Happy Father’s Day!


Wishing all of our fathers and patients a happy Father’s Day!



Reversals: Changing Lanes

Letter reversals.

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.

  1. It is normal to make reversals.
  2. Not recognizing Object Constancy is a reasonable cause.
  3. Inspecting of pattern from the right rather than the left is common for young children.
  4. Children don’t always grow out of their reversals.
  5. Frith, mentioned in 1971, ” that reversals have been found in some brain injury cases, especially those effecting the parietal and occipital regions.” This has certainly been the case with the large number of brain injury cases seen by this office.
  6. Finally, Moyer said, ” that reversals constitute about 45% of all errors of 4 year olds, 23% of 5 year olds, and drops to 7% of 7 year olds.”

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

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.

Not Ockham’s Razor

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.