Investigation of accommodative and binocular function in dyslexia

Routine binocular examination of young Taiwanese adults as a predictor of visual behavior performance

BACKGROUND

Morgan and Scheiman's Optometric Extension Program (OEP) expected binocular vision findings have longstanding use in optometry. With technological advances, the demands and standards of binocular function have changed. This study aimed to investigate which binocular visual functions can effectively predict visual behavior performance.

METHODS

Participants aged 15-24 years were recruited from two colleges and two universities. After completing the CSMU-Visual Behavioral Performance questionnaire (CSMU-VBP, with four components: near work, visual perception, visual comfort, and whole-body balance), participants were divided into symptomatic and asymptomatic groups based on questionnaire findings (cutoff: < 12 vs. ≥ 12 symptoms). Then a 24-step binocular visual examination was undertaken. Data were analyzed with one-sample, Student's, and paired t-tests. Additionally, receiver operating characteristic analysis was used to determine the predictors of binocular visual function required for near work, visual perception, visual comfort, and body balance dimensions.

RESULTS

Among 308 participants, 43 (14%) and 265 (86%) were symptomatic and asymptomatic, respectively. Among the 46 participants with abnormal binocular vision, 36 (78%) reported that they had no obvious symptoms. The commonest dysfunctions were accommodative excess and convergence excess. Most of the binocular visual findings significantly diverged from traditional normal values: amplitude of accommodation, as well as base-in prism to break and recovery points at distance were higher than traditional normal values, whereas others were lower than traditional normal values. Total CSMU-VBP scores indicated that the asymptomatic and symptomatic groups had significant differences in DBO recovery (t = 2.334, p = 0.020) and BAF (t = 1.984, p = 0.048). Receiver operating characteristic curve analysis yielded the following binocular visual functional cutoff points: near work (DBO blur < 7, DBO recovery < 5.5), visual perception (MAF < 10.5, BAF < 10.25), visual comfort (DLP <  - 2.25, DBI break > 11.5, NBI blur > 15, NBI break > 17.5, NBI recovery > 13, NPC < 5.75), and body balance (NFD_H >  - 0.5, gradient AC/A [minus] > 2.25, NPC < 4.75).

CONCLUSIONS

The mean values of binocular visual function among young Taiwanese adults were statistically different from traditional normative values. Further research is required to confirm whether these findings reflect impaired binocular vision or stringent criteria. Assessments of binocular visual function, especially binocular accommodation sensitivity, are crucial in routine optometric examination.

Randomised controlled trial of an accommodative support lens designed for computer users

PURPOSE

Accommodative support (AS) lenses are a low add progressive addition spectacle lens designed to ease symptoms in computer vision syndrome (CVS). The study aims to investigate if (1) AS lenses improve CVS symptoms; (2) binocular/accommodative functions predict a benefit from AS lenses and (3) wearing AS lenses for six months impacts on binocular/accommodative functions.

METHODS

Pre-presbyopic adults with symptoms of CVS (Computer Vision Syndrome Questionnaire, CVS-Q^© , score ≥ 6) were randomly allocated to wear AS lenses or control single vision (SV) lenses. The CVS-Q^© and a battery of optometric tests were applied at baseline and after three and six months. Participants and researchers were masked to participant group. After six months, the SV group were unmasked and changed to AS lenses and one week later asked to choose which they preferred.

RESULTS

The change in CVS-Q^© scores from baseline to six months did not differ significantly in the two groups. At the end of the one week period, when the control group wore the AS lenses, control group participants were significantly more likely to prefer AS lenses to SV lenses. No optometric functions correlated with the benefit from AS lenses. AS lenses did not have any adverse effects on binocular or accommodative function.

CONCLUSIONS

In pre-presbyopic adults, there was no greater improvement in CVS-Q^© scores in the group wearing AS lenses than in the control group. No adverse effects on optometric function (including accommodation) are associated with wearing AS lenses.

Differential diagnosis of vergence and saccade disorders in dyslexia

Previous studies suggest vergence and saccade abnormalities in dyslexic adolescents. However, these studies are mainly clinically based and do not provide objective measurements of eye movements, but rather subjectively evaluate vergence using haplosopic conditions in which the two eyes are dissociated (via polarizers, prisms, or intermittent spectacles). Other studies have identified deficits with binocular coordination during reading in dyslexics. Yet, there are few studies that provide objective measurements of eye movements in the dyslexic population to help provide more information regarding if these deficits could be due to an intrinsic motor problem or if they are the consequence of poor reading. 47 dyslexic adolescents (18 female, 29 male; mean age 15.5) and 44 non-dyslexic adolescents (22 female, 22 male; mean age 14.8) wore a head-based eye tracker (PupilCore, Pupil Labs, Berlin) which recorded wide angle saccade and vergence eye movements at 200 Hz. Tests were run using the REMOBI device, which produced a saccade or vergence audiovisual target. Analysis of eye movements was performed with lab-developed software, AIDEAL. The results showed statistically significant abnormalities in vergence and saccades. In vergence, dyslexics displayed a reduced amplitude of the visually driven portion of convergence and a longer duration in the initial phase of divergence. In saccades, dyslexic adolescents demonstrated slower saccades in both directions. They also had an increased disconjugate drift in the first 80 or 160 ms following saccades to the right, suggesting poor binocular coordination. For both vergence and saccades, the peak velocity and time to peak velocity was higher and earlier, respectively, in non-dyslexics compared to dyslexics; yet the average velocity of both movements was lower in dyslexics. Thus, these results indicate peculiar velocity profiles in dyslexics, particularly a slow deceleration phase in both vergence and saccades. The study provides an objective method to diagnose vergence and saccade abnormalities while viewing targets in the real three-dimensional space in a dyslexic population. Vergence abnormalities are demonstrated to be a problem in dyslexics, occurring independently from reading. We hypothesize these disconjugate drifts following saccades are the result of slow vergence capacity. Rehabilitation programs, such as those using REMOBI, should aim to target these deficits in vergence velocity, as this has been shown to improve binocular control.

Sources of error in clinical measurement of the amplitude of accommodation

Measurement of the amplitude of accommodation is established as a procedure in a routine optometric eye examination. However, clinical methods of measurement of this basic optical function have several sources of error. They are numerous and diverse, and include depth of focus, reaction time, instrument design, specification of the measurement end-point, specification of the reference point of measurement, measurement conditions, consideration of refractive error, and psychological factors. Several of these sources of inaccuracy are composed of multiple sub-sources, and many of the sub-sources influence the common methods of measurement of amplitude of accommodation. Consideration of these sources of measurement error casts doubt on the reliability of the results of measurement, on the validity of established normative values that have been produced using these methods, and on the value of reports of the results of surgery designed to restore accommodation. Clinicians can reduce the effects of some of the sources of error by modifying techniques of measurement with existing methods, but a new method may further improve accuracy.

Frequency of Visual Deficits in Children With Developmental Dyslexia

Importance

Developmental dyslexia (DD) is a specific learning disability of neurobiological origin whose core cognitive deficit is widely believed to involve language (phonological) processing. Although reading is also a visual task, the potential role of vision in DD has been controversial, and little is known about the integrity of visual function in individuals with DD.

Objective

To assess the frequency of visual deficits (specifically vergence, accommodation, and ocular motor tracking) in children with DD compared with a control group of typically developing readers.

Design, Setting, and Participants

A prospective, uncontrolled observational study was conducted from May 28 to October 17, 2016, in an outpatient ophthalmology ambulatory clinic among 29 children with DD and 33 typically developing (TD) children.

Main Outcomes and Measures

Primary outcomes were frequencies of deficits in vergence (amplitude, fusional ranges, and facility), accommodation (amplitude, facility, and accuracy), and ocular motor tracking (Developmental Eye Movement test and Visagraph eye tracker).

Results

Among the children with DD (10 girls and 19 boys; mean [SD] age, 10.3 [1.2] years) and the TD group (21 girls and 12 boys; mean [SD] age, 9.4 [1.4] years), accommodation deficits were more frequent in the DD group than the TD group (16 [55%] vs 3 [9%]; difference = 46%; 95% CI, 25%-67%; P < .001). For ocular motor tracking, 18 children in the DD group (62%) had scores in the impaired range (in the Developmental Eye Movement test, Visagraph, or both) vs 5 children in the TD group (15%) (difference, 47%; 95% CI, 25%-69%; P < .001). Vergence deficits occurred in 10 children in the DD group (34%) and 5 children in the TD group (15%) (difference, 19%; 95% CI, -2.2% to 41%; P = .08). In all, 23 children in the DD group (79%) and 11 children in the TD group (33%) had deficits in 1 or more domain of visual function (difference, 46%; 95% CI, 23%-69%; P < .001).

Conclusions and Relevance

These findings suggest that deficits in visual function are far more prevalent in school-aged children with DD than in TD readers, but the possible cause and clinical relevance of these deficits are uncertain. Further study is needed to determine the extent to which treating these deficits can improve visual symptoms and/or reading parameters.

Accommodation, Convergence, and Stereopsis in Dyslexic Schoolchildren

BACKGROUND

Previous studies have shown a correlation between reading problems and binocular function, but few studies have assessed visual skills in dyslexic students, particularly in Iranian Farsi-language students. This study is aimed to determine some of the binocular functions of dyslexic children and compare it with a group of age, sex, and social class-matched control children.

MATERIALS AND METHODS

We conducted a case-control study on 27 dyslexic children and 40 age, sex, and social class-matched control children (all between 7 and 13 years old) in grades one to six. This study was performed at three elementary schools in Tehran, Iran. Monocular and binocular near point of accommodation (NPA) were measured using the subjective push-up method, near point of convergence (NPC) was determined using the standard push-up technique, and stereoacuity was tested with the Titmus stereotypes in all of the children.

RESULTS

Mean NPA of the right eye was 6.90 cm in dyslexic group and 5.98 cm in the control group (P = 0. 003). Mean NPA of the left eye in dyslexic children was 7.32 cm and in the control group was 6.23 cm (P = 0. 003). Mean binocular NPA was 6.66 cm in dyslexic and 6 cm in the control group (P = 0. 049). However, mean NPC (P = 0.33) and mean stereoacuity (P = 0.785) did not differ significantly between the dyslexic and control groups.

CONCLUSION

Our findings showed a reduced monocular and binocular NPA in dyslexic children so that this function should be assessed by an optometric clinician in children with dyslexia.

A New Dyslexia Reading Method and Visual Correction Position Method

Pediatricians and educators may interact daily with several dyslexic patients or students. One dyslexic author accidently developed a personal, effective, corrective reading method. Its effectiveness was evaluated in 3 schools. One school utilized 8 demonstration special education students. Over 3 months, one student grew one third year, 3 grew 1 year, and 4 grew 2 years. In another school, 6 sixth-, seventh-, and eighth-grade classroom teachers followed 45 treated dyslexic students. They all excelled and progressed beyond their classroom peers in 4 months. Using cyclovergence upper gaze, dyslexic reading problems disappeared at one of the Positional Reading Arc positions of 30°, 60°, 90°, 120°, or 150° for 10 dyslexics. Positional Reading Arc on 112 students of the second through eighth grades showed words read per minute, reading errors, and comprehension improved. Dyslexia was visually corrected by use of a new reading method and Positional Reading Arc positions.

A systematic review of controlled trials on visual stress using Intuitive Overlays or the Intuitive Colorimeter

Claims that coloured filters aid reading date back 200 years and remain controversial. Some claims, for example, that more than 10% of the general population and 50% of people with dyslexia would benefit from coloured filters lack sound evidence and face validity. Publications with such claims typically cite research using methods that have not been described in the scientific literature and lack a sound aetiological framework. Notwithstanding these criticisms, some researchers have used more rigorous selection criteria and methods of prescribing coloured filters that were developed at a UK Medical Research Council unit and which have been fully described in the scientific literature. We review this research and disconfirm many of the more extreme claims surrounding this topic. This literature indicates that a minority subset of dyslexics (circa 20%) may have a condition described as visual stress which most likely results from a hyperexcitability of the visual cortex. Visual stress is characterised by symptoms of visual perceptual distortions, headaches, and eyestrain when viewing repetitive patterns, including lines of text. This review indicates that visual stress is distinct from, although sometimes co-occurs with, dyslexia. Individually prescribed coloured filters have been shown to improve reading performance in people with visual stress, but are unlikely to influence the phonological and memory deficits associated with dyslexia and therefore are not a treatment for dyslexia. This review concludes that larger and rigorous randomised controlled trials of interventions for visual stress are required. Improvements in the diagnosis of the condition are also a priority.

Visual performance and the use of colored filters in children who are deaf

PURPOSE

To assess visual performance and the effects of color overlays on reading in children who were deaf and children who could hear.

METHODS

Thirty-one children who were deaf (mean [± SD] age, 14 [± 1.99] years) and 39 children who could hear (mean [± SD] age, 13.58 [± 3.09] years) underwent an optometric examination with specific emphasis on near vision. Participants chose an overlay with color optimal for clarity and comfort and completed the Wilkins Rate of Reading Test both with and without an overlay of this color. Nineteen of the participants who were deaf were retested a year later with a modified rate of reading test that used only words that can readily be signed. This modified rate of reading test was repeated 1 week after its first administration.

RESULTS

Participants who were deaf had greater ametropia (p = 0.003), a more distant near point of convergence (p = 0.002), and reduced amplitude of accommodation (p < 0.001) compared with normal-hearing participants. All the children who were deaf chose a color overlay, with 45% choosing a yellow overlay, which increased the rate of reading by 18%. Only 66% of the participants who could hear chose an overlay, and it had no effect on reading speed. With the modified reading test, 7 of 19 (37%) again chose yellow. These participants showed a 9% increase in reading speed with the yellow overlay, which was repeatable 1 week later. The remainder showed no increase in rate of reading with their chosen overlay.

CONCLUSIONS

An eye examination of children who are deaf needs to include a comprehensive assessment of near visual function so that deficiencies of amplitude of accommodation, near point convergence, and ametropia can be treated. A yellow overlay improved reading speed in the participants who were deaf, whereas other colors did not, a finding at variance with earlier work on hearing populations.

Can vergence training improve reading in dyslexics?

BACKGROUND

Dyslexia affects 5%-8% of the population of the Western world. While reading, different eye movements are required. Compared to other persons, dyslexics have more and longer fixations, shorter saccade amplitude, a higher percentage of regression, and more fixation disparity when reading. In non-reading situations, dyslexics do not have more binocular problems than others. The aim of the present study was to investigate whether computerized orthoptic vergence training could improve reading ability for dyslexic children.

METHODS

The study was conducted at Ängkärrskolan, Solna, an elementary school exclusively for dyslexic children. Twelve subjects, aged 13-14 years, were trained with RetCorr, a computerized vergence training program. Reading speed was assessed before and after treatment. The results were compared with an age-matched control group.

RESULTS

The dyslexic subjects conducted on average 11.75 sessions (±2.53 SD) of orthoptic training over a 5-week period. On average, the number of words read per minute before training were 87.83 (±16.80 SD) and after training 95.58 words (±18.08 SD). The difference was statistically significant (p=0.0066). In the control group, the change was from 85.00 (±19.68 SD) words to 89.37 words (±19.71 SD) over the same time period. This difference was not significant (p=0.1235).

DISCUSSION

Most scientists agree that dyslexia is mainly a phonological impairment. Nevertheless, the results show that vergence treatment might help dyslexics. Larger studies are required to provide guidance in this area.

Evaluation of aspects of binocular vision in children with dyslexia

BACKGROUND

Prevalence of dyslexia is 5%-10% of the population. Opinions differ on how binocular function affects dyslexia. The aim of the present study was to evaluate the binocular function in dyslexic children and compare it with a group of age-matched control children.

METHODS

The study was performed at Ängkärrskolan and at Kungsholmen elementary schools in Stockholm, Sweden. Sixty-three children with dyslexia and 60 control children between fourth and ninth grade participated. Monocular and binocular visual acuity, refractive error, best corrected visual acuity at distance and near, near point of convergence, amplitude of accommodation, stereopsis, phorias, and fusional reserves were evaluated in all of the children.

RESULTS

The results show that there was no difference in the visual functions tested except for the amplitude of accommodation, which was found to be reduced both monocularly and binocularly in the dyslexic children.

CONCLUSION

This study showed that only the amplitude of accommodation seems to differ in children with dyslexia as compared with the control children; however, the ability to accommodate was still good and is unlikely to hamper reading and learning ability. The results therefore support that the recent findings of binocular deficits in dyslexic children are a result of the phonological deficit of dyslexia and not an underlying cause of dyslexia.

The effect of spectral filters on reading speed and accuracy following stroke

Purpose

The aim of the study was to determine the effect of optimal spectral filters on reading performance following stroke.

Methods

Seventeen stroke subjects, aged 43–85, were considered with an age-matched Control Group (n = 17). Subjects undertook the Wilkins Rate of Reading Test on three occasions: (i) using an optimally selected spectral filter; (ii) subjects were randomly assigned to two groups: Group 1 used an optimal filter, whereas Group 2 used a grey filter, for two-weeks. The grey filter had similar photopic reflectance to the optimal filters, intended as a surrogate for a placebo; (iii) the groups were crossed over with Group 1 using a grey filter and Group 2 given an optimal filter, for two weeks, before undertaking the task once more. An increase in reading speed of >5% was considered clinically relevant.

Results

Initial use of a spectral filter in the stroke cohort, increased reading speed by ∼8%, almost halving error scores, findings not replicated in controls. Prolonged use of an optimal spectral filter increased reading speed by >9% for stroke subjects; errors more than halved. When the same subjects switched to using a grey filter, reading speed reduced by ∼4%. A second group of stroke subjects used a grey filter first; reading speed decreased by ∼3% but increased by ∼4% with an optimal filter, with error scores almost halving.

Conclusions

The present study has shown that spectral filters can immediately improve reading speed and accuracy following stroke, whereas prolonged use does not increase these benefits significantly.

Ocular dominance stability and reading skill: a controversial relationship

PURPOSE

Evidence is mixed concerning the relationship between stability of ocular dominance and reading deficits. Contrasting results may be due to the use of different tests of dominance, different samples of readers, and different scoring methods. The aim of this study was to investigate the relationship among ocular dominance, general visual abilities, and reading performance, and to evaluate the consistency and reliability of different tests of ocular dominance and the effects of different types of eye dominance scoring.

METHODS

In a group of young adults, we measured: (a) main optometric parameters; (b) reading time and accuracy; and (c) ocular dominance in two sighting and four motor tests. Dominance was determined using different scoring methods (relative, absolute, and binary scores).

RESULTS

All dominance tests showed good levels of internal reliability. Sighting tests were consistent regardless of the scoring method, and all participants had stable dominance. Three of four motor tests were moderately consistent when dominance was measured with relative scores but not when it was measured with absolute or binary scores. No relationship was found between stability of dominance and reading performance, regardless of the type of test or scoring method. No systematic pattern of correlation was found between binocular vision variables and dominance measures.

CONCLUSIONS

Choosing the type of motor test to measure ocular dominance is crucial, because the level of consistency among tests is low to moderate. Furthermore, motor tests were not correlated with reading performances. Present results suggest caution when trying to link reading difficulties with specific profiles of ocular dominance.

Learning disabilities, dyslexia, and vision

Learning disabilities constitute a diverse group of disorders in which children who generally possess at least average intelligence have problems processing information or generating output. Their etiologies are multifactorial and reflect genetic influences and dysfunction of brain systems. Reading disability, or dyslexia, is the most common learning disability. It is a receptive language-based learning disability that is characterized by difficulties with decoding, fluent word recognition, rapid automatic naming, and/or reading-comprehension skills. These difficulties typically result from a deficit in the phonologic component of language that makes it difficult to use the alphabetic code to decode the written word. Early recognition and referral to qualified professionals for evidence-based evaluations and treatments are necessary to achieve the best possible outcome. Because dyslexia is a language-based disorder, treatment should be directed at this etiology. Remedial programs should include specific instruction in decoding, fluency training, vocabulary, and comprehension. Most programs include daily intensive individualized instruction that explicitly teaches phonemic awareness and the application of phonics. Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities. Because they are difficult for the public to understand and for educators to treat, learning disabilities have spawned a wide variety of scientifically unsupported vision-based diagnostic and treatment procedures. Scientific evidence does not support the claims that visual training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, "training" glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate.

Binocular function in school children with reading difficulties

INTRODUCTION

Prior findings suggest that poor readers tend to have poor binocular vision skills, but data on the binocular abilities of children with poor reading skills are lacking. Our aim was to characterize distance and near horizontal heterophoria, distance and near horizontal fusional vergence ranges, accommodative convergence/accommodation (AC/A) ratio, near point of convergence, and stereopsis in poor-reading school-age children without dyslexia selected from a non-clinical population.

METHODS

We conducted a cross-sectional study on 87 poor readers and 32 control children (all 8-13 years of age) in grades three to six recruited from eleven elementary schools in Madrid, Spain. With best spectacle correction in each subject, distance and near horizontal heterophoria measurements were obtained using the von Graefe technique, distance and near horizontal fusional vergence ranges were obtained using Risley rotary prisms, the AC/A ratio was measured using the gradient method, near point of convergence (NPC) was evaluated by the standard push-up technique using a transilluminator, and stereoacuity was tested with the Randot stereotest.

RESULTS

Mean distance base-in break and base-in recovery values were nearly 2 Delta lower (p < 0.01) in the poor readers than those recorded in the control group. However, mean distance base-out vergences (blur, break and recovery), mean distance and near horizontal heterophoria, mean near horizontal fusional vergence ranges, mean AC/A ratio, mean near point of convergence (NPC), and mean stereoacuity did not differ significantly between the poor readers and controls.

CONCLUSIONS

This study provides information on the binocular ability of children with poor reading skills but without dyslexia. Our findings suggest reduced distance base-in break and base-in recovery, such that distance fusional vergence ranges should always be assessed in children who complain of reading difficulties.

Accommodative function in school children with reading difficulties

BACKGROUND

Prior findings suggest correlation between reading problems and accommodative function, but few studies have assessed accommodation in children with poor reading skills. Our aim was to characterize monocular accommodative amplitude, relative accommodation and binocular accommodative facility in a population of healthy, non-dyslexic primary school children with reading difficulties.

METHODS

We conducted a cross-sectional study on 87 poor readers and 32 control children (all between 8 and 13 years of age) in grades three to six recruited from 11 elementary schools in Madrid, Spain. In each subject with best spectacle correction, negative relative accommodation (NRA) and positive relative accommodation (PRA) were measured using a phoropter, monocular accommodative amplitude (MAA) was determined using the minus lenses method, and binocular accommodative facility (BAF) was measured using the Bernell Acuity Suppression Slide (VO/9) and a +/- 2.00 D accommodative demand for a period of 1 minute.

RESULTS

Monocular accommodative amplitude was significantly lower (p < 0.001) in the group of poor readers (right eye 9.1 D +/- 2.3, left eye 9.0 D +/- 2.3) than in the control group (right eye 10.5 D +/- 1.7, left eye 10.5 D +/- 1.7). Binocular accommodative facility values were significantly lower (p < 0.05) in the poor readers (4.9 cpm +/- 3.1) than controls (6.3 cpm +/- 2.9). Negative and positive relative accommodation values were similar in both groups of children.

CONCLUSIONS

This study provides data on the accommodative capacity of a population of children with reading difficulties. Our findings suggest a reduced monocular accommodative amplitude and binocular accommodative facility, such that this function should be assessed by an optometric clinician in children whose reading level is below average.

Gender differences in early accommodation and vergence development

A remote haploscopic photorefractor was used to assess objective binocular vergence and accommodation responses in 157 full-term healthy infants aged 1-6 months while fixating a brightly coloured target moving between fixation distances at 2, 1, 0.5 and 0.33 m. Vergence and accommodation response gain matured rapidly from 'flat' neonatal responses at an intercept of approximately 2 dioptres (D) for accommodation and 2.5 metre angles(MA) for vergence, reaching adult-like values at 4 months. Vergence gain was marginally higher in females (p = 0.064), but accommodation gain (p = 0.034) was higher and accommodative intercept closer to zero (p = 0.004) in males in the first 3 months as they relaxed accommodation more appropriately for distant targets. More females showed flat accommodation responses (p = 0.029). More males behaved hypermetropically in the first two months of life, but when these hypermetropic infants were excluded from the analysis, the gender difference remained. Gender differences disappeared after three months. Data showed variable responses and infants could behave appropriately and simultaneously on both, neither or only one measure at all ages. If accommodation was appropriate (gain between 0.7 and 1.3; r(2) > 0.7) but vergence was not, males over- and under-converged equally, while the females who accommodated appropriately were more likely to overconverge (p = 0.008). The apparent earlier maturity of the male accommodative responses may be due to refractive error differences but could also reflect gender-specific male preference for blur cues while females show earlier preference for disparity, which may underpin the earlier emerging, disparity dependent, stereopsis and full vergence found in females in other studies.

Monovision: a review

In presbyopia, patients can no longer obtain clear vision at distance and near. Monovision is a method of correcting presbyopia where one eye is focussed for distance vision and the other for near. Monovision is a fairly common method of correcting presbyopia with contact lenses and has received renewed interest with the increase in refractive surgery. The present paper is a review of the literature on monovision. The success rate of monovision in adapted contact lens wearers is 59-67%. The main limitations are problems with suppressing the blurred image when driving at night and the need for a third focal length, for example with computer screens at intermediate distances. Stereopsis is impaired in monovision, but most patients do not seem to notice this. These limitations highlight the need to take account of occupational factors. Monovision could cause a binocular vision anomaly to decompensate, so the pre-fitting screening should include an assessment of orthoptic function. Various methods have been used to determine which eye should be given the distance vision contact lens and the literature on tests of ocular dominance is reviewed. It is concluded that tests of blur suppression are most likely to be relevant, but that ocular dominance is not fixed but is rather a fluid, adaptive, phenomenon in most patients. Suitable patients can often be given trial lenses that allow them to experiment with monovision in real world situations and this can be a useful way of revealing the preferred eye for each distance. Of course, no patient should drive or operate machinery until successfully adapted to monovision. Surgically induced monovision is less easily reversed than contact lens-induced monovision, and is only appropriate after a successful trial of monovision with contact lenses.

The Near Mallett Unit Foveal Suppression Test: a cross-sectional study to establish test norms and relationship with other optometric tests

When the binocular system comes under prolonged stress in decompensated heterophoria, a small suppression area can develop at the fovea. This foveal suppression (FS) may be an adaptation to eliminate symptoms. The near Mallett unit (NMU) is a hand-held instrument that contains a binocular status test for detecting and quantifying FS. We measured FS in a cross-sectional study of 131 patients to investigate the normal range of responses. A ratio scoring method was devised which considers the number of letters read with dichoptic viewing when binocularly fused (b) and under monocular (m) conditions, using the formula 100 x (m - b)/m. The 95th percentile value of the FS ratios was calculated as the limit of the normal range and this gave a value for the right eye (RE; 33%), left eye (LE; 43%) and total (38%). This result shows that statistically significant FS occurs when a patient can read approximately one line further in the test monocularly, compared to under fused dichoptic conditions. A statistically significant correlation was found between absolute values of horizontal aligning prism (associated heterophoria on the NMU) and FS ratio. Some limitations of the FS test and unexpected results became apparent during our research and an abnormal result on the test does not always indicate a binocular vision anomaly. Nonetheless, we feel that the test can provide useful information when the results are taken in the context of other clinical tests. Our results are used to develop recommendations and clinical guidelines for using the FS test, and to make suggestions for improvements in future designs of the test.

Attention, dyslexia, and the line-motion illusion

Dyslexic readers have been found to have a reduced line-motion illusion. This has been interpreted as evidence for an attention deficit of magnocellular origin. We show that this interpretation has severe problems: 1) to link reduced line-motion illusion to attention overlooks other factors, 2) to link the line-motion illusion specifically to the magnocellular system is problematic because the illusion can be obtained with isoluminant stimuli, 3) reduced illusory motion in dyslexic individuals may reflect sensory deficits, and 4) to link dyslexia specifically to the magnocellular system is in general problematic.

Evidence for frequent divergence impairment in French dyslexic children: deficit of convergence relaxation or of divergence per se?

AIM

There is a controversy as to whether dyslexic children present visuo-motor disabilities such as vergence and accommodative problems assessed with orthoptic tests. The purpose of this study is to re-examine this issue in a large population of children.

METHODS

Extensive orthoptic evaluation was made in 57 dyslexic and 46 non-dyslexic ("normal") age-matched children. Convergence and divergence capacities were evaluated at two distances (30 cm and 400 cm).

RESULTS

Binocular vision measured with stereo-acuity tests was normal in dyslexics. In contrast, the near point of convergence was significantly more remote in dyslexics; most importantly, divergence at both far and near distance was significantly more reduced in dyslexics (median value 4 pD and 10 pD, respectively, at far and near) than in "normals" (median value 6 pD and 12 pD, at far and near).

CONCLUSION

The existence of the divergence deficit at far distance indicates the presence of deficit of divergence per se, independently from convergence and accommodation relaxation. This result is novel and corroborated by physiological studies indicating distinct control of convergence and divergence, both at the cortical and subcortical premotor level. We conclude that vergence deficits are frequently present in dyslexics, and that dyslexics should be re-educated; training should address distinctively convergence and divergence subsystems.

Use of the Hermann grid illusion in the measurement of contrast perception in dyslexia

We measured contrast thresholds for perception of the Hermann grid illusion, using different contrast polarities and mean luminances, in dyslexics and non-dyslexics. Both groups of subjects gave significantly lower thresholds with grids having dark squares and light paths, but there was no significant threshold difference between groups. Perceived strength of illusion was also measured in grids at suprathreshold contrast levels. Dyslexics perceived the illusion to be significantly stronger than non-dyslexics when the grid had light paths and low luminance.

Smooth pursuit eye movements are associated with phonological awareness in preschool children

Phonological awareness is strongly related to reading ability, but reports are more conflicting concerning the association of high level oculomotor skills with reading. Here, we show that phonological awareness is specifically associated with the ability to perform smooth pursuit eye movements in preschool children. Two large independent samples of preschool children (n=838 and n=732) aged 5-6.4 years, without history of neurological disorder, were examined by school medical doctors for visual and oculomotor problems. Nineteen percent of the children in the first sample and 14% in the second failed at the clinical evaluation of smooth pursuit eye movements, and 17 and 15%, respectively, presented another visual or oculomotor problem. Ten short cognitive tests were performed by the same children. Visual and oculomotor problems other than a failure on smooth pursuit were not consistently related to the cognitive tasks, with one exception, the visual recognition of letters. Children who failed at smooth pursuit obtained lower scores at a number of cognitive tasks, and especially phonological awareness tasks and copy of visually presented trajectories. Poor working memory and/or failure of anticipation during the tracking of a visual or auditory stimulus related to frontal cortex immaturity may explain these associations in preschool children.

Vision screening for children: current trends, technology, and legislative issues

PURPOSE OF REVIEW

The purpose of this review is to examine current trends in vision screening for children.

RECENT FINDINGS

Literature within the past year regarding children's vision screening has been dominated by clinical validation studies of autorefractors or photoscreeners that allow the detection of amblyogenic refractive errors, misalignment of the eyes, or media opacities. New technologies reported include wave-front analysis for amblyogenic factors and a visual evoked potentials-based screening tool for the preverbal child. Studies evaluating the goals of the screening program, the target population, and the physical limitations of the screening environment have prompted multipronged or hybrid studies designed to more accurately detect vision problems, particularly in the preschool child, in whom cooperation and cognitive development affect reliability of results. State and federal legislation in the United States has been proposed or adopted to regulate and partially fund pediatric vision screening and comprehensive examinations.

SUMMARY

Through improvements and new developments in technology, study design, the efforts of organized medicine, and legislative initiatives, vision screening for children continues toward the goal of bringing all children with eye disease or vision problems to treatment in a timely fashion.

Vision Health Care Providers?? Attitudes and Experiences with Preschool Vision Screening in Ontario

PURPOSE

The validity of preschool vision screening has been questioned in the light of the World Health Organization's criteria for determining the validity of screening programs. However, recommendations toward preschool screening have been made by a number of organizations. Given the contrasting views of screening, the purpose of this study was to examine visual health care provider experiences and attitudes toward preschool screening.

METHOD

Optometrists, public health administrators, pediatric ophthalmologists, and orthoptists were surveyed about opinions of, recommendations for, and experiences with preschool vision screening in Ontario. The survey focused on four areas, including general opinion of preschool screening, screening standards and practices, provider experience with preschool screening, and barriers to preschool screening. In addition, survey responses were broken down by regional access to health care.

RESULTS

Overall, strong support for preschool vision screening and movement toward standardization of screening practice was found among all surveyed groups. Although support for vision screening in low health care access areas was strong, providers estimated that parent compliance to screening was weaker in low access areas. Providers also reported considerable variability in vision screening practices. In addition, although the majority of providers had been involved in a screening program, the majority was no longer involved because of lack of program organization, structure, and funding. Lack of sufficient funding, public education, organization of screening, training, and government support were listed as barriers to preschool vision screening.

CONCLUSION

Providers are interested in the development of structured screening programs. However, although screening may be a way to offer some level of vision care service to low health care access areas, a number of factors need to be addressed in discussions of vision screening program standards or screening best practice. In general, preschool screening programs need to be structured, be supported, have quality control, and be evaluated.

Reading disorders in children

Reading difficulties are a complex set of disorders. Current research indicates that these disorders are not caused by vision abnormalities. Treatment of these disorders requires a multidisciplinary approach involving educators, psychologists, and physicians. Parents, physicians, and school officials should understand that there are no quick cures for these children.

The sensory basis of reading problems

Learning to read is much more difficult than learning to speak. Most children teach themselves to speak with little or no difficulty. Yet a few years later when they come to learn to read they have to be taught how to do it; they do not pick up reading by themselves. This is because we speak in words and syllables, but we write in phonemes. Syllables do not naturally break down into the sounds of letters and letter units (i.e., phonemes) because these do not correspond to physiologically distinct articulatory gestures (Liberman, Shankweiler, & Studdert-Kennedy, 1967). Alphabetic writing was only invented when people realized that syllables could be artificially divided into smaller acoustically distinguishable phonemes that could be represented by a small number of letters. But these distinctions are arbitrary cultural artifacts, and their mastery was originally confined to a select social class. And until about 100 years ago it did not matter much if the majority of people could not read; the acquisition of reading probably had no serious disadvantages. Reading requires the integration of at least two kinds of analysis (Castles & Coltheart, 1993; Ellis, 1984; Manis, Seidenberg, Doi, McBride-Chang, & Petersen, 1996; Morton, 1969; Seidenburg, 1993). First, the visual form of words, the shape of letters, their order in words, and common spelling patterns, which is termed their orthography, has to be processed visually. Their orthography yields the meaning of familiar words very rapidly without needing to sound them out. But for unfamiliar words, and all words are fairly unfamiliar to the beginning reader, the letters have to be translated into the speech sounds (i.e., phonemes) that they stand for, and then those sounds have to be melded together in inner speech to yield the word and its meaning. Reading exclusively by the phonological route is more time consuming than if words can be accessed directly without requiring phonological mediation.

Coloured overlays in schools: orthoptic and optometric findings

In two studies, the first in a school in Peterborough and the second in a school in Norwich, more than 233 children aged 8-12 years received either an orthoptic examination, or an optometric examination, together with an examination using coloured overlays and a test of reading fluency. In both studies more than one-third of the children reported visual symptoms. More than one-third of the children chose to use an overlay, and they read more quickly with it than without. The colour of the overlay chosen was weakly related to the binocular amplitude of accommodation: overlays reflecting greater energy at long wavelengths were chosen more frequently by children with a higher amplitude of accommodation. Although the visual symptoms were strongly related to the use of an overlay, in neither study was the benefit from an overlay strongly related to the orthoptic or optometric findings. Nevertheless, children who used an overlay had slightly, but significantly, reduced mean binocular amplitude of accommodation and fusional reserves. On average, children with 'sensory' or 'motor' instability of the nonius strips of the Mallett unit read more slowly than others, as did those with poor stereopsis. However, 60% of those demonstrating sustained overlay use gave a normal response on the Mallett aligning prism test, compared with 80% of those who did not use an overlay for a sustained period. Another indicator of decompensated heterophoria, Sheard's criterion, did not differentiate subjects who used overlays from those who did not. Although binocular and accommodative anomalies do not appear to be the underlying mechanism for the benefit from coloured filters in most cases, there may be some individuals who respond to coloured filters and in whom these ocular motor factors require treatment. Children with visually precipitated symptoms and/or reading difficulties need both a careful evaluation of their accommodative and binocular status, and an investigation of the effect of coloured filters.

The magnocellular theory of developmental dyslexia

Low literacy is termed 'developmental dyslexia' when reading is significantly behind that expected from the intelligence quotient (IQ) in the presence of other symptoms--incoordination, left-right confusions, poor sequencing--that characterize it as a neurological syndrome. 5-10% of children, particularly boys, are found to be dyslexic. Reading requires the acquisition of good orthographic skills for recognising the visual form of words which allows one to access their meaning directly. It also requires the development of good phonological skills for sounding out unfamiliar words using knowledge of letter sound conversion rules. In the dyslexic brain, temporoparietal language areas on the two sides are symmetrical without the normal left-sided advantage. Also brain 'warts' (ectopias) are found, particularly clustered round the left temporoparietal language areas. The visual magnocellular system is responsible for timing visual events when reading. It therefore signals any visual motion that occurs if unintended movements lead to images moving off the fovea ('retinal slip'). These signals are then used to bring the eyes back on target. Thus, sensitivity to visual motion seems to help determine how well orthographic skill can develop in both good and bad readers. In dyslexics, the development of the visual magnocellular system is impaired: development of the magnocellular layers of the dyslexic lateral geniculate nucleus (LGN) is abnormal; their motion sensitivity is reduced; many dyslexics show unsteady binocular fixation; hence poor visual localization, particularly on the left side (left neglect). Dyslexics' binocular instability and visual perceptual instability, therefore, can cause the letters they are trying to read to appear to move around and cross over each other. Hence, blanking one eye (monocular occlusion) can improve reading. Thus, good magnocellular function is essential for high motion sensitivity and stable binocular fixation, hence proper development of orthographic skills. Many dyslexics also have auditory/phonological problems. Distinguishing letter sounds depends on picking up the changes in sound frequency and amplitude that characterize them. Thus, high frequency (FM) and amplitude modulation (AM) sensitivity helps the development of good phonological skill, and low sensitivity impedes the acquisition of these skills. Thus dyslexics' sensitivity to FM and AM is significantly lower than that of good readers and this explains their problems with phonology. The cerebellum is the head ganglion of magnocellular systems; it contributes to binocular fixation and to inner speech for sounding out words, and it is clearly defective in dyslexics. Thus, there is evidence that most reading problems have a fundamental sensorimotor cause. But why do magnocellular systems fail to develop properly? There is a clear genetic basis for impaired development of magnocells throughout the brain. The best understood linkage is to the region of the Major Histocompatibility Complex (MHC) Class 1 on the short arm of chromosome 6 which helps to control the production of antibodies. The development of magnocells may be impaired by autoantibodies affecting the developing brain. Magnocells also need high amounts of polyunsaturated fatty acids to preserve the membrane flexibility that permits the rapid conformational changes of channel proteins which underlie their transient sensitivity. But the genes that underlie magnocellular weakness would not be so common unless there were compensating advantages to dyslexia. In developmental dyslexics there may be heightened development of parvocellular systems that underlie their holistic, artistic, 'seeing the whole picture' and entrepreneurial talents.

Monocular occlusion can improve binocular control and reading in dyslexics

Developmental dyslexia is a neurodevelopmental condition which causes 5-10% of children to have unexpected difficulty learning to read. Many dyslexics have impaired development of the magnocellular component of the visual system, which is important for timing visual events and controlling eye movements. Poor control of eye movement may lead to unstable binocular fixation, and hence unsteady vision; this could explain why many dyslexics report that letters appear to move around, causing visual confusion. Previous research has suggested that such binocular confusion can be permanently alleviated by temporarily occluding one eye. The aim of the present study was therefore to assess the binocular control and reading progress of dyslexic children with initially unstable binocular control after the left eye was patched. One hundred and forty-three dyslexics were studied. They were selected from children aged 7-11 years referred to a learning disabilities clinic if they were dyslexic and had unstable binocular control. They were randomly assigned to wear yellow spectacles with or without the left lens occluded, and were followed for 9 months. Significantly more of the children who were given occlusion gained stable binocular fixation in the first 3 months (59%) compared with children given the unoccluded glasses (36%). This advantage was independent of IQ or initial reading ability. Furthermore, at all the 3-month follow-ups, children were more likely to have gained stable binocular control if they had been wearing the occluded glasses. Gaining stable binocular control significantly improved reading. The children who did so with the help of occlusion improved their reading by 9.4 months in the first 3 months, compared with 3.9 months in those who were not patched and did not gain stable fixation. Over the whole 9 months, children who received occlusion and gained stable fixation nearly doubled their rate of progress in reading compared with those who remained unstable. At all the follow-ups the reading of those given occlusion was significantly better than that of those not occluded. Thus monocular occlusion helped children with unstable binocular control to gain good binocular fixation. If they gained stability, they made significantly faster reading progress. The progress made by the children who gained stable fixation was much greater than that achieved with other remedial techniques.

The prevalence of optometric anomalies and symptoms in children receiving special tuition

A case-control study was performed where 9 pupils receiving special tuition (ST-group) were compared with 36 controls. Six (66.7%) of the pupils in the ST-group were diagnosed as dyslexic. No significant correlation was revealed between receiving special tuition and having reduced visual function, nor between reduced visual function and number of visually related symptoms. Although the number of symptoms was not significantly greater in the ST-group, some of the symptoms were significantly more common in the ST-group, and none were significantly more common in the control group.

Normal reading despite limited eye movements

Many investigators have demonstrated that poor readers exhibit abnormal eye movements during reading. An association between defective vergence, accommodation, and poor reading skills has also been noted by some investigators. Children who are poor readers have been subjected to therapeutic interventions on the basis of the assumption that improving their eye movements, as part of a multifaceted program of "vision therapy," will yield commensurate improvement in reading performance. This approach has been controversial, and other authors have expressed opposing views. We report the ophthalmologic and reading assessments of two children with Möbius' syndrome who were average to above-average readers despite essentially absent horizontal eye movements.

Developmental dyslexia: passive visual stimulation provides no evidence for a magnocellular processing defect

Livingstone et al. [Livingstone, M. S., Rosen, G. D., Drislane, F. W. and Galaburda, A. M. Physiological and anatomical evidence for a magnocellular defect in developmental dyslexia. Proceedings of the National Academy of Science U.S.A. 88, 7943-7947, 1991] presented evidence for a defect of the magnocellular visual processing stream in developmental dyslexia. We attempted to replicate this effect using transient and steady-state VEPs to checkerboard reversal stimuli in a group of adult developmental dyslexics. Several different reversal rates and contract levels were utilized. No differences were found between the dyslexic and control groups for the low-contrast, rapidly reversing patterns, nor for any combination of stimulus rate or contrast that was tested. Thus, these findings do not support a magnocellular processing deficit in developmental dyslexia.

An investigation of some sensory and refractive visual factors in dyslexia

The role of visual factors in dyslexia has been a long-standing source of controversy. Recent research has suggested that there may be a deficit of the transient visual subsystem in dyslexia. The evidence for this hypothesis comes principally from investigations of spatial and temporal contrast sensitivity and visual persistence. This evidence is reviewed and it is noted that previous work has never applied two of these purported "tests of transient function" to the same subject group. The hypothesised transient system deficit in dyslexia was investigated in a study comparing 43 control with 39 dyslexic children who were matched for age, sex, and intelligence. Comprehensive psychometric and optometric data were obtained, including visual acuities and refractive errors. The spatial contrast sensitivity function was determined in such a way as to investigate further the findings of Lovegrove, Martin, Bowling, Blackwood, Badcock and Paxton [(1982) Neuropsychology, 20, 309-315] and Martin and Lovegrove [(1984) Neuropsychologia, 22, 73-77]. It might be expected, from the work of Merigan and Maunsell [(1990) Neuroscience, 5, 347-352], that a better test of magno-cellular function would be to investigate the modulation threshold for a virtually uniform field that was flickering sinusoidally at 10 Hz. This temporal contrast sensitivity was studied in a similar way to Brannan and Williams [(1988) Clinical Vision Sciences, 3, 137-142]. A non-verbal simulated reading visual search task was used to investigate the effect of any visual deficits on a test that was, in its low-level visual requirements, similar to reading. The following factors were found to be significantly associated with dyslexia: reduced visual acuity, impaired flicker detection at 10 Hz, reduced low spatial frequency contrast sensitivity, and slightly slower performance at a simulated reading visual search task. The two alleged "tests of transient function" were only weakly correlated with one another (r = 0.183), suggesting that these variables do not measure the same function. Much of the dyslexic group's slightly slower performance at the simulated reading task could be accounted for by the psychometric variable of visual sequential memory. Like reading, the simulated reading task requires the accurate perception of sequential characters. Hence, it seems unlikely that the low-level visual deficits in the dyslexic group were major causes of their poor reading performance. Alternative explanations for the results are discussed.