin- itive diagnoses and subsequent treatment(s). In order to effectively do this, a classification of non-ophthalmic learning disorders will now be outlined. A. Learning disabilities (differences) 1. Developmental speech and language based disorders (epidemiology) a. Articulation disorders b. Expressive language disorders c. Receptive (1) Dyslexia—phonologic processing disorder (a) genetics (b) pathophysiology (b) remediation (d) early preschool identifying characteristics (2) Other receptive language disorders 2. Nonverbal learning disabilities (epidemiology) a. Definition b. Characteristics and affected areas of learning (1) visual-spatial perception (2) visual memory (3) psychomotor coordination (4) complex tactile-perceptual skills (5) reasoning (6) concept formation (7) mathematical abilities (8) psychological behavioral difficulties (9) good verbal and reading skills c. Early identification traits d. Differential diagnosis e. Methods of treatment. What exactly is optometric vision training? f. Rationale of therapy based on the traditional closed head trauma/stroke rehabilitation model 3. Attention deficit hyperactivity disorder (epidemiology) a. Definition b. Characteristics (DSM-IV) and diagnostic criteria observable during an eye exam (1) squirms in seat, fidgets with hand and/or feet (2) unable to remain seated when required to do so (3) easily distracted (4) blurts out answers before a question is finished (5) difficulty following instructions (6) unable to sustain attention in work activities (7) interrupts or intrudes on others
    • Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 257 (8) does not appear to listen (9) loses items for tasks such as toys, pencils, and books (10) often engages in dangerous activities without considering the consequences c. Subclassification (1) inattention (2) impulsivity (3) hyperactivity d. Differential diagnosis (1) Tourette’s syndrome (2) conduct disorder (3) oppositional defiant disorder (4) other tic disorders e. Treatment and community support (1) pediatric neurologist (2) pediatric developmental specialist (3) pediatric psychiatrist (4) special education teacher or tutor (5) various support groups 4. Pervasive developmental disorders/autistic spectrum disorders (PDD/ASD) a. Definition b. Characteristics: defects in social relatedness and language/ communication skills c. Subclassifications (1) Asperger’s syndrome (chief eye symptom is “lack of eye contact”) (2) Rett syndrome (3) classic autism (4) unclassified PDD/ASD d. Referral and treatment options e. Micro and primary dyskinetic strabismus as a presenting sign of PDD f. Hyperlexia V. Patient Support Groups for Learning Disabled (LD) Individuals A. CHADD (Children and Adults with ADD) B. CEC (Children’s Educational Counsel) C. ASLHA (American Speech, Language and Hearing Association) D. LDAA (Learning Disabilities Association of America) E. PERC (Parents Educational Resource Center) F. The Orten Dyslexia Society G. AHA (American Hyperlexia Association) H. HALO (Health Achievement Learning Opportunities Centers)
    • 258 ICDL Clinical Practice Guidelines VI. Role of the Pediatric and Comprehensive Ophthalmologist Concerning Individuals with Learning Disabilities A. Identify and treat any eye or eye-related systemic disease or abnormality. B. By observation and careful history, identify which broad category of learning differ- ences the patient likely has and convey that impression to the pediatrician, the family, and any other interested parties. These children have often been through many psychological tests, tutoring, and other attempts at remediation without a definitive diagnosis or combination of diagnoses. Suggest a comprehensive neuropsychologic/ educational evaluation from a qualified, credentialed neuropsychologist when all inter- ested parties agree. C. Help the family by giving them a direction in which to proceed so that the child with non-ocular learning differences can start to achieve his full potential. Not every indi- vidual with learning disabilities requires every possible specialist. These professionals include: 1. Pediatric neurologist 2. Pediatric psychiatrist 3. Pediatric developmental specialist 4. Pediatric endocrinologist 5. Pediatric geneticist 6. Pediatric otolaryngologist 7. Pediatric ophthalmologist 8. Speech and language pathologist (audiologist) 9. Neuropsychologist 10. Educational psychologist 11. Educator with special education credentials 12. Reading tutor 13. Physical therapist 14. Occupational therapist 15. Pediatric social worker 16. School placement expert (educator) 17. Disabilities attorney 18. Family physician or general pediatrician D. A specialized attorney is often beneficial for helping families receive federal LD ben- efits to which they are entitled under the terms of the Individuals with Disabilities Education Act (IDEA) and Americans with Disabilities Act (ADA). E. When the answer the question, “Is the child’s reading and/or learning problem in school due to his eyes?” is “No,” the ophthalmologist must explain why it is not and offer a positive and constructive method to direct those families toward obtaining the proper and appropriate care. The public still believes that eye specialists are knowledgeable in the field of visual perception as well as visual function.