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Vision: Another Piece of the Puzzle
JENNIFER IDONI OD, FAAO, FCOVD
Developmental Optometrist
VISION: ANOTHER PIECE OF THE PUZZLE
JENNIFER IDONI, OD, FAAO, FCOVD
DEVELOPMENTAL OPTOMETRIST
VISION: ANOTHER PIECE OF THE PUZZLE
ABSTRACT
Individuals with ASD can have developmental delays that affect visual processing. Furthermore, vision can
affect cognitive, speech-language, social-emotional and perceptual development. The signs of vision
problems can be masked by behaviors. Universally, we assume that behaviors seen in ASD are a result of
the disorder, not a consequence of vision problems. Dr. Idoni is an optometrist specializing in pediatrics
and vision therapy. She will speak on the developmental process of vision, vision exams for individuals
with ASD and treatment to improve quality of life. Parents and professionals will learn how to identify
visual challenges and understand evaluation and management options.
“THE EYES DO NOT TELL PEOPLE
WHAT TO SEE, THE BRAIN TELLS THE EYES WHAT TO LOOK FOR”
“When vision works well, it guides and
leads the body; when not, it interferes”
LECTURE OBJECTIVE & OUTLINE
◼ Objective
◼ To understand the functional impact of vision on quality of life
◼ To understand the vision evaluation and treatment options
◼ Outline
◼ Developmental Process of Vision
◼ Identifying Visual Challenges
◼ Vision Exams
◼ Vision Treatment
By having to use so
much effort on the
“mechanics of seeing,”
there is little energy left
to remember or
understand what was
just read
THE DEVELOPMENTAL PROCESS OF VISION
VISION IS LEARNED
◼ Sight: the eye’s ability to view a 20/20 sized
image at a distance of 20 feet
◼ Vision: the ability to see something, relate it
to past experiences and to all the other senses,
and to act on it in an appropriate way
◼ A newborn has the wiring in the brain for sight,
but needs experiences relating vision with the
other senses to understand the light patterns
on the retina
VISION IS
LEARNED
Vision Involves Both the Eyes and the Brain
Seeing is more than the prescription in your glasses
Have you ever picked up a new prescription that didn’t seem quite right at first?
After a short time, your brain adapts to a new way of seeing
Optometrists use lenses therapeutically to change perception to foster development
Why? Because perceptual deficits translate into impaired social skills, delayed language, motor problems, and many other symptoms, even in children with 20/20 eyesight
VISION IS LEARNED
A baby is not born recognizing its parent’s face
Seeing it while being held, fed and spoken to allows him to understand that this particular pattern of light on the
retina is related to these other sensory inputs, that this is someone on whom he can depend
VISION IS LEARNED
Sight
◼ Babies need to have a clear image on each retina, the lining of the eye that sends messages to the brain
◼ If the image is not clear, amblyopia (lazy eye) may develop, where the eye cannot get 20/20 sight even with the best glasses prescription
Vision
◼ Visual skills are learned through a developmental sequence of movement and processing skills
◼ Optometrists should be aware of the age ranges of developmental milestones
◼ When a child sits upright, walks, uses language to communicate, draws different shapes, etc.
◼ Deficiencies in normal childhood development in one area may relate to deficiencies in vision development
VISION IS LEARNED
◼ The development of vision in the child is complex
◼ Child must develop physiological, neurological and cognitive skills
◼ Visual development occurs as the child becomes increasingly proficient in eye movements to absorb
large amounts of information for processing and function
◼ Vision is not a separate isolated function
◼ It is integrated with the development of the total action system of the child, including posture, coordination,
personality and intelligence
◼ Development of the visual system is dependent on neurological development
VISION AND BEHAVIOR
• The brains of children with learning issues and sensory processing disorders prevent them from correctly focusing on and perceiving what their eyes see
Most don’t associate attention, learning, processing, and difficult behaviors with vision
• What it is?
• Where it is?
In perception, the brain must answer two questions about objects in the environment:
If the answer to either of these questions is faulty, perception suffers
VISION AND
BEHAVIOR
Abnormal postures, such as a head tilt and fleeting eye contact, are
adaptations to distorted perception of the environment
Some may over attend to space and have difficulty locating objects
Others may over focus on details and not see the whole
configuration
Attempting to eliminate these behaviors without addressing their
cause is nonsensical
Changing the underlying visual dysfunction can often eliminate the
behaviors, allowing the child to be more available for learning
THE DEVELOPMENT OF VISION
◼ Vision is not simply optical for clear sight
◼ Vision is learned and can be remediated on a neurological level
◼ The best cure is prevention
◼ When we stay ahead, watching for each step in development and
setting the stage for the next developmental step, we go a long way in
providing the opportunities to reach full potential
IDENTIFYING VISUAL CHALLENGES
VISION AND
LEARNING
Vision is our dominant sense and our primary source for gathering information
Vision accounts for as much as 80% of the learning process
Vision problems can have a profound effect on how we learn
Many children who experience academic difficulty may have a visual dysfunction in addition to their primary reading or learning dysfunction
VISION AND LEARNING
◼ When a child is struggling in school the FIRST question you need
to ask: do they have a vision problem?
◼ Is their current level of visual skill adequate to allow them to function
successfully or is it getting in the way?
◼ 25% of students in grades K-6 have vision problems that are
serious enough to impede learning
◼ 80% of children with a learning disability have an undiagnosed
vision problem
VISION AND LEARNING
Children with disabilities often have unmet needs for vision care
Poor visual skills, by interfering with the process, can impede remedial efforts
Learning problems can decrease the quality of life, delay academic achievement, and reduce employment opportunities
Self-esteem and peer relationships can be negatively influenced
VISUAL ACUITY
◼ Visual acuity is just one aspect of good vision,
and it’s not even the most important!
◼ Acuity gives no information as to how much
effort is needed to see clearly, to use both
eyes together, or how much meaning is
obtained from visual input
VISUAL SYSTEM COMPONENTS
◼ Visual Efficiency
◼ Visual Acuity
◼ Eye Tracking
◼ Eye Focusing
◼ Eye Teaming
◼ Visual Information Processing
◼ Non-motor aspects of visual perception and cognition, and their
integration with motor, auditory, language, and attention systems
WHAT IF YOUR EYES JUMPED
AROUND LIKE THIS?
visionandlearning.org
WHAT IF YOUR EYES JUMPED
AROUND LIKE THIS?
visionandlearning.org
WHAT IF YOUR EYES JUMPED
AROUND LIKE THIS?
visionandlearning.org
WHAT IF YOUR EYES JUMPED
AROUND LIKE THIS?
visionandlearning.org
WHAT IF YOUR EYES JUMPED
AROUND LIKE THIS?
visionandlearning.org
VISUAL
EFFICIENCY:
EYE
TRACKING
Well-integrated eye movements allow for rapid and accurate shifting of the eyes along the lines of print in a book, quick and accurate shifts from desk to chalkboard
and good visual tracking in sports
Eye Movements:
Fixations: steady maintenance in one place
Pursuits: smooth following of a target
Saccades: jump eye movement
Students with tracking problems cannot control their eye movements during reading
SIGNS & SYMPTOMS OF POOR EYE TRACKING
◼ Moving head excessively when reading
◼ Skipping lines/loss of place
◼ Omitting and transposing words
◼ Use of finger or marker to keep place
◼ Difficulty copying from board
◼ Re-reading
◼ Difficulty hitting or catching a ball
HOW EASILY CAN YOU READ THIS PASSAGE?
VISUAL
EFFICIENCY: EYE
FOCUSING
• Eye Focusing is the visual skill needed to maintain clear images
and shift focus from near to far and back
• Visual focus is directly related to visual attention
• Poor eye focusing results in near work being more difficult because
it is out of focus
• Students with focusing problems often quit
• They have to work so hard to keep print clear that they just give up
SIGNS & SYMPTOMS OF POOR EYE FOCUSING
• Excessive blinking or rubbing eyes
• Holding things very close
• Complaints of burred vision
• Task avoidance
• Headaches when reading
• Eyes “hurt” or “tired”
• Slow reading speed
• Short attention span
• Daydreaming
• Fatigue
• Excessive time completing assignments or copying from board
HOW EASILY CAN YOU READ THIS PASSAGE?
visionandlearning.org
HOW EASILY CAN YOU READ THIS PASSAGE?
visionandlearning.org
HOW EASILY CAN YOU READ THIS PASSAGE?
visionandlearning.org
HOW EASILY CAN YOU READ THIS PASSAGE?
visionandlearning.org
VISUAL EFFICIENCY: EYE TEAMING
Eye teaming is the visual skill needed to
coordinate the eyes together effectively
Students with eye teaming problems fight double vision every time they read – even if they
see 20/20
They are only able to aim their eyes together
correctly for short periods of time
As their ability to accurately aim their
eyes breaks down, their eyes end up pointing at slighting different places
The result is a visual stain and eventually
blurred, scrambled, or double vision
VISUAL EFFICIENCY:
EYE TEAMING
SIGNS & SYMPTOMS OF POOR EYE TEAMING
• Double vision
• Words moving around on page
• Short attention span
• Headaches
• Closing or covering of one eye
• Excessive blinking
• Poor handwriting
• Reduced reading comprehension
• Difficulty catching/hitting a ball
VISUAL INFORMATION PROCESSING SKILLS
Visual Perception
◼ Cognitive skills to extract and organize visual
information from the environment, as well as
interpreting it to direct meaningful action
◼ Integrates with motor, auditory, language, and
attention systems
◼ Related to learning readiness and academic
achievement
Learning
◼ Acquiring information through experience and
storing information
◼ Learning facilitates the perceptual process since
the acquired and stored information is used as a
model against which the environmental
information is measured
VISUAL SPATIAL SKILLS
• Ability to understand directional concepts, both
internally and external visual space
• Awareness of one’s own position in space relative
to other objects
• Location of objects relative to each other
• Includes:
• Body knowledge and control
• Bimanual integration
• Important skills for:
• Balance and coordinated body movements
• Navigation in environment
• Following spatial directions
• Understanding orientation of alphanumeric
symbols
SIGNS & SYMPTOMS OF POOR VISUAL SPATIAL SKILLS
• Delayed development of gross motor skills
• Decrease coordination, balance and ball-playing skills
• Confusion of right and left
• Letter/number reversals
• Inconsistent directional attack when reading
• Inconsistent dominant handedness
• Difficulty in tasks requiring crossing of midline
VISUAL ANALYSIS SKILLS
• Processes for locating,
selecting, extracting,
analyzing, recalling and
manipulating relevant
information in the visual
environment
• Core skills for letter and
number recognition, sight
word vocabulary and
mathematical concepts
SIGNS & SYMPTOMS OF POOR VISUAL ANALYSIS SKILLS
• Delayed learning of the alphabet
• Frustration with letter and word recognition
• Difficulty performing basic math operations
• Difficulty in visual search-like tasks
• Difficulty determining what is significant from what is
insignificant
• Difficulty in spelling non-regular words
• Poor recognition of likenesses and differences
• Difficulty remembering proper sequences presented
visually
• Ignores details in visual tasks
• Can do several parts but not put together
• Stops work before finished or fixates on details
• Difficulty with visual tasks with more than one step
VISUAL DISCRIMINATION
VISUAL DISCRIMINATION
VISUAL FIGURE GROUND
VISUAL FIGURE GROUND
VISUAL MEMORY
VISUAL MEMORY
VISUAL MEMORY
VISUAL-MOTOR INTEGRATION
◼ The coordination of visual perceptual abilities and motor control
◼ Skill that allows us to use our eyes and body in a coordinated
and efficient way
◼ Gross motor: eye-body coordination
◼ Balance and coordination
◼ Sports performance
◼ Fine motor: eye-hand coordination
◼ Important for copying and writing
SIGNS & SYMPTOMS OF POOR VISUAL-MOTOR INTEGRATION
◼ Difficulty copying from the board
◼ Writing delays, mistakes, confusions
◼ Poor spacing of written work
◼ Difficulty maintaining written work on printed lines
◼ Misalignment of columns when doing math
◼ Can respond orally, but not produce answers in writing
◼ Excessive erasures
◼ Exaggerated paper rotations
◼ Awkward pencil grip
VISUAL-AUDITORY INTEGRATION
• The ability to link together visual information
with information heard
• Seeing a word and saying it out loud
• Hearing a word and writing it down
Signs & Symptoms
• Difficulty with sound-symbol associations
• Difficulty with spelling
• Difficulty learning the alphabet
• Difficulty reading phonetically
CENTRAL-PERIPHERAL & SENSORY INTEGRATION
◼ Central-Peripheral Integration
◼ Cannot fixate or look directly at an object
◼ Cannot use peripheral vision for awareness
◼ Sensory Integration
◼ Unable to attend to information heard and seen at the same time
◼ Overwhelmed easily with sensory stimuli
HOW WE READ
◼ To understand the problems we must first understand the
reading process
◼ Educators often use decoding (figuring out what the word
means) as the first step
◼ To figure out what a word means:
◼ Phonetic
◼ Context
◼ Sight words
◼ This is not the first step! It is actually step 4
◼ Good visual skills provide a solid foundation for learning
HOW WE READ
Step 1: Where is the word? (eye tracking)
Step 2: Aim the two eyes at the same point (eye teaming)
Step 3: Focus the two eyes to keep the word clear (eye focusing)
Step 4: Figure out what the word means (decoding)
If there are problems with steps 1-3 the child is ALREADY BEHIND.
READING COMPREHENSION
◼ We must take in the visual information and
decode it from the written word into a mental
image
◼ Memory and visualization are used to
constantly relate the information to what is
already known and to help make sense of what
is being read
HOW WE WRITE
◼ We start with an image in our mind and code
it into words
◼ At the same time, we control the movement
of the pencil while continually working to keep
the written material making sense
◼ Throughout all this, we focus our eyes and
move them together just as in the reading
process
VISUAL BEHAVIORS OF AUTISM SPECTRUM DISORDER
◼ Atypical gaze or gaze avoidance
◼ Extreme lateral gaze/side looking
◼ Visual inattention
◼ Poor visual awareness of surroundings
◼ Fascination with spinning objects, lights and
shadows, and bright, metallic objects
◼ Limited or no eye contact/visual inattention
◼ Eye pressing
◼ Hand flicking
◼ Light gazing
◼ Poor visual awareness of surroundings
VISUAL BEHAVIORS OF AUTISM SPECTRUM DISORDER
◼ Deficits in joint attention seem to be one of the most distinguishing characteristics
of young children with ASD
◼ Joint attention is a normal, spontaneously occurring behavior whereby the infant
shows enjoyment in sharing an object or event with another person by looking
back and forth between the two
◼ Visual curiosity can indicate a level of visual function and/or cognitive potential
◼ Functional visual information often translates into visual communication boards
◼ Ex: use of letters, spacing, size of details, color issues
◼ Research indicates correlations between visual skills and attentional deficits
WHERE TO REFER?
Patient
Optician
Ophthalmologist
Optometrist
OPTICIAN
◼ Technical practitioner who fits and dispenses glasses
◼ Determines the specifications of and orders frames and lenses
OPHTHALMOLOGIST
◼ “Medical and Surgical Experts”
◼ Diagnosis and treatment of eye diseases
◼ Performs surgical procedures
◼ Generally not trained in visual development,
processing, and function
OPTOMETRIST
◼ Primary Eye Care Provider
◼ Specialties within optometry
◼ Pediatrics
◼ Vision therapy
◼ Low Vision
◼ Ocular Disease
◼ Contact Lenses
DEVELOPMENTAL OPTOMETRIST
◼ Unique role to evaluate all aspects of vision
◼ Prescription glasses
◼ Contact lenses
◼ Eye health
◼ Visual efficiency
◼ Visual information processing
THE EYE EXAM
EYE EXAM: MODIFICATIONS
Objective measurements under less than ideal conditions are better
than no measurements
Precise testing conditions are not always as
important as adapting to get reliable responses
Start with tests that can be made fun, with no
pass/fail criteria obvious to the patient
Failure to get a response is an opportunity to try another approach or
different version of the test
Focus on the patient, not the stimulus• If a patient does not respond,
it might not mean he can’t see it, but that it is not of interest to him
Because an exam cannot be completed in one
appointment does not mean that it can never be
done
EYE EXAM: CASE HISTORY
• Intake forms and questionnaires on the patient’s medical and ocular history sent beforehand Preparation should begin before the patient enters the clinic
• What do the parents and patient expect from the evaluation? Exam goals?
• In patients with communication difficulties this may include observations from many professionals and the parents
• Children are often better at describing problems than expected – ask the child
Full exploration of symptoms
EYE EXAM: CASE HISTORY
◼ Information needed, if performed:
◼ Neuropsychological evaluation
◼ IEP evaluation/Psycho-educational evaluation
◼ Occupational therapy assessment
◼ Physical therapy assessment
◼ Speech and language assessment
◼ Behavioral assessment
EYE EXAM: CASE HISTORY
◼ Medications can have ocular side effects
◼ Anticonvulsants – blurred vision, dilated pupils, light sensitivity
◼ Antipsychotics – blurred vision, increased eye pressure, light sensitivity
◼ Antidepressants – blurred vision, dry eyes, eye focusing problems,
increased eye pressure
◼ Stimulants – blurred vision, eye focusing problems, dilated pupils
◼ Valium – blurred vision, double vision
EYE EXAM: PREPARING THE PATIENT
◼ The more the patient understands of what to expect, the
smoother the exam will go
◼ Send home a copy of the shapes used to test visual acuity
◼ The exam may require the patient to wear a patch or glasses
◼ If possible, have the patient practice wearing a patch and/or
glasses at home
◼ Tactile sensitivities
◼ Resistance to unfamiliar things
EYE EXAM:
PREPARING THE
PATIENT
◼ Read age/development appropriate books about eye exams at
home
◼ Send home a Social Story for the office
◼ Arrive early to tour the office
EYE EXAM: OBSERVATION OF THE PATIENT
◼ Wheelchairs are set up to contain, not always best for vision
◼ Mobility, gait, body posture and head position
◼ Under what postural conditions is the person most easily visual
◼ What posture indicates stress
◼ Interaction with people
◼ Under what conditions will they look away/look at you
◼ Visual curiosity / Intentional use of vision
◼ Can indicate a level of visual function and cognitive potential
EYE EXAM: VISUAL ACUITY TESTING
◼ What can the patient see?
◼ What is the visual potential?
◼ Adaptive positioning
◼ Isolate lines or individual letters/symbols
◼ Test different formats to probe ability and attention
EYE EXAM:
VISUAL ACUITY TESTING
EYE EXAM: COLOR VISION TESTING
EYE EXAM: DEPTH PERCEPTION TESTING
EYE EXAM: EYE MOVEMENT TESTING
EYE EXAM: EYE FOCUSING AND EYE
TEAMING TESTING
EYE EXAM: PRESCRIPTION MEASUREMENT
EYE EXAM: OCULAR HEALTH ASSESSMENT
EYE EXAM
◼ Be flexible in approach
◼ Sometimes there is more
than one way to get it done
◼ Set limits, but make sure
rules are understood
◼ Know when to quit
VISION TREATMENT
VISION
TREATMENT
◼ Vision services may:
◼ Prevent disability from becoming more severe
◼ Build on an individual’s strengths
◼ Maintain self-esteem
VISION TREATMENT
Do not let expectations modify what you do or suggest as treatment
01A small measurable improvement may relate to a significant benefit to the patient
02Some changes are small and slow in coming, but often the “ripple” effect” that vision care along with other therapies can provide is profound
03
PRESCRIBING GLASSES
• What are the patient’s visual demands
• What are the unmet visual needs
Glasses are considered for all patients
• Eye contact
• Posture
• Functional use of vision
Look for improvement in:
PRESCRIBING
GLASSES
Impact resistant lenses
Consider sensory issues
Consider a trial period with the prescription
Consider a partial prescription
Don’t fail to prescribe for reading because the patient doesn’t read
Glasses might be what was needed to get the patient interested in reading
PRESCRIBING
GLASSES
◼ http://www.specs4us.com
◼ Frames specially designed to
fit children and adults with
Down Syndrome and others
with special needs
◼ Shortened temples
◼ Extra wide frame fronts
◼ Lowered bridge
PRESCRIBING GLASSES
◼ Yoked prism
◼ Disrupt the visual system
◼ Change how you process visual information
◼ More comfortable visual experience
◼ Increased visual attention and awareness
◼ Improved peripheral awareness
◼ Improved ability to visually direct themselves
OCULAR SURGERY
Eye turn / Strabismus Surgery Prescription / Refractive Surgery
VISION THERAPY
Vision therapy is a sequence of activities prescribed by an optometrist that builds visual skills and the ability to take in, understand and use visual information
Vision therapy can be done at any age
Individualized to fit the visual needs of each patient
VISION THERAPY
Vision therapy cannot be done “to” anyone
Must have participation for full benefit
Need to consider: • Is the problem amenable to
therapy?
• Are they a good candidate for vision therapy?
• Is there a support system to help maintain commitment?
VISION
THERAPY
◼ Vision Therapy is most effective when the patient can:
◼ Be actively engaged
◼ Maintain some level of cognitive and visual
attention
◼ Have the ability to follow verbal instructions or
copy demonstrated behavior
VISION
THERAPY
◼ Many factors specific to the patient must be taken into
account:
◼ Feasibility
◼ Motivation
◼ Realistic goals and expectations must be determined
◼ The desire is for progress, not perfection
VISION THERAPY
◼ Know the unmet visual
needs and goals
◼ Consider brief sessions for
short attention spans
◼ Have many activities
working on the same visual
skill – only a short time on
each activity
◼ Know how the disability
may affect therapy
VISION THERAPY
◼ Choose activities that will
maintain interest
◼ Can modify cognitive or physical
demands
◼ When using toys must be aware
if they like the toy or if they are
fixated on the toy
◼ Use activities with a feedback
mechanism
◼ Integrate with other therapies if
needed
VISION THERAPY
Treatment to improve visual efficiency and visual information processing, thus allowing the patient to be more responsive to educational instruction
Treatment for vision problems • Does not correct a learning disability
• Vision problems can contribute to learning problems
You don’t do vision therapy forever • The brain is constantly changing and adapting
• Changes are made in the brain – visual control occurs in the brain
VISION THERAPY
◼ The activities gradually change and become more complex as visual skills develop until they become proficient and automatic
◼ Vision therapy is highly successful, supported by decades of research and the testimony of countless patients whose lives have been changed
VISION THERAPY
◼ We aren’t working on the eyes, we
are working on the brain
◼ Step 1: teaching a new way of seeing
◼ Step 2: practicing new schemes
◼ Step 3: making the new way of seeing
automatic
SCHOOL
ACCOMMODATIONS
Move student to the front of the classroom
Reduce conflicting peripheral stimuli
Minimize board-to-desk copying
Use a straight edge, marker or finger to follow along with text
Reduce written work
Shorter visual work periods
Extended time on tests
Make sure lines on the paper are easily visible
Enlarge test used for reading
MULTIDISCIPLINARY CARE
◼ Evaluation must translate into practical applications
◼ All treatments communicated with the primary care physician and specialists
◼ Team members work together to provide early diagnosis, intervention and
treatment that maximizes each patient’s quality of life
◼ Treat optically, functionally and medically
SUMMARY
◼ There is a great deal to offer all patients
◼ Exam techniques can be modified
◼ Work to identify and treat the unmet visual
needs
◼ Success involves setting priorities and working
with other members of the care team
◼ With proper care and education, every individual
can reach their full potential