Wishing all of our fathers and patients a happy Father’s Day!
Letter Reversal is a controversial area, but has been related to higher orders of vision and visual processing. Reversal seems to be the most often feared problem by the parents. So many parents are convinced that this is a dyslexic problem, but in many cases its simply just vision and visual processing issues.
Let’s begin with the following: if a child read the sentence “I saw a Zebra,” it is a good bet that they won’t get the word saw backwards. They would certainly be confused if they read “I was a Zebra.” This problem occurs if you’re reading only one word at a time and if scanning RIGHT to LEFT. This in itself is a problem with the eye movements or ocular-motor skills.
Perhaps the child is a gambler. The odds are with her when guessing the letters since left sided letters (b) and numbers exceed right sided (d) and of course “e” is the most frequently used letter so a left to right guess is submitted. In other words, she has a better chance at guessing if she faces the letter to the right (b). This would be a problem of recognizing the letter in the “mind’s eye” or visualizing the individual letter.
Did you know that children that reverse words and letters tend to reverse the same letters and words consistently? The common letters are q,p,b,d,u and n. The common words are was, saw, no, on, pot, of and for and don’t forget stop and spot. The key to the word issue is that they are not randomly chosen, these words make sense when reversed. This not a neurological issue, it’s simply a problem with Spatial Discrimination.
Let’s look at some basic facts regarding reversal.
It’s important to note that children 3 years to 8 will respond to the contour of a form before responding to the detail. Therefore, understanding of Visual Closure before Visual Discrimination seems to be the earliest concept. The orientation is not so important for the 3 to 5 year old’s. They don’t much care what side of the circle to put the stick on (l o l, b,d,q,p).
Reversals that are from writing or printing are considered to be kinetic or movement reversals. The other type of reversal is when confusion occurs from letter orientation or sequencing in a word as one reads. This would be called stationary reversal or static.
Stationary reversals tend to be associated with the problem of Visual Constancy. Here is an example, if you take a chair and turn it upside down, paint it black, and shrink it small, your result is what? A chair! A chair is a chair no matter what orientation, size, or color change is made. Now add in Spatial Awareness and you begin to see that moving from the 3 dimensional world to the 2 dimensional world becomes somewhat confusing. These children are not suffering from some deep neurological impairment but rather confusing a simple visual processing concept. Simner (1984) states “children must have an understanding of their own body imagery. If a child can’t differentiate between right and left, then he can’t be expected to differentiate b and d.”
As stated previously, Letter Reversal is a controversial area, but has been related to higher orders of vision and visual processing. The intent of this article was to help see the interplay of some of the visual and visual processing skills that are involved in the reversal of letters and words.
I would like to thank Ken Lane, OD, FCOVD author of Developing Ocular Motor and Visual Perceptual Skills for his terrific insight into Reversals.
Ockham’s Razor, the idea that a hypothesis with the fewest assumptions should be selected over hypotheses with many assumptions. This is a term I learned for the first time a few years ago in a psychology class, a term I never thought I’d use again. After a recent patient encounter while shadowing Dr. Weinberg the concept re-surfaced and the case was quite interesting to hear.
A young man came to our office not knowing why he was there. He had been to every type of doctor and therapist he could think of. He had been to the neurologist, he had been to ophthalmologists, he had been to the masseur and chiropractor. Not one had been able to “cure” him. He had been admitted into one hospital to rule out Rocky Mountain Spotted Fever. He was released with no signs of RMSF and all accompanying reports had come back negative. CT scans were performed which also returned negative results. The patient presented ongoing symptoms of blurry vision, headaches and neck muscle pain. These symptoms had been occurring for over a year at this point and he had been in and out of hospitals and therapy sessions ever since the onset. He stated the massages helped with the muscle pain. The blurry vision remained constant. His final stop and last hope for an answer was at a Developmental Optometrist.
Dr. Weinberg performed a thorough visual evaluation. The young man had nearly perfect vision at both far and near. A very slight eye turn was discussed, however a simple “in home” exercise was prescribed to alleviate this symptom. Sitting in the exam room and watching the interaction, a prognosis seemed a mystery. After careful study of the young mans near vision the doctor asked the patient what kind of work he did, then how much time he spends in front of the computer. The patient confessed that at one point in the past year there was a stretch where he had to sit and work in front of a computer for more than ten hours a day.
Mulling over the information gathered during the exam, the doctor hypothesized that this mystery ailment the patient suffered from was an extreme case of simple problem…Eye Strain. Dr. Weinberg explained how doing so much near work for so long puts stress on the eye. It takes a lot of energy for the eyes to fixate and stay focused at a near distance. The strain became so much that the body has over compensated to alleviate the eye strain. The overcompensation induced neck pain and headaches. Needless to say the patient was quite shocked to hear that this was the problem. After all he had seen a neurologist, an ophthalmologist, masseur and chiropractor. For all of his troubles, all that was needed was a new Rx for near work to relieve his eye strain. Ockham’s Razor!
Something I would like to point out from this exposé is the relationship that vision has with the brain and body. Just as this young mans eye strain caused neck pain and headaches, a person suffering from an acquired brain injury or other neurological insult may experience a visual midline shift as described by Dr. William Padula, OD, DPNAP, FAAO, FNORA. The patients (spinal) posture changes in accordance to the their visual orientation being off kilter, for example a lean to one side or the other. The case above as well visual midline shift syndrome from an acquired brain injury may seem to be the extremes, however think how a visual problem may affect a child’s behavior who is struggling due to a visual deficit. One problem leads to another then another and so on, causing a much larger problem than what it began as. Remember Ockham’s Razor and the law of parsimony because much of the time there is a much more succinct solution for a large number of problems.
It seems that when Vision Therapy is mentioned then the following condition seems to be automatically mentioned and that is Convergence Insufficiency (CI). CI is that binocular condition in which the two eyes have difficulty maintaining near demanded tasks. This condition may result in double vision, asthenopia, and headaches. No wonder it would cause reading issues as well as learning related problems. But, you don’t have to have this visual condition to have a visually related learning problem.
General visual skills dysfunction can be comprised of inadequate teaming skills, inadequate eye movement skills, focusing (Accommodative) problems or visual processing skills.
Teaming skills can be inadequate. This means that the skills may not provide the desired ranges necessary for free and easy binocular movement of the eyes. The eyes seem to fatigue easily, asthenopia or discomfort sets in, headaches may or may not occur, or the individual just has no desire to read for any length of time.
Eye movement skills may be inadequate. Simple observation may reveal inadequate fixation or scanning skills. Evaluation may include but is not limited to Fixation tests such as the modified King-Devic test. A timed test of displayed single digit numbers in an array called out by the patient.
Focusing problems may be exhibited by what the optometrist refers to as Accommodative Infacility. AI is an inability to change focus rapidly from near to far and then far to near. Usually the child is slow at copying information from the board. This exhibits a delay in focus slowing down the child as he waits to receive the distance information and then responds with the near activity which is in most cases writing the information down.
Visual Processing skills can be measured in a variety of ways;
1) Visual Memory
2) Visual Motor Integration Skills-Speed and Accuracy
4) Letter Reversals
Visual Memory can be tested in many ways but so much information is gathered when the memory test is presented as a set of symbols that must be memorized and reproduced on paper. Visual Motor Integration-SA is an evaluation that requires the gathering of information (eyes), the processing of the information (visual brain) and then the integration or the use of this processed information. Visualization is tested by manipulating shapes in the mind. It is an important skill especially when incorporated with reading. In order to retain the written word it must be visualized. Letter Reversals is a controversial area, but has been related to higher orders of vision in respect to visual processing. Due to the complexity and controversy of the subject, Letter Reversals will be discussed in detail at a later date.
Teaming, focusing, and fixation skills along with visual processing skills may be at the core of most learning related problems.
Happy (belated) Mother’s day!
To all the moms out there, we know how hard you work. We see it every day in our office. We see mothers who come in and are doing everything in their power to see that their children are happy and healthy. We love it!
We know it’s a bit late, but we want to express our thanks and gratitude to all the mothers out there. This blog has been created to help many people, yet we know the vast majority of our readers are indeed concerned mothers. Those of you with children in vision therapy and those who are beginning to research the field, you’re on the right track!
We appreciate the schlepping back and forth between school and vision therapy, the hours spent assisting with homework and often dealing with your child’s frustration. It is our goal to help you find the answers and get the breakthrough you’re looking for in your child’s learning. We know it will pay off. Without you and your dedication we wouldn’t be able to help get your child on track. We wanted to take this time to thank you for everything that you do.
So mothers, this one is for you. Happy Mother’s Day!
Keep an eye out for upcoming post on the “why’s” of vision therapy as Dr. Weinberg will be discussing the links between vision and learning.
What is Vision Therapy?
The definition is very complex and after reviewing the Wikipedia information that fictitious Brittany’s mother may have perused she must have become even more confused by vision therapy. A better definition comes from the organization that certifies both doctors and therapists in the art and science of developmental optometry. The College of Optometrists in Vision Development is the world leader in this area.
“Optometric Vision Therapy is:
A progressive program of vision procedures
Depending on the case, the procedures are prescribed to:
Optometric Vision Therapy Is Not Just Eye Exercises
Unlike other forms of exercise, the goal of Optometric Vision Therapy is not to strengthen eye muscles. Your eye muscles are already incredibly strong. Optometric Vision Therapy should not be confused with any self-directed program of eye exercises which is or has been marketed to the public. Optometric vision therapy is supported by ongoing evidence-based scientific research. Here you can read the latest research published on optometric vision therapy.”
However, this definition just does not tell us what vision therapy encompasses.
The Optometrist Network offers an alternative definition.
“Vision Therapy is an individualized, supervised, treatment program designed to correct visual-motor and/or perceptual-cognitive deficiencies. Vision Therapy sessions include procedures designed to enhance the brain’s ability to control:
Visual-motor skills and endurance are developed through the use of specialized computer and optical devices, including therapeutic lenses, prisms, and filters. During the final stages of therapy, the patient’s newly acquired visual skills are reinforced and made automatic through repetition and by integration with motor and cognitive skills.
Now that we have established a working definition for Vision Therapy its important to note who benefits from Vision Therapy.
Who Benefits from Vision Therapy?
Typically children and adults with visual challenges, such as:
Learning-related Vision Problems have benefited from these services.
Poor Binocular (2-eyed) Coordination
Convergence Insufficiency (common near vision disorder)
Amblyopia (lazy eye), Diplopia (double vision), and Strabismus (cross-eyed, wandering eye, eye turns, etc.)
Stress-related Visual Problems – Blurred Vision, Visual Stress from Reading and Computers, Eye Strain Headaches, and/or Vision-induced Stomachaches or Motion Sickness
Visual Rehabilitation for Special Needs – Traumatic Brain Injury (TBI), Stroke, Birth Injury, Brain Damage, Head Injury, Whiplash, Cerebral Palsy, MS, etc.
Sports Vision Improvement
To summarize, the definition for vision therapy is at best complex and complicated. Vision and Vision Processing is involved from Amblyopia to Sports Vision and everything in between.
Working for a developmental optometrist it is inevitable that you will be asked the question,”what is vision therapy?” As an optometric technician it is our obligation to answer this daunting question. We all know the answer to the question, but for some reason there is a disconnect when explaining vision therapy to patients. Allow me to paint a familiar picture for you:
Our (fictitious) patient “Brittany” is referred by a local eye doctor. Brittany’s mother is so distraught she can’t keep it together in the office. She’s running a thousand errands that day, has three kids with her and now she’s been told her daughter is in need of vision therapy. Mom sends her three children to the play room and slides here iPhone out of her purse. She contemplates the term vision therapy but has no Idea what that means. She thinks to herself, “Google is my only friend.” Mom now studies what Google has told her, looks it over a few times to get a grasp of the concept and then peers over her phone to look at the optometric tech who is vigorously typing away at the computer.
“May I help you?” the tech asks sensing the question coming.
“Yes” the mother replies hesitantly. “The doctor told me Brittany needs some sort of therapy. What is that, is it like some sort of physical therapy?”
Their eyes meet and each seems just as puzzled as the other. The mother’s question is met with a low sigh as the optometric tech bites her lip while she conjures up the best response to the question. The tech musters up the courage to respond and replies with hesitation “yeah, it kind of is….but…there umm…there’s a lot of….well…no, not really”. After carefully rethinking her mumbled response the optometric tech comes back with a simple reply “it’s like exercising the eyes!”
Well, you can imagine what mom thought of that response. I have been in this situation before as an optometric technician, and believe me the problem has nothing to do with the competence of either party. Vision therapy is hugely complex and is not only difficult to comprehend but is equally daunting to explain. That is why I have asked Dr. Weinberg O.D. FCOVD to explain what vision therapy is for us. Keep a look out for Dr. Weinberg’s response in “what is vision part 2”.
In the mean time here are some helpful links:
Hello blogosphere, welcome to the official blog of Advanced Vision of Louisville! Through this blog we intend to share our appreciation for the art and science of visual rehabilitation and learning. The two are interwoven tighter than any known fabric and we would like to show you how. ThinkVision will feature interviews with developmental optometrist Dr. Daniel Weinberg O.D. FCOVD, insight from the vision therapists at Advanced Vision of Louisville, patient testimonials and much more! Future posts are already in the works so stay tuned.
“The more that you read, the more things you will know. The more that you learn, the more places you’ll go.”
-Dr. Seuss, I Can Read With My Eyes Shut.