Reading and attention struggles frequently become more noticed after the third grade when students begin to rely more heavily upon written materials to supplement their learning. As students progress to middle school and on to high school, reading difficulties may emerge changing an avid reader to a “reading avoider.” In other situations, educational teams may question why an otherwise capable student is not making the expected progress in reading despite the use of reading interventions and other supports. While many things may be impairing a student’s progress (e.g. use of the wrong reading intervention, incorrect implementation of an intervention, attention/processing/cognitive deficits, etc.), sometimes a student’s difficulties may be related to a vision deficit or impairment.

As students progress through the K-12 system, class materials usually change from a “sans serif” font (such as Arial or comic sans) to a smaller sized or “serif” font (e.g. times roman). Changes in the font size and type will usually be accompanied by the smaller spacing between the lines (e.g. single line versus 1.5). Compare, for example, a third grade reading book with an 8th-grade book. While most students experience no difficulties with the presentation changes as they move up in grade, for others these changes can cause the reading to become more difficult, hampering or preventing reading progress altogether. When reading problems persist or emerge, schools and parents often explore whether a vision deficit could be a contributing factor.

A vision deficit may exist even if a student has 20/20 eyesight. Eye exams are given at schools or at a pediatrician’s office commonly use a version of the “Snellen eye chart” (developed in the 1800s) or the LogMAR chart (developed in 1976) to explore how well a student can see near and far. However, these types of traditional eye exams are intended to measure visual acuity and typically do not measure how long a student’s eyes can focus on the text before tiring, how long it takes the student’s eyes to focus in order to read the text, whether the student has troubles reading or tracking multiple lines on a page (versus a single line), or other things which may affect a student’s ability to read. Students with vision issues may see 20/20 in a small setting during the testing, but in the class or at home they may:

• blink or rub their eyes frequently,
• complain they are tired or have a headache,
• have burning, teary or itchy eyes,
• feel nauseous when reading,
• not pay attention,
• experience a “clicking” movement when their eyes move back and forth,
• visually jump around on a page or skips lines when they try to read,
• lose their place when reading,
• need to use a finger to help them track when reading,
• have poor handwriting and letter placement on lined paper,
• tilt their head when reading,
• complain that the words jump around, fade in or out, or are blurred,
• omit or misread words, or
• have troubles copying images.

A commonly used screening tool for non-acuity vision development issues is the COVD-QOL checklist (College of Optometry Vision Development – “Quality of Life” Checklist). San Diego Unified has its own checklist: Checklist of Visual Behavior that incorporates much of the COVD checklist. A student demonstrating any of the above may be incorrectly perceived as having ADHD or another learning disability when they really have a vision deficit in one or more of the below areas:

Fixation: the ability to focus on an object and move to another quickly,

Convergence: the ability to turn the eyes in to look at words to read and keep the eyes together to clearly read the text for extended periods of time,

Tracking: the ability to following objects with the eyes to keep their place during reading or when playing a sport,

Binocular vision: the ability to use both eyes properly to bring in information to the brain,

Stereopsis: the ability to determine distances between objects,

Form perception: the ability to recognize the differences between objects so that the brain can organize them,

Field of Vision: the ability of the eye to assimilate information from an appropriate visual field.

If a student has some of the aforementioned physical symptoms and struggles with focusing and reading, the educational team should discuss whether the student needs a “developmental vision assessment.” If an assessment reveals that the student has difficulties with eye movement control, eye alignment, eye teaming, or refraction, vision therapy should be considered by the student’s IEP team.

In California, “vision services” are a related special education service if the student has an IEP and the team feels that the student’s vision is impacting his/her educational performance. See, e.g. Ca. Ed. Code § 56363(b)(7). In California, vision therapy may include, “Remedial and/or developmental instruction provided directly by or in consultation with the optometrist, ophthalmologist, or other qualified licensed physician and surgeon,” and even by “appropriate school personnel,” when prescribed by a qualified medical professional. 5 CCR § 3051.75 (California Code of Regulations).

Districts have a responsibility to assess a student in areas of suspected disabilities when the student’s performance is below the child’s capabilities. If you have reason to believe that your child or student is experiencing learning difficulties, consider requesting a developmental vision exam to explore whether the child’s learning difficulties are the result of vision deficits. Parents should request an assessment in writing and submit it to the child’s teacher or case manager with reasons why they believe an assessment is warranted. Districts such as the the San Diego Unified School District have detailed procedures that set forth the responsibilities of the case manager and IEP team to ensure that such requests are considered and parents should familiarize themselves with those procedures in advance of making a request.

Sample Resources:

College of Optometrists in Vision Development

Study on the use of COVD-QOL for screening

Randomized Clinical Trial of Treatments for Convergence Insufficiency in Children (2005)

Vision therapy in adults with convergence insufficiency (Optometry Vision Science, 12/10, abstract posted by National Institute of Health)

Efficacy of vision therapy for convergence insufficiency in the adult male population, Journal of American Optometry Association, April 1999 (Conclusion: Vision therapy is effective in eliminating asthenopia and improving convergence function in adult patients. In-office therapy combined with home therapy tends to produce better results than does home therapy alone).

American Association for Pediatric Ophthalmology and Strabismus

Vision Therapy FAQs (Optometrists Network)

Videos showing vision therapy (WebMD)

Attention Deficit Disorder (ADD, ADHD) and Vision

CNN Report: “Seeing Straight” (12/22/09)

Vision therapy ideas on pin interest

Vision Therapy Blog

Presentation on how to use apps in vision therapy

Sample Vision Therapy Games

Sample vision apps

All About Vision

A patient’s guide to insurance coverage for vision therapy