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

Contact

• Jennifer Idoni, OD, FAAO, FCOVD

• idonij@gmail.com