disabilities Learning

1. Vision in Aging: A Focus on Falls
and the Driving Debate
Susan J. Leat PhD, FCOtom FAAO
School of Optometry and Vision
Science,
University of Waterloo
Canada
Learning Disabilities

2. Outline
• Introduction and prevalence
• Prevalence
• Causes and Definitions
• Correlates
• Components of the reading process
• What happens at school - Psycho-educational assessment
• Vision and reading
• Visual correlates
• Eye movements
• Meares-Irlen syndrome
• Visual perceptual skills
• OEP
• Optometric assessment and management – a staged approach
• Case study

3. Introduction
• Reading disability is a life-long
handicap and limits educational,
vocational and avocational choices
• Optometrists don’t treat reading
disability
, but are part of a multi-
disciplinary team.

4. Prevalence
•5-17% of all school children
•Higher in boys
•21.6% in boys vs 7.9% in girls (NZ)
•20.6% in boys vs 9.8% in girls (NZ)
•17.6% in boys vs 13.0% in girls (UK)
•18.0% in boys vs 13.0% in girls (UK)
•1.4-3x more common in boys
•But may still be trends that boys are identified more
readily by schools than girls
Rutter et al (2004) JAMA., 291, 2007-2012 Shaywitz and Shaywitz (2003) Pediatrics in Review, 24, 147-153
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msh mohmeh

5. • Reading ability/disability is not an all or nothing affair but
probably more of a continuum and multifactorial.
• Reading difficulty is part of a spectrum of learning
disabilities

6. Causes of poor reading
•Low IQ
•Not taught (no opportunity to learn)
•Emotional/behavioural problems
•Poor role models
•Poor reading readiness
•Sensory problems
•No particular cause found - Specific reading
disability (dyslexia)
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low visual acuity
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intelegant mesurment

7. Wechsler Intelligence Scale for Children (WISC
IVCDN)
Verbal IQ Performance IQ
Full Scale IQ
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the most common one at school
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involve reading and writing task
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every thing togather
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the kids may do very will with this part
w
h
i
c
hdoes not involve reading

8. Causes of poor reading
•Low IQ
•Not taught (no opportunity to learn)
•Emotional/behavioural problems
•Poor role models
•Poor reading readiness
•Sensory problems
•No particular cause found - Specific reading
disability (dyslexia)
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no good home situation . the kid does n
o
t
see his parent reading
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2016-06-01 07:11:47
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very limited experiance . they don not k
n
o
w
much about what happening out side of
thier house . what they reading about it
does not meaning any thing to them

9. Classification of poor reading
•Non-specific reading disability
•Low IQ
•Not taught (no opportunity to learn)
•Emotional/behavioural problems
•Poor role models
•Poor reading readiness
•Sensory problems (vision,hearing)
•Specific reading disability (dyslexia)
Poor reading
is 2ndary -
extrinsic
- Poor reading
is primary, intrinsic
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if the others on top doe not exiset . then t
h
e
child diagnose as having dyslexia

10. Definition of specific reading disability
•Diagnostic and Statistical Manual of Mental Disorders -
DSM-5
• A persistent difficultyin reading,writing, arithmeticor mathematical
reasoning skills during the formal years of schooling.Symptoms may
include inaccurate or slow and effortful reading,poor written
expression that lacks clarity
,difficulty remembering number facts,or
inaccurate mathematical reasoning.Current skills must be below the
average range of scores in culturally and linguistically appropriate tests
of reading,writing or mathematics.The individual’s difficulties must not
be better explained by developmental,neurological,sensory (vision or
hearing) or motor disorders and must significantly interfere with
academic achievement,occupational performance or activities of daily
living.
Simpler definition
“an unexpected difficulty in learning to read in children
who seem otherwise capable and intelligent”
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not just reading . it incloud other defecultey

11. Dyslexia
• “…is constitutional in origin,part of one’s make-up and
independent of socio-economic status or language
background.’
• “Accompanying weaknesses may be identified in areas of
speed of processing, short-term memory, organisation,
sequencing,spoken language and motor skills.There may be
difficulties with auditory and /or visual perception.
• It is particularly related to mastering and using written
language,which may include alphabetic,numeric and musical
notation”
British DyslexiaAssociation (BDA)
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we should assess the chiled in this area
to make the dignose
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not just reading

12. •The basic/most common difficulty that poor readers
have is with learning to decode print i.e.word
identification.
•It is probably related to basic skills such as visual-
auditory coding,alphabetical knowledge,phonological
awareness i.e.it is a linguistic problem

13. Correlates
•Genetic
•50% of children of dyslexic parents
•50% of siblings of dyslexic children
•50% of parents of dyslexic children may have the
disorder
•Pregnancy complications
•Perinatal difficulties
Shaywitz and Shaywitz (2003) Pediatrics in Review, 24, 147-153
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it is genetic and inviromantal aspect

14. •Prematurity
•LBW
•Socio-economic class
•Postnatal complications
•Cigarette smoking during pregnancy
•LBW; learning disorders,hyperactivity and
impulsivity
•Hearing loss
•in first 1-2 years
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low birth wieght
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these increase the risk of having reading
defeculty

15. •Associated with slight developmental delays e.g.
•physical milestones e.g.fine motor coordination
•delayed speech
•handedness may develop later
,incomplete handedness
•laterality difficulties
•subtle perceptual problems
•short term memory problems
•This allpoints to abiological, intrinsic cause in many
cases
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difecultey with B and D FOR EXAMPLE
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DIFECULTY WITH RT AND LT HAND

16. Some components of reading
• Phonological awareness
• the conscious sensitivity to the sound
structure of language,ability to
auditorily distinguish parts of speech
• predictor of an individual’
s reading
ability

17. •Auditory perception/language
•TAAS (T
est ofAuditoryAnalysis Skills)
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THE ONE that the optometrist use

18. •Decoding
•decoding makes use of all graphenomic and semantic
cues
•Includes phonics (nonsense words e.g.borrowgroves)
“T
was brillig and the slithy toves,
Did gyre and gimble in the wabe,
All mimsy were the borrowgroves,
And the mome raths outgrabe” Lewis Carroll
•And word recognition
•ability of a reader to recognize written words
correctly and virtually effortlessly
•Sight words,rapid automatic naming
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abilitey to sound out the word
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other names for word recognition

19. •T
op down difficulties
•Syntax and semantics
•poor understanding of language,grammar and
pronunciation
•Comprehension
• Failure to comprehend can be caused by
•insufficient vocabulary
•insufficient world knowledge
poor reading readiness
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the meaning for syntax and semantics

20. What happens (should happen) when
a child has difficulty reading?
When a child is identified with an exceptionality;
• Five categories of exceptionalities
1.Behaviour
2. Intellectual
• Giftedness
• Mild intellectual disability
3.Physical
• Physical disability
• Blindness and low vision
4.Multiple
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- ADHD CHILD
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CHILDREN WITH down syndrome
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children with high level of intellectual we
may put them in a higher level for
learning because they have the ability
to learn very fast

21. 5. Communication
• Autism
• Language Impairment
• Speech impairment
• Learning disability
• not primarily the result of
• Impairment of vision or hearing
• Physical disability
• Developmental disability
• Primary emotional disturbance
• Cultural difference
• 10% of children need above and beyond standard
curriculum

22. •The EducationAct requires that schools provide ….
special programs and services for exceptional
students.
•The IPRC (Individual Placement and Review
Committee) decides whether achild is exceptional
and decides appropriate placement.Should be
reviewed once per year
.
•Parents or Principal may initiate the process.
•Educational assessment should then be done.
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if the school discover that this child has
d
e
f
e
c
u
l
t
ylearning , that what they should do
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2016-06-01 07:38:57
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this process is not for kid with reading
d
i
s
a
b
i
l
i
t
ybecause they do not recocnize it as
medical condetion so their is no fund
for this problem

23. Psycho-educational/educational
assessment
• Through school or privately
• Reports
• Teachers
• Parents
• Educational assessments (from teacher)
• Medical
• Optometric
• Audiological
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they need to collect reports about that k
i
d
from diffrent parts

24. • Assessments
• Intelligence (WISC-IV)
• Verbal (verbal comprehension,working memory)
• Performance (Perceptual reasoning,processing speed)
• Academic achievement
• Math skills
• Calculation
• Reasoning
• Reading skills
• Decoding (word and non-word recognition)
• Comprehension
• Writing

25. • Phonological processing
• Attention
• Executive functioning
• Memory
• Visual perception ???
• Visual-motor coordination (BeeryVMI)
• Letter reversal (Jordan or Gardiner)
• TVPS(R) – Test ofVisual Perceptual Skills
• Visual discrimination (Matching)
• Spatial relationships
• Form constancy
• Visual memory
• Visual sequential memory
• Figure-ground discrimination
• Visual closure
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abilitey to break down a big task in order
to be able to solve the proplem and to
reach to the goal

26. General approach to management
• Primary school – remediation e.g.
• Phonemic awareness
• Guided repeated oral reading
• T
eaching vocabulary
• Interactive reading
• Secondary school – accommodations e.g.
• Extra time for assignments
• Spell checkers on laptops
• T
ape recorders and recorded books
• Speech recognition programmes
• Computer rather than handwriting
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this at earley stage
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we need to read to be able to learn

27. Vision and reading
Intuitively obvious that visual disorders may
interfere with the reading process or decrease
incentive
▫ 1.Occasional blur
,diplopia,visual distortions may
interfere with identifying symbols
▫ 2.Asthenopia  avoidance of reading
▫ 3.Difficulty following a line of text
• There are more vision disorders among poor
readers
• But not so many among children with SRD.

28. Optometric correlates of poor reading
Associated with poor reading Probably
associated
Not associated
Hyperopia Astigmatism Myopia (ass with
better reading)
Anisometropia Crowded VA Distance VA
Aniseikonia Reduced steroacuity
Accommodative dysfunctions
Near exophoria Esophoria
Convergence insufficiency Alternating strabismus Constant unilateral
strabismus
Hyperphoria Amblyopia
Associated phoria Deep suppression
Unstable heterphoria (variability in
phoria or associated phoria)
Colour vision defect
Deficient fusional reserves
Deficient vergence facility
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mohm

29. • If child has a suspected or actual reading difficulty:
• Optometrist’
s role
• Correct Refractive errors
• Hyperopia
• ≥1.5 D definitely
• And smaller errors
• Astigmatism
• ≥0.75D
• Anisometropia
• ≥0.75D in any meridian
• Consider near phoria
Leat SJ, CEO 2011, 94, 514, Narayanasamy S, 2015 PhD thesis

30. •BV and accommodative training
•If outside norms
•Consider demands
•Fixation changes 10x per minute (need 5 cpm for bin.
vergence and acc facility)
•Continuous near fixation for 23 minutes
•W D = 23 cms = 4.38D
Narayanasamy S, 2015 PhD thesis

31. Other suggested links with vision- what
is the evidence?
•Do poor eye movements cause a learning/reading
disability?
•Poor readers do show different patterns of eye
movements e.g.
•longer fixation duration
•more regressive saccades
•But evidence is that in most cases,these are caused
by
,not the cause of,RD

32. •DEM (Developmental Eye
Movement) test
•Designed to measure fixation
and saccadic eye movements
including a visual to verbal
component
•Pre-test (T
estA) to ensure
that the child knows their
numbers
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the first step of the test
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3"lt

33. Razan
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no deffrance between A and B

35. Scoring for DEM
•Vertical time = time to completeA and B (?adjusted)
for errors
•Horizontal time = test time C x [80/(80-o+a)]
•Ratio = Horizontal time
Vertical time

36. DEM manual
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- MSH MOHMEH

37. Validity of DEM?
•It does not measure basic eye movements (Ayton et al
2009 OVS, 86,722)
•Difference in horizontal directions depends on
familiarity (English readers vsArabic readers, Medland et al (2010) OPO 30,
740.
•Its repeatability is questionable (Orlansky et al (2011) OVS 88,
1507)
•It does measure aspects of reading rate,visual
processing speed and tracking.
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abilitey to quick name numbers

38. •Does training EMs or tracking improve reading?
•Anecdotal evidence
•Few good RCT studies
• Recent study (Powers,ARVO 2016) showed that tracking and reading
training did not improve DEM, but“visual skills” training did.
•If EMs are abnormal for non-word targets (use SCCO
or NSUCO grading systems)
•Or clear oculomotor deficiencies e.g.CP or
oculomotor apraxia

39. The Meares-Irlen Syndrome (Scotopic Sensitivity
Syndrome, Visual Stress, MISVS)
• Adults and children complained of certain symptoms and
anomalous perceptions while reading or other visually
intensive activities
• Some are good readers
• Some also have reading disability
• Often a history or family history of migraine
• Irlen claims that 12-14% of the population have M-I
syndrome and 46% of people with reading disability have
SSS

40. •Tints help with the symptoms and with the reading
difficulties
•tint colour is idiosyncratic to the child/adult
•tints are supplied as an overlay and then in spectacles
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a color paper that we put it in top of the p
a
g
e
or use this color in glassess to help
with reading

41. •Now claiming that they can help
• Headaches,migraines,fatigue and other physical symptoms
• ADD/HD
• Autism andAsperger Syndrome
• Behavioral and emotional problems
• Light Sensitivity/Photophobia
• Traumatic brain injury (TBI),whip lash,and concussions

42. • Is there any evidence?
• some children report genuine improvements and about
50% continue to use tints
• There is a pattern within families
• 81-85% with MISVS symptoms had one or both parents with
symptoms (Robinson et al 2000)
• 50-70% with MISVS symptoms have a brother or sister affected
• 1 RCT
• 3 experimental studies
• 1year longitudinal study
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with these tint
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randomize clinical trials .
ask the people to report what symptoms
they have with ech tint (the people do
not know which tint they are using )
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2016-06-01 08:21:22
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this study showes that the kids who have
the syndrome are developing with the
same rat as the childs who do not have
the syndrom by using the tint

43. •Theory
People with MISVS,migraine and seizures are more
susceptible to pattern glare (Evans)

44. • Cerebral palsy describes a group of non-progressive conditions in which motor control is impaired due to damage of areas
of the brain which control motion.Cerebral palsy can be the result of prenatal,perinatal or postnatal causes,including
genetic,anoxia,toxaemia,maturnal thyroid abnormality,infection (maturnal e.g.herpes xoster,influenza,or of the child
postnatally e.g.meningitis,mumps),prematurity
,or trauma (including non-accidental).It is now thought that the most
common causes are prenatal and genetic.In spastic cerebral palsy (66-70% of cases) damage is primarily in the motor
cortex,causing the muscles of the affected areas to be in spasm which increases when movement is attempted.In the
athetoid or dyskenetic child (20%), damage is in the brain basal ganglia,and the result is unplanned,slow,writhing motions
which begin when a planned motion is attempted,while in ataxic CP (10%) damage is to the cerebellum resulting in poor
coordination and balance.Mixed forms can occur
, most frequently spasticity with athetosis.The incidenceof ocular
disorders in cerebral palsy is known to be high.Jones and Dayton (1968) report that between 56 to 75% of children with
cerebral palsy (CP) have some ocular disorder.The frequency of ocular disorders is as follows:- presence of significant
refractive errors between 40 and 76%, strabismus between 34 and 60%,(esotropia being more common than exotropia in
most studies,and 43% having an additional vertical component),incommitant eye movements or difficulty tracking a target
(40%), reduced visual acuity between 12 and 24%, and ocular pathology (most commonly optic atrophy) 28%.There is some
evidence that most of these ocular disorders are approximately twice as common amongst those with spastic rather than
athetoid cerebral palsy
.Reduced accommodation has been reported in 100% using a subjective test,and 42% using objective
dynamic retinoscopy.Other reported disorders are visual perceptual difficulties and nystagmus.

46. Minimum cortical hyper-excitability mediated by
light
Tints lower the activity in sets of neurones tuned
for wavelength
•There is some evidence of validity to this treatment
•Overlays available from the College of Optometrists
(UK) and Irlen Institute

47. Visual perceptual skills assessment and
?training
•perceptual skills are the ability to analyse patterns into
their component parts
•Visual or auditory
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ability to extract and organise information

48. •Children with poor reading and LD do show more
visual perceptual skills difficulties
•But weaker association once controlled for IQ
•And will have many other deficits too (auditory
,
executive function,memory,attention)
•Early reading ability may be linked to visual
perceptual skills [although later ability (6-7 years)
linked to auditory skills]

49. VPS assessment
• UndertakeVPS testing if this has not been done as part of
educational assessment
• Results of visual perceptual skills testing may be used to argue
for further assessment
• DON’T doVPS assessment in isolation
• DO refer for full psycho-educational assessment/push for an
educational assessment through the school.
• Not covered by OHIP
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without getting an educational assesment

50. DVMI (BVMI, VMI,
Beery) – Developmental
test of Visual-Motor
Integration
(Beery-Buktenica)
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lots of names

51. •TVPS(R) – T
est ofVisual Perceptual Skills
•Visual discrimination (Matching)
•Spatial relationships
•Form constancy
•Visual memory
•Visual sequential memory
•Figure-ground discrimination
•Visual closure

52. Visual
Discrimination -
Matching
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let the child to point to the similar one

53. Spatial relationships
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abilitey to see the diffrance one

54. Spatial relationships

55. Form
constancy
1 2 3 4 5
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abilitey to detect the number with deffrent
size and shaps

56. •Visual Memory

57. Visual memory

58. Visual memory

59. Gardiner Reversal Frequency Test
Slide courtesy of L. Christian
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childe with lateralety problem

60. Jordan R-L Reversal
Slide courtesy of L. Christian

61. Jordan R-L Reversal
Slide courtesy of L. Christian

62. Jordan R-L Reversal
Slide courtesy of L. Christian
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we have to follow the instruction for each
test .

63. •But what to do with the results?
•Rosner:Perceptual deficits (visual and auditory)
cause learning difficulties and training these will
remove the obstacle to reading.
•i.e.that training them is more effective than
spending time training the child to read.

64. •VPS training?
•In a young child who has been identified very early e.g.
before 7
•When other avenues have been pursued
•When waiting for a full educational assessment
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when we have to do it
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when the child still strugeling
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we sholud be onset with the parents that
it may not work

65. Developmental vision program (Optometric
Extension Program, COVD)
• E.g.Balance beam,throwing and catching,OKN
treatment,stimulation with flashing lights
•Concept is that early developments were not achieved
properly and need to be re-learned.
•lack of development in one major area impacts
learning in another major area
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physical treaning
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physical development

66. •But
•very controversial and equivocal effectiveness
•empirical basis
•“It works for me,and ifI can help my patients,I will”.
•No randomised clinical trials

67. Optometric assessment & management – staged approach
Child with suspected or diagnosed reading or learning difficulty
(either by parent, school or teacher or there are concerns with symptoms associated with reading)
Full oculo-visual eye examination
Case history (prenatal and birth history, development, family history of LD
Is child happy?, family issues, performance at school, whether the child has been diagnosed/identified? Any current extra
tuition/intervention? Who is concerned?, Parents expectations from exam, Has an educational/psycho-
educational assessment been done? thorough review of symptoms)
V
As (distance and near, crowded and un-crowded)
Motility, NPC and stereopsis
Ocular motor balance (careful measures of distance and near phoria including hyperphoria)
Careful refraction (binocular refraction; Humphriss, septum, polarised dissociation and a cycloplegic refraction)
Full ocular health assessment
Disorder found
Treat in usual optometric way
(refractive correction, orthoptics, OH)
Follow-up in appropriate period
At follow-up or after therapy
Symptoms ceased, disorder remedied and/or
reading /learning improving
Child may still need extra tuition to catch up
Report to school/ doctor/other professionals
At follow-up or after
therapy
Symptoms still
present, reading
/learning difficulty
not improving Disorder not found

68. Disorder not found or
disorders already treated
In depth BV and accommodative testing
associated phoria, fusional reserves,
vergence facility, suppression,
accommodation assessment; amplitude of accommodation, facility (if
over 7 years), dynamic retinoscopy (Nott)
eye movement testing; fixation, pursuits, saccades for non-word
targets, DEM
Other assessment dependant on findings e.g. aneiseikonia,
visual fields, CS
Disorder found or not meeting
demands
Consider vision training or optical correction
(including prisms) or a combination
Follow up in appropriate period.
At follow-up or after therapy
Symptoms ceased, disorder remedied
and/or reading /learning improving
Child may still need extra tuition to
catch up
Report to school/ doctor/other
professionals
At follow-up or after therapy
Symptoms still present,
reading /learning difficulty
not improving
Disorder not found

69. Disorder not found
Consider visual perception testing (if not already done as part of a psycho-
educational assessment)
Consider overlays (if there are symptoms of MISVS – Meares-Irlen
Syndrome/Visual stress)
Consider referral to another optometrist who undertakes this testing
Referral for psycho-educational assessment is indicated if not
already done
Disorder found
Consider visual perceptual training
(more likely in younger children) or
recommendation of accommodations
(more likely in older children/tinted
overlays
Follow up in appropriate period.
Child may still need extra tuition to
catch up
Report to school/ doctor/other
professionals
Disorder not found
Diagnosis of exclusion
indicates a reading
disability with no visual
cause or contribution
Report to school/
doctor/other professionals

70. Hugo…. Mar 2012
• 11 year old boy
.
• Hx of learning difficulties,specifically in the areas of attention and working
independently,since ayoung age.At 10 years he was diagnosed with a
CentralAuditory Processing Deficit.
• In February 2012,he had a psychological assessment.included theWISC-IV,
WRAML2,Woodcock-Johnson, Beery VMI, CTOPP and Grey Oral Reading
Test.This assessment isolated several areas of need including visual
processing speed, rapid naming,verbal memory, math computations, as
well as reading fluency
,spelling and grammar
.It was concluded that Hugo
mayhaveAttention Deficit Disorder: Predominantly InattentiveType
(ADHD:1).
• Hugo was referred to our clinic for a thorough visual assessment and
visual perception testing.

71. •Sx; no difficulty with blackboard, no blur
,loses place
when reading,uses finger to keep place,has difficulty
going between two tasks because loses spot.
•GH good,Omega 3 pill due to concern withADHD

72. •Hugo’s profile
•WISC-IV (IQ);
Percentile
Verbal
comprehension
27 average
Working
memory
58 Average
Perceptual
reasoning
10 Low average
Processing speed 1 Extremely low
Full Scale IQ 10 average

73. •BeeryVMI
Percentile
Visual/motor co-
ordination
91 superior

74. Woodcock-Johnson Percentile Category
Letter-word identification 43 Average
Decoding 58 Average
Reading fluency 4 Low
Passage comprehension 30 Average
CTOPP (Comprehensive Test
of Phonological Processing)
Phonological awareness 84 High average
Rapid naming 1 Extremely low

75. Math
Calculation 3 Borderline
Math fluency 1 Extremely low
Writing
Writing fluency 5 borderline

76. •Hugo has an IEP;Accommodations; peer tutoring,
duplicated notes,extra time for processing,note-taking
assistance,rewording or rephrasing of information,
work space close to instructor
,study carrel to reduce
distractions,open book for tests,extra time.
•work on written language,assistance to begin a task

77. • VisualAcuities: Snellen @ 6m,OD: 6/4.5,OS: 6/4.5,OU:
6/4.5
• Cover test: Distance:NS, ortho, Near:NS, 4 exophoria
NPC; 6,6,7
• Accommodative amplitude; OD 16,OS 15
• Accommodative Facility;OU 10,OD 11,OS 8 cpm
Dry Retinoscopy:
OD: +1.50/-0.25x090,OS: +1.25/-0.25 x 080
Note: accommodation was fluctuating
• Modified Nott Dynamic Retinoscopy: variable,ranging
from accurate accommodation to a large lag outside the
normal range.

78. •Cycloplegic Retinoscopy (0.5% cyclopentolate);
•OD: +1.75/-0.25x090,OS: +2.25/-0.25x180
•Cycloplegic Subjective:
•OD: +1.50DS = 6/6-2, OS: +1.75DS = 6/4.5-1
•Ocular Health; external and internal examination
WNL; deep physiological cupping;c/d ratio; OD
0.4/0.34,OS 0.55/0.6

79. •Rx;O D +1.25,OS +1.25
•For all school work,reading,homework etc
•Counsel that hyperopia may be a factor
,but is probably
not the cause of LD
•Review in 6-8 weeks for full BV work-up
•Visual perceptual skills testing afterwards (only one
done as part of educational assessment)?

80. Conclusion
•Optometrists have an important role to play
•But don’t work on your own.
•Ethics of recommending extensive,expensiveVT?
•Don’t only concentrate on Vis Perc Skills and other
vision testing,if a Psycho-educational assessment has
not been done
•Vis perc skills testing may augment full Psycho-
educational assessment or be used to trigger one
•Remember there are only 24 hours in a day!