Part IX – Assessing and Managing Vision
As a rule, all children should be checked for possible visual impediments during Kindergarten in preparation for formal reading instruction.
Visual Impediments to Learning (VIL) are the most common undetected cause of apparent learning and reading difficulties. VIL even affect children who are apparently good learners, and cause them to struggle needlessly and even report a variety of medical concerns. If vision problems are not detected and properly managed, the child will not be able to reach their potential. For children suspected of reading and learning problems, including problems of attention, hyperactivity, and emotional stress, addressing vision first is the only means of achieving meaningful therapeutic ends through more traditional methods of remediation.
Vision is complex, and standard checks of ‘eyesight’ using eye charts are virtually of no use in detecting the most significant problems. This information sheet provides a brief summary of the elements of vision, as well as a checklist to try to determine whether a child is likely to be struggling against ‘invisible’ vision troubles. These are ‘invisible’ because they are most often not detected through psychological or medical assessments, and will not be reported by the student.
Of great importance is the fact that in EVERY school classroom there are many children who are certain to struggle silently with vision problems, and this is even more of a problem among some ethnicities. Early assessment of vision and management of VIL is critical in avoiding unnecessary testing and in accelerating reading and learning therapies.
Assessing VIL Risk – The VIL Checklist
The following checklist can be used as a general guide in assessing relative risk for visual impediments to learning. It is by no means a clinically accurate tool for determining specific diagnosis, but it is valuable in pointing out what behavioural and learning patterns that are likely to be either caused by or related to challenged visual function. It is worth reviewing the list and sharing with parents, teachers, and other developmental professionals including Occupational Therapists, Medical Doctors, MDs, and psychologists. See attached distributable PDF file: VIL Symptom Checklist and Notes
Who Requires Assessment
All children need to be assessed in Kindergarten for visual health and function deficits. Furthermore, this assessment must adhere to the standards outlined in ‘Clinically Speaking Part II: Measuring Vision in the Classroom’. This standard is comprehensive, yet not overly burdensome to clinicians, schools, or parents. This approach provides a few key advantages to the current model of either simply acuity checks, or no checks at all:
- It is designed to meet clinical needs for site-based assessments of larger groups. In other words, this approach is efficient in time and cost.
- It is nearly 100% specific and selective for the most common serious visual impediments to learning and thus allows all affected children to be identified and treated early.
- It provides insight into the functional and developmental status of the child, and has predictive value regarding reading and learning success.
At this time, there is no mandated requirement for visual assessment of children in school. When a child presents for assessment through medicine, psychology, or occupational therapy regarding learning and reading problems, that child should be immediately referred to vision assessment before any extensive and invasive testing occurs, and this for three reasons:
- Visual impediments might well be at the root of the problems observed.
- Uncorrected vision will impair the child’s ability to respond to adjunctive academic therapies.
- Uncorrected VIL can and will interfere with aspects of psychoeducational assessments that rely upon visual stimuli for inferring cognitive functions, bringing the results into questions. This is especially important in that the results of such testing are often used to determine treatment trials.
Referrals: When and to Whom?
When a child is identified as having reading, learning, or possible visual deficiencies, they must be seen by a visual developmental specialist on an urgent basis. This is to assess health and function. Options for these assessments include developmental optometrists and pediatric ophthalmologists, with the differences summarized below:
Developmental Optometry: Considers health and function in detail. Serious health concerns are addressed immediately, or referred to tertiary care, such as pediatric ophthalmology, for advanced medical care including surgical intervention as required. Detailed functional assessment of motor and cognitive behaviour is available on-site, but more extensive psychoeducational batteries must be contracted out to psychology. Developmental ODs will not prescribe behaviour modifying medications, but will refer to medicine for assessment as is appropriate. They are however more likely to recommend assistive or corrective lenses when these will improve performance and comfort. The wait time to see developmental ODs is rather short, and costs are also modest.
Pediatric Ophthalmology: Considers health in detail, but with only limited consideration of the functional aspects of vision. Serious health concerns will be addressed, and medical-surgical interventions are available. Pediatric OMDs are unlikely to spend much time with the individual child and prefer to have technicians compile data, with little attention paid to reading and learning-related visual and cognitive function. More advanced psychoeducational assessment is referred out to psychology. Pediatric OMDs are more likely to suggest behaviour modifying medications and surgical interventions, as appropriate, but are reluctant to prescribe corrective lenses unless the child is frankly symptomatic or if there is the beginning of an esotropic eye turn from hyperopia. Wait times for pediatric OMD consult is typically a matter of months or longer, and costs are significantly higher than for optometric assessment.
Ophthalmology emphasizes health from an allopathic view – the goal is a healthy eye. Developmental optometry ensures good health, including referral to ophthalmology where indicated, and then looks at function from a behavioural perspective. It is rare to have a serious ocular or systemic health concern causing reading, learning, and behaviour problems, but there are nearly always co-morbid visual functional deficits that can both be treated, and can point to developmental concerns. It should be underlined that in Alberta and most Provinces and States, optometrists are licensed and more than qualified to diagnose and treat most ocular disease, including neurologically-based conditions, with referrals to tertiary care as required.
It is worth noting that the current standard of care for strabismus is to refer to surgery. Experience and studies show that visual therapeutic intervention is as good as, and arguably a better alternative to, surgery. Parents are often happy when they see their child with a straightened eye after surgery, but this does not reveal the underlying sensory deficits that virtually always occur with turned eyes, namely amblyopia and spatial awareness deficits. When these are not addressed, the brain has no ‘fusional glue’, no means of matching the images between the eyes to maintain alignment, and this can and will lead to a new turn of the eye and repeated surgeries. Furthermore, muscle alignment is affected post-surgically requiring the visual system to learn how to manage the new targeting dynamic. Developmental optometry can help improve surgical outcomes through pre-operative therapy to improve perception and motor skills, as well as training after the fact.