1. science
2. medicine
3. pediatrics

Why Can’t “EYE” Read
Todd Goldblum, MD
Pediatric Ophthalmology
Family and Children’s Eye Center of NM
Sheryl Handler
Pediatric Ophthalmology
Financial Disclosure
I have NO financial interest
in any of the material
presented
Sheryl Handler
Pediatric Ophthalmology
“ The more you read, the more things you will
know. The more that you know, the more places
you will go” (Dr Seuss)
Sheryl Handler
Pediatric Ophthalmology
Learning to Read
 Most children spend
the first few years
of school learning
to read
 Then they need
reading to learn
Sheryl Handler
Pediatric Ophthalmology
“The act of reading a text is like playing
music and listening to it at the same time”
Margaret Atwood (2002), “Negotiating with the Dead”
Sheryl Handler
Pediatric Ophthalmology
Learning to Read
 According to a
leading reading
researcher,
Dr. Louisa Moats:
 “Teaching
reading IS
rocket science”
Sheryl Handler
Pediatric Ophthalmology
Early Speech and Language Milestones









Smile
Imitate speech sounds
Monosyllabic babbling
Polysyllabic babbling
Comprehends individual words
Mama / Dada correct use
First word (other than above)
Two word combination
Vocabulary 50(+) words
1-2 months
4-6 months
4-8 months
5-9 months
6-10 months
7-12 months
9-14 months
16-22 months
16-24 months
Delay in meeting these milestones may indicate, among
other problems, a future learning disability
Sheryl Handler
Pediatric Ophthalmology
Language Development Sequence
Understanding
Speaking
Reading
Writing
Sheryl Handler
Pediatric Ophthalmology
Oral Language
Sheryl Handler
Pediatric Ophthalmology
Oral Language
 The development of oral language is an
ongoing natural process – pre-programmed
into human development
 Oral language is the foundation for reading
 The number of words in a child’s vocabulary
is an indicator of his “linguistic health”
 It is extremely important for parents to begin
talking to their child in infancy
Sheryl Handler
Pediatric Ophthalmology
Exposure to Oral Language
 Hart & Risley –30 Million Word Difference in 4 years
 Talkative parents

2153 words/hour

11.2 million words/year
 Moderately talkative parents

1250 words/hour

6.5 million words/year
 Minimally talkative parents

616 words/hour

3.2 million words/year
Sheryl Handler
Pediatric Ophthalmology
Exposure to Oral Language
 Hart & Risley (1995)
 Expressive language practice is linked
to receptive language experience
 30 Million Word Difference in 4 years
 Toddlers’ talkativeness stops growing
when it matches the level of their
parents’ talkativeness
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Oral Language
 Oral language is the foundation for reading
 Oral language is broken up into phonemes
 Sounds signaling differences of meaning
 English is a phonemically complex language
 44 Phonemes (sounds) in 70 letter
combinations
Sheryl Handler
Pediatric Ophthalmology
Oral Language
 Phonemes - sounds signaling differences of meaning

44 Phonemes in English

Cannot break letters into phonemes

“Pet” & “Bet” are distinguished by the sounds of their
initial consonants
 Semantics – meaning of words, combining words into phrases
and sentences
 Syntax - Use of language to communicate needs, get information
– grammatical structure
 Pragmatics - use of language for functional communication –
connected sentences
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
 Oral language is pre-programmed into
human brain development
 Reading is not pre-programmed
 Reading is the complex process of
extracting meaning from written
symbolic characters
Sheryl Handler
Pediatric Ophthalmology
What is Reading?
A complex process of extracting meaning from
written symbolic characters
Sheryl Handler
Pediatric Ophthalmology
Reading
Reading is more difficult than speaking
Children must understand the
connection between the sounds of
spoken language
Then utilize the corresponding
alphabetic code to acquire the
sound/symbol connection
Sheryl Handler
Pediatric Ophthalmology
Reading
Learning to read is a sequential process;
each new skills builds on mastering the
previously learned skills
Decoding written symbols
Converting the symbols to sound
Converting the symbols to meaning
Progressively increasing fluency
Building comprehension skills
Storing cumulative information in memory
Sheryl Handler
Pediatric Ophthalmology
The Basics of Reading
Fixation >>Visual Processing >> Decoding
>>Fluency>> Comprehension >>Retention
= Success !
Sheryl Handler
Pediatric Ophthalmology
The History of Reading
Spoken communication
has been an evolutionary
“gift” for 6 million years
Written communication
has been around only
6000 years……no time for
the brain to evolve !
Sheryl Handler
Pediatric Ophthalmology
The History Of Reading
Spoken words are the
symbols of mental
experience
Written words are the
symbols of spoken words
Aristotle On Interpretation
2000 BC--Phoenician
alphabet contained
consonants only
Sheryl Handler
Sumerian Logographs
- circa 4000 BC
Pediatric Ophthalmology
Written Language
 Written language is artificial
 Writing is the use of abstract symbols to
represent language
 Writing Systems
 Ideographic – symbol represents an idea
 Logographic – symbol represents an object/word
 Alphabetic – symbol represents an abstract
building block of that language’s phonemes
 Written language must be actively learned
Sheryl Handler
Pediatric Ophthalmology
Ideographic
Sheryl Handler
Pediatric Ophthalmology
Logographic
Sheryl Handler
Pediatric Ophthalmology
Alphabetic
Sheryl Handler
Pediatric Ophthalmology
Alphabetic
Sheryl Handler
Pediatric Ophthalmology
Written Language
 English uses
 Alphabetic system – symbols
represent an abstract building block
of that language’s phonemes
Sheryl Handler
Pediatric Ophthalmology
Object Constancy
Object constancy is the understanding
that objects continue to exist even when
they cannot be seen, heard, or touched
And that objects are the same even
when they are moved
Peek-a-boo game
Usually fully ingrained by 24 months
Sheryl Handler
Pediatric Ophthalmology
This is the same dog in different directions “Object Constancy”
30
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
 Orthographic Perception
 b
This is nearly the same shape turned
 d
 p
in different directions –
creating 5 unique letters & 2 numbers




q
g
9
6
?? New Concept ??
“Incomplete Object Constancy ??”
Unless the child can convert these symbols into the
phonetic code - they are just lines and circles
devoid of linguistic meaning
Sheryl Handler
Pediatric Ophthalmology
How we Read - Language
 Important terminology
 Phonological awareness is the ability to hear
individual sounds, manipulate them and remember
the order of the sound
 Phonemes are the small units of sound in words that
signal differences in meaning (“bat” vs “cat”)
 Phonemic awareness is the ability to hear the
individual sounds in words and knowing that these
sounds signal differences in meaning
 Phonics is the understanding that segmented units
of speech can be represented by printed letters
Sheryl Handler
Pediatric Ophthalmology
How we Read
 Comprised of




Perception
Decoding
Fluency
Comprehension
 Requires




Sheryl Handler
Adequate vision
Adequate memory
Ability to sustain attention
Absence of these do not equal dyslexia
Pediatric Ophthalmology
Decoding
 Phonemes: spoken word can be segmented into different
sounds
 Phonics: puts those sounds into printed forms
Sheryl Handler
Phoneme
Example
/A/
a (table)
/a/
a (flat)
/r/
r (road), wr (wrong)
/s/
s (say), c (cent)
/u/
u (thumb), a (about), e (loaded), o (wagon)
Pediatric Ophthalmology
Decoding
 44 phonemes in English language
 Then need to blend the phonemes to form word
Sheryl Handler
Phoneme
Word
/f/ /o/ /n/ /e/ /m/
phoneme
Pediatric Ophthalmology
Decoding
Hebrew
letter
Phoneme
Hebrew word
Phonemes
English
translation
‫ל‬
/l/
‫לא‬
/lo/
no
‫מ‬
/m/
‫מה‬
/ma/
what
‫ ו‬,‫ב‬
/v/
‫נבל‬
/nevel/
harp
Sheryl Handler
Pediatric Ophthalmology
What Does it Feel Like to be Dyslexic?
Decoding & Working Memory
 A/a = А/a
 В/в = V/v
 г/г = G/g
 Д/д = D/d
 Е/е = E/e
 И/и = I/i
 К/к = K/k
 М/м = M/m
 Н/н = N/n
•
•
•
•
•
•
•
•
О/о = O/o
П/п = P/p
P/p = R/r
C/c = S/s
Т/т = T/t
Y/у = U/u or W/w
Х/х = H/h
Э/э = E/e
п
э
н
Пэн
Декодинг путс хэви дэмандс он
уоркинг мэмори, уэн нот аутоматик
Sheryl Handler
Pediatric Ophthalmology
What Does it Feel Like to be Dyslexic?
Decoding & Working Memory
Пэн
= Pen
п
э
Декодинг путс хэви дэмандс он
н
уоркинг мэмори, уэн нот аутоматик
=
Decoding puts heavy demands on
working memory, when not automatic
Sheryl Handler
Pediatric Ophthalmology
What Does it Feel Like to be Dyslexic?
Decoding & Working Memory
‫יש לך עיניים יפות‬
Sheryl Handler
What Does it Feel Like to be Dyslexic?
.gnidaer era yeht tahw dneherpmoc
ot elbanu era yeht taht gnimusnoc
emit dna suoirobal os signidoced fo
ssecorp eht nerdlihc emos roF
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
For some children the process of
decoding is so laborious and time
consuming that they are unable to
comprehend what they are reading.
What Does it Feel Like to be Dyslexic?
What Does it Feel Like to be Dyslexic?
For some children the process of
decoding is so laborious and time
consuming that they are unable to
comprehend what they are
reading.
Sheryl Handler
Pediatric Ophthalmology
The Complexity of the Mind
Believe it or not, you can read this…
Sheryl Handler
Pediatric Ophthalmology
The Complexity of the Mind
I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd
waht I was rdgnieg. The phaonmneal pweor of the
hmuan mnid. Aoccdrnig to rscheearch at
Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr
the ltteers in a wrod are, teh olny iprmoatnt tihng is
that the frist and lsat ltteer be in the rghit pclae.
Yaeh and I awlyas thought slpeling was ipmorantt!
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
 Fluency
 Ability to read connected text
with expression rapidly, smoothly,
effortlessly, and automatically
with little conscious attention to
the mechanics of reading such as
decoding
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
Fluency
 Children must become
accurate readers before they
can become fluent readers
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
 Fluency - Sight words
 Sight words include any word that readers
have practiced reading sufficiently often to
be read automatically from memory
 Sight words are read as whole units with no
pauses between sounds
 Sight of the word activates its pronunciation
and meaning in memory immediately
without any sounding out or blending
required
Sheryl Handler
Pediatric Ophthalmology
What Does it Feel Like to be Dyslexic? Fluency
It
isn't
as
if
the
are
difficult
to
or
understand,
but
the
make
you
between
words,
which
your
reading
is
less
words
identify
spaces
pause
means
fluent.
Sometimes you can identify words and comprehend
them, but, if the processes don't come together
smoothly reading will be labored & non-fluent
Sheryl Handler
Pediatric Ophthalmology
How We Read - Language
 Comprehension– Higher Order Linguistic Function
 General Intelligence
 Reasoning
 Vocabulary
 Pragmatics
 Syntax - grammar
 Comprehension – Other Factors
 Attention
 Memory
 Knowledge
 Cultural influences
Sheryl Handler
Pediatric Ophthalmology
What Does it Feel Like to be Dyslexic?
Comprehension
The Montillation of Traxoline
It is very important that you learn about
traxoline. Traxoline is a new form of
zionter. It is montilled in Ceristanna.
The Ceristannians gristeriate large
amounts of fevon and then bracter it to
quasel traxoline. Traxoline may well be
one of our most lukized snezlaus in the
future because of our zionter lescelidge.
Attributed to Judy Lanier
Sheryl Handler
Pediatric Ophthalmology
How We Read - Comprehension
The Montillation of Traxoline
What is traxoline ?
Where is it montilled ?
Why will it be one of our most lukized
snezlaus in the future ?
Sheryl Handler
Pediatric Ophthalmology
How We Read – Visual Functions
 Visual acuity
 Accommodation
 Convergence
 Saccades
 Fixations
Sheryl Handler
Pediatric Ophthalmology
How We Read – Vision
Print characteristics
Kindergarten books
1st grade books
3rd grade books
Paperback books
Average Print Size
20/200
20/100
20/70
20/50
As children begin to read faster the print size and
spacing becomes much smaller over a few years and
many children including good readers don’t like it
Slightly larger print and spacing helps all readers but
especially those who are having reading difficulties
Sheryl Handler
Pediatric Ophthalmology
How We Read - Accommodation
Sheryl Handler
Pediatric Ophthalmology
How We Read - Accommodation
 Accommodation (Focusing)
 Children under the age of 10 have
tremendous power to focus at near
 Half is available for sustained use
 Under the age of 10 the near point of
focusing is 1 inch from the nose
 This is why young children often hold
books closely especially when they
are concentrating – because they can!!
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
How we Read – Accommodation Problems
 Accommodative Insufficiency
Decreased focusing ability at near
 EXTREMELY RARE in children
 Due to: Uncorrected refractive error,
medications, illness, eye trauma
 Treatment
 Reading glasses
 Near fusion exercises
Sheryl Handler
Pediatric Ophthalmology
How We Read - Vergence
 Vergence
 The ability to keep the eyes aligned
on a visual target to maintain fusion
(binocular interaction)
 Convergence
 Turning the eyes inward
 Is needed for near reading
Sheryl Handler
Pediatric Ophthalmology
Convergence
Sheryl Handler
Pediatric Ophthalmology
How We Read - Vergence Problems
 Convergence Insufficiency
 Unable to fully converge eyes at near
 Frequently over-diagnosed in children!
 Recommend getting 2nd opinion if CI diagnosed
 Much less common in children
 Most people have NO symptoms
 Symptomatic CI Is treatable
 Does NOT cause dyslexia
Sheryl Handler
Pediatric Ophthalmology
How We Read - Vergence Problems
 Symptomatic Convergence Insufficiency
 Treatment will make reading more
comfortable
 But does NOT improve decoding or
comprehension directly
 Patching one eye in CI relieves symptoms
but does NOT improve decoding or
comprehension
Sheryl Handler
Pediatric Ophthalmology
How We Read - Fixation
 Fixation
 Visual information is perceived
during foveal fixation
 Short words are read with 1 fixation
 Longer words with 2 fixations
 90% of our reading time are fixations
 Duration of fixation 45-450 millisec
(average 180 milliseconds)
Sheryl Handler
Pediatric Ophthalmology
How We Read - Problems with Fixation
Nystagmus –
movements shortens fixation time and
reduces vision
Foveal Scar –
reduces visual acuity and necessitates use of
non-foveal retina
Foveal Hypoplasia –
legal blindness which necessitates use of
non-foveal retina and may also be associated
with nystagmus
Pediatric Ophthalmology
Saccades
 Rapid eye movements
 Bring images seen in periphery to
center
Pediatric Ophthalmology
How We Read - Saccades
 Saccades - small jumping eye movements
 Forward saccades - 85% of saccades
 Adult saccade average distance is 2 degrees
(eight letters)
 Saccade length is dependent on the ability
to recognize letters, the difficulty of the
text and the length of the word prior to the
saccade
 Backwards saccades - 15% of saccades
 Half the distance of forward saccades
 Increase with difficulty of the text
 Used for verification & comprehension
 Used to jump to the next line
Sheryl Handler
Pediatric Ophthalmology
Physiologic Saccadic Movement for Adult Reading
Sheryl Handler
Pediatric Ophthalmology
LINE OF SIGHT
Saccadic eye movements were recorded while reading 2 pages of a 2 column
newspaper
Sheryl Handler
67
Pediatric Ophthalmology
How We Read – Saccades & Fixation
 Child/early or dyslexic reader
 Saccades - 1/2 length
 More backwards saccades
 Fixates - 2 times as long and twice as often
 Dyslexic readers show saccadic eye
movements and fixations similar to the
beginning reader
 Dyslexic readers show normal saccadic
function when not reading
Sheryl Handler
Pediatric Ophthalmology
How We Read
 NOT involved in reading
 Smooth Pursuit (“TRACKING”)
 Vestibular System
Sheryl Handler
Pediatric Ophthalmology
Smooth Pursuit (TRACKING)
 Extremely slow eye movements
 Helps keep the image of a moving
target on the fovea (retina)
 AKA: “tracking”
 Very inefficient and rarely used
Pediatric Ophthalmology
Eye tracking
is NOT used for
reading
Sheryl Handler
Pediatric Ophthalmology
Vestibular
 Holds images on the retina during head
rotation or movements
 Inner ear sends signal to brain
Pediatric Ophthalmology
How We Read – Visual Functions
 Children with reduced vision often are good
readers
 Accommodation deficits require reading
glasses
 Symptomatic convergence insufficiency is
extremely rare in young children
 Children with inability to make saccades can
be good readers
 Children with nystagmus (jiggling eyes) can be
good readers
Sheryl Handler
Pediatric Ophthalmology
Difficulties in Early Reading
 Initial difficulty in learning to read occurs
in nearly 40% of students in the U.S.
 It may have a number of different causes:
 Deficits in oral language
 Lack of background knowledge
 Inadequate instruction
 Insufficient reading practice
 Reading disability = Dyslexia
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Learning Disabilities
Are common problems
5 – 20% of the U.S. population has
a learning disability depending on
the definition chosen
2.6 million children aged 6 – 11
years in the U.S. are affected
Sheryl Handler
Pediatric Ophthalmology
Learning Disabilities
Arise from neurological differences
in brain structure and function
Affect the brain’s ability to store,
process or communicate information
Do not arise from malfunctions in
the visual system
Sheryl Handler
Pediatric Ophthalmology
Learning Disabilities
LDs may cause difficulty in learning to:
Read
Listen
Speak
Spell
Write
Reason
Solve mathematical calculations
Organize information
Sheryl Handler
Pediatric Ophthalmology
Specific Learning Disabilities
 Dyslexia
 Reading disability
 Dysgraphia
 Writing disability
 Often found in addition to dyslexia
 Dyscalculia
 Mathematics disability
Sheryl Handler
Pediatric Ophthalmology
Dyslexia-A Language-Based Learning Disorder
 International Dyslexia Association
Dyslexia is a specific learning disability that
is neurological in origin. It is characterized by
difficulties in accurate and/or fluent word
recognition and by poor spelling and decoding
abilities. These difficulties typically result
from a deficit in the phonological component
of language that is often unexpected in
relation to other cognitive abilities and the
provision of effective classroom instruction.
Sheryl Handler
Pediatric Ophthalmology
Dyslexia
 Dyslexia is the most
common learning disability
 80% of all learning
disabilities
 20% of children in the U.S.
have some degree of dyslexia
 But only 5% of children with
dyslexia have been diagnosed
Sheryl Handler
Pediatric Ophthalmology
Dyslexia
 Dyslexia runs in families
 40% affected sibling
 40 % affected parent
 Multiple genes are suspected
Sheryl Handler
Pediatric Ophthalmology
Dyslexia - Shaywitz
 Dyslexia is not related to intelligence
 Dyslexia occurs at all levels of intelligence
 Children with dyslexia are not “dumb” or
“lazy” their brains just process information
differently
 They are often very bright, analytic,
creative and gifted in other areas
Sheryl Handler
Pediatric Ophthalmology
Dyslexia - Shaywitz
 Dyslexia can vary from mild to severe
 Reading disability represents the lower
tail of a normal distribution of reading ability
Sheryl Handler
Pediatric Ophthalmology
Dyslexia - Shaywitz
Dyslexia does not represent a transient developmental lag
 Dyslexia is a life-long condition
 A child doesn’t just “grow out of it”
Sheryl Handler
Pediatric Ophthalmology
Dyslexia
Associated Problems
 ADHD in 20 – 40% & vice versa
 Spoken language difficulties
 Dysgraphia (writing disabilities)
 Difficulties learning a foreign language
 Math word-problem difficulties
 Motor coordination difficulties
 Anxiety
 Depression
Sheryl Handler
Pediatric Ophthalmology
Brain Regions Involved In Reading
Healthy readers use both !
Sheryl Handler
Pediatric Ophthalmology
When is the Phonological Pathway Used?
 Used for “regular words”
 Can is a regular word – the c, a, and n
are pronounced in the regular way
 Not used for “irregular sight words” =
Words that cannot be “sounded out”
 Yacht” or “eye” are examples
 These words must be memorized and are
often called “irregular sight words”
Direct Pathway is used
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Neurobiologic Pathology
Brain Research –
FMRI & PET scans have made an
“invisible” diagnosis “visible”
The brain of people with dyslexia are
“wired” differently even before they start
to read
Children with dyslexia use a different area
of the brain for processing written words,
compared to typical readers
This alternative pathway has trouble
retrieving the sounds in spoken words
making it difficult to read
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Neurobiologic Pathology
Normal Readers
Dyslexic Readers
Inferior Frontal
(Broca’s Region)
Left
Left & Right
Left Parieto-temporal
Yes
Decreased
Left Occipito-temporal
Yes
Decreased
Left Posterior-inferior
temporal
Yes
Decreased
Right Occipto-temporal
No
Yes
The dyslexic pattern improves after effective
phonological remediation
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Phonologic Deficit
The primary problem or “core
deficit” for most children with
dyslexia is:
A phonological deficit causes
weak decoding skills leading to
labored reading and secondary
difficulties with spelling
Sheryl Handler
Pediatric Ophthalmology
Decoding Difficulties
Dyslexia - SE Shaywitz
Scientific American.1996;275(5):98-104
available at: http://dyslexia.yale.edu/Dyslexia_articleintro.html
Sheryl Handler
Pediatric Ophthalmology
Spelling Difficulties
Sheryl Handler
Pediatric Ophthalmology
Dyslexia is a Language-Based Problem
 Dyslexia is a language-based
problem
 Phonologic coding, analysis,
and word identification
deficit
 Verbal memory deficit
 Not a vision-based problem
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Not a Vision-Based Disorder
MYTH:
 Dyslexia is caused by the eyes
FACT:
 The scientific evidence does not show that
subtle eye or visual problems including
abnormal focusing, jerky eye movements,
misaligned or crossed eyes cause or
increase the severity of dyslexia
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Not a Vision-Based Disorder
MYTH:
 Dyslexia is caused by a vision problem
FACT:
 No specific vision problem causes dyslexia
 No relationship between visual function & academic
performance or reading ability has been shown
 Children with LDs do not have more visual problems
than children without LDs

Visual problems may co-exist with dyslexia but are present
with the same incidence as in the general population
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Not a Vision Based Problem
 People with dyslexia do NOT see things
backwards
 Difficulties in maintaining proper
directionality have been demonstrated
to be a symptom, not a cause, of
reading disorders
 Word reversals and skipping words and
lines are due to linguistic deficiencies
and not visual or perceptual disorders
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Not a Vision-Based Disorder
 If deficiencies in motor and visual-motor
development or defects in eye movements
caused perceptual impairment reading
problems one would be at a loss to explain
why:
 So many children with cerebral palsy,
strabismus, amblyopia, nystagmus
become good readers
 So many children with dyslexia play
video games
Sheryl Handler
Pediatric Ophthalmology
Can’t Read Because of a “Tracking” Problem ???
Sheryl Handler
Pediatric Ophthalmology
Dyslexia is a Language-Based Problem
Contrary to popular belief
The primary sign of dyslexia is
not reversing letters
Rather it is a difficulty
interpreting the sound
components of our language
Sheryl Handler
Pediatric Ophthalmology
Dyslexia is NOT Caused by a “Tracking Problem”
 Children with dyslexia often skip words
or lines when reading
 Some people call this word and line
skipping a “tracking problem”
 Fluent reading is not based on “eye
tracking”
Sheryl Handler
Pediatric Ophthalmology
Dyslexia is NOT Caused by a “Tracking Problem”
 Fluent reading or “reading tracking”
has nothing to do with “eye tracking” =
either ocular smooth pursuit or horizontal
saccades
 Fluent reading has to do with
decoding abilities, comprehension,
memory and attention !
 “Tracking problems” are over-diagnosed!
Sheryl Handler
Pediatric Ophthalmology
Dyslexia
 Risk Factors
 Family history of dyslexia
 Fetal exposure to drugs or alcohol
 Prematurity or birth problems
 Infections of the central nervous system
 Exposure to toxins (lead)
 Severe head injuries
 Other neurological problems
Sheryl Handler
Pediatric Ophthalmology
Possible Early Indications of Dyslexia
 History of:
 Family history
 Speech delay
 Difficulty with rhymes
 Confusing words that sound alike
 Delay in learning letters
 Delay in learning phonics
Sheryl Handler
Pediatric Ophthalmology
Dyslexia - Common Signs
 Significance of the signs are age dependent
 If a student has several signs that persist -he/she should undergo testing
 Difficulty remembering the names of the letters
 Difficulty remembering the sounds of the letters
 Reversing letters and words
 Reading words incorrectly - guessing
 Adding, dropping, changing words & skipping lines
 Slow reading in adolescents & adults
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Other Signs
 Trouble with reading comprehension
 Trouble spelling
 Frustration with schoolwork and
homework
 Not wanting to go to school
 Problems with attention
Sheryl Handler
Pediatric Ophthalmology
Possible Indications of Dyslexia
 May be overlooked because the child has been
labeled as a:
 Slow learner
 Underachiever
 Lazy
 Problem child
 By the time a child may be found to have
dyslexia he/she may have labeled himself/herself
as stupid and have damaged self-esteem
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Secondary Consequences
The ripple effect = secondary
problems caused by dyslexia
The extra amount of work expended
by dyslexic readers combined with
the frustration of failing to achieve
meaningful comprehension makes
reading unpleasant, tiring &
unrewarding
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Secondary Consequences
Students who
cannot read well
tend to read less
and this negatively
impacts their:
Reading fluency
Vocabulary
Comprehension
Concept knowledge
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – Secondary Consequences
Can damage self-esteem
Cause emotional problems
Withdrawal
Anxiety
Depression
Aggression
Children may be teased or bullied
by others
Sheryl Handler
Pediatric Ophthalmology
Teacher Knowledge & Preparation
 Many teachers receive only a cursory
introduction to reading instruction and
often have not been exposed to the latest
research
 Currently, the majority of teachers have
not been sufficiently prepared to prevent
reading problems and they are not aware
of the signs of dyslexia
 Which leads to delays in assessments &
interventions
Sheryl Handler
Pediatric Ophthalmology
Teacher Knowledge & Preparation
 Educators need to be trained on:
 Language structure
 Reading theory
 Reading development
 Reading problems
 The early signs of possible dyslexia
 Reading assessment
Sheryl Handler
Pediatric Ophthalmology
Teacher Knowledge & Preparation
 In many states the teachers who have
been trained in science-based reading
intervention programs are improving
reading scores
Sheryl Handler
Pediatric Ophthalmology
Role of Education
 Early recognition and intervention is
a cost effective solution to improving
reading skills
 Delaying identification and
intervention is “penny-wise but
dollar-foolish”
financially for schools
Sheryl Handler
Pediatric Ophthalmology
Role of Education - Screening
 Early detection of reading difficulties
by yearly reading screening
 K – Alphabet recognition, phonemic
awareness & rapid naming
 1st – Add word identification fluency
 2nd – Add oral reading fluency
Sheryl Handler
Pediatric Ophthalmology
Role of Education
 2 approaches can be utilized in the young
underachieving child
 Persistently poor academic achievement prior to
referral & assessment – 2 years behind
 Response To Intervention (RTI) method
 Screening allows earlier identification of LDs
than the “wait to fail” approach
 Child is directly placed in an educational
intervention program when difficulties arise
 Only children who do not show significant
improvement with both the group intervention &
2nd tier targeted intensive individual intervention
will undergo a full educational assessment
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
The diagnosis and treatment depends
on the collaboration of a team
Making the correct diagnosis in
children with reading weaknesses
is important before a therapeutic
regimen can be prescribed
Evaluation for attention (ADHD) and
other problems is very important
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
Comprehensive Medical & Psychological Evaluation
& Treatment Team
 Primary Care Physician
 Developmental Pediatrician
 Pediatric Ophthalmologist
 Pediatric Otolaryngologist
 Pediatric Psychiatrist
 Pediatric Neurologist
 Pediatric Psychologist
 Educational Psychologist
 Neuropsychologist
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
Special Services Team & more






Educational Therapy
Speech Therapy
Occupational Therapy
Physical Therapy
Educational Legal Advocate
Schools specializing in Learning
Disabilities
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
Formal Assessment for Learning Disabilities







Cognition
Intellectual ability
Information processing
Psycho-linguistic processing
Academic skills
Social-emotional development
Adaptive components
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
Formal Assessment for Reading Disabilities





Receptive listening skills
Receptive written language skills
Expressive oral language skills
Expressive written language skills
Phonologic skills – including phonemic
awareness
Sheryl Handler
Pediatric Ophthalmology
Multidisciplinary Approach
Formal Assessment for Reading Disabilities






Alphabet knowledge
Rapid naming of letters and pictures
Vocabulary
Reading accuracy
Fluency
Comprehension
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 Federal Laws :
 Individuals with Disabilities
Education Act (IDEA) & (IDEIA)
 Section 504 of the Rehabilitation Act
of 1973 (504)
 Americans with Disabilities Act (ADA)
 2008 ADA Amendments Act (ADAAA)
 No Child Left Behind (NCLB)
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 Federal Laws :
 Under (IDEA) & (IDEIA) – a “child with a
disability” is one who is eligible for special
education & related services
 IDEA guarantees a “free and appropriate”
public education
 Provides funding for special education &
services
 In the least restrictive environment possible
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 The I.E.P. team determines eligibility for
special education
 Need to have 1 or more of 13 disabilities
(including specific learning disability)
 AND need special education because of
the disability
 If your child is eligible - an IEP plan will
be written
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 An I.E.P. Plan will include:
 Student’s educational needs
 Specific learning goals
 Different instructional methods
 Treatments necessary
 In addition to remedial education,
accommodations and modifications
may be included
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 Generally only students with severe
dyslexia will qualify for an IEP
 Many struggling students with a learning
disability will not show severe enough
difficulties on evaluation to be qualified
as “learning disabled” as defined by
IDEA and will not be eligible for special
education and related services
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia
 504 plans are used to provide a child equal
access to education
 If dyslexia has been shown to
“substantially limit” a student’s learning
 And if he/she still needs targeted reading
or other assistance to be able to fully
participate in school he/she may be a
candidate for a 504 plan
 Accommodations or other assistance may
be provided
Sheryl Handler
Pediatric Ophthalmology
Role of Education – Remediation
 Dyslexic children who receive effective
phonological training in K & 1st grade
10 – 25% will continue to show
problems in learning to read
 Vs. children not identified until 3rd grade
74% will continue to show problems
through high school
Sheryl Handler
Pediatric Ophthalmology
Role of Education – Remediation
 Intensive treatment
90 minutes in regular classroom
60 minutes extra instruction
 Sufficient duration
 Individual or small group instruction
 Individualized multi-sensory (visual,
auditory, tactile) reading and language
program by a high quality instructor
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 The spoken code must be understood
before children can progress to the
written code
 In Kindergarten both phonologic and
phonemic awareness should be taught
before instruction on the alphabet and
phonics begins
 Otherwise, the phonics instruction will
not make sense to the dyslexic child
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Decoding Training
 Phonology and Phonological Awareness
 Rhyme & Alliteration
 Exaggerating sounds
 Segmenting words
 Blending words
 Separating words into syllables
 Separating syllables into phonemes
 Sound-Symbol Association – Alphabetics
 Sight words - memorize
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Phonics – Learning about and using different
sound and letter combinations to decode words
 Letter-sound relationship
 Vowel sounds
 Complex letter-sound patterns
(ex. sh-, -ng, -dge, -ight)
 Rules (ex. silent e rule)
 Spelling
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Fluency Training
 Practice, practice, practice!!
 Just as an athlete must practice to
optimize his or her skills, a child should
read aloud each day to practice
decoding, memorize new sight words
 Greater fluency is developed by
re-reading previously decoded and
memorized words
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Fluency Training
 Guided oral reading
 Paired reading
 Repeated reading
 Vocabulary Training
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Comprehension Training – Active reading
 Prior to reading
 Purpose for reading
 Predictions
 During reading
 Who, what, where, when, and why
 Visualization and predictions
 After reading
 Retell the sequence of events
 Summarization and drawing conclusions
 Other activities to improve language development
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 Accommodations & Modifications can include
 Extra time
 Separate quiet room
 Testing alternatives – oral instead of written tests
 Preferential seating
 Computers
 Spell checkers
 Recorded books
 Computer assisted reading programs
 Lecture notes
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 The accommodation of extra time
 Allows the student to show what he/she knows
 It is more important to show what he/she knows
than how fast he/she can show it
 Decreases stress and anxiety
 As an adult, life is not a timed test – it matters
how you do the job
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 What can be done in the classroom?
 Explicit instruction in phonologic awareness,
basic print concepts, & knowledge of letter
sounds
 Sequenced phonics instruction
 Do not encourage students to sound out
irregular words such as: the, of, come, some,
have, said, was, one, two, you, be, by etc.
 Use multisensory learning – hearing, seeing &
touching
 Integrate listening, speaking, reading & writing
Sheryl Handler
Pediatric Ophthalmology
Overcoming Dyslexia - Treatment
 What can be done in the classroom?
 Work with student in groups of 2 - 5
 Student paired reading & repeated reading
 Allow students to preview reading
assignments
 Allow students to preview vocabulary – give
definitions and pictures
 Give tests orally
 Allow extra time
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – The Whole Child
 We need to look at the “whole child” not
only at their weaknesses
 It is a disservice to the child to concentrate
on only their weaknesses
 We must stop viewing these children as
“broken”
 Even though the child has difficulty reading
it does not mean that he/she has difficulty
thinking
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – “The Gift”
 Frequent strengths of children with dyslexia
 “Out-of-the-box thinking”
 Bright, analytic, creative & gifted in
other areas
 High ability to reason and understand
concepts, excellent at solving problems
in a novel fashion
 **Necessary for the 21st Century **
Sheryl Handler
Pediatric Ophthalmology
Dyslexia – “The Gift”
 Children with dyslexia often have many
strengths
 Everyone succeeds on their strengths
NOT on their weaknesses
 Children need time to concentrate on
their strengths
 Long list of entrepreneurs, inventors,
scientists, actors, doctors, lawyers, and
other professionals
Sheryl Handler
Pediatric Ophthalmology
Famous People with Dyslexia
Sheryl Handler
Pediatric Ophthalmology
Examining the Evidence
Sheryl Handler
Pediatric Ophthalmology
Levels of Evidence in Medicine
Sheryl Handler
Pediatric Ophthalmology
Dr. Hokum’s Cure for the Common Cold



100,000 patients
treated with
Cold-B-Gon
100% cure rate!
Proves it’s effective,
right?
• What about the
control group??
Sheryl Handler
Pediatric Ophthalmology
Dr. Hokum’s Cure for Cancer of the Elbow





Sheryl Handler
Treated 100 patients
with Eye of Newt
(and standard
chemotherapy/radiation)
96% cure rate
Proves Eye of Newt
works, right?
What about the control
group?
Was it the Eye of Newt
that helped them?
Pediatric Ophthalmology
Controversial Theories and Treatments
Key points:
The more things that a theory explains,
the more likely it is to be false
Public dissemination of “fact” needs to be
validated
The results of small studies are likely to
be disproved in larger studies
Studies without matched controls have a
high false positive error
Sheryl Handler
Pediatric Ophthalmology
Controversial Treatments - Silver
 The treatment is proposed to the public prior to
research or before preliminary research has
been replicated
 The treatment is commercially pushed before
the research shows any support or evidence
shows that it does not work
 The treatment proposed goes beyond what
research data supports
Am J Dis Child. 1986 Oct;140(10):1045-52
Sheryl Handler
Pediatric Ophthalmology
Questions to ask in assessing the claims
of dyslexia trials:
Where’s the control group?
•
How were “reading disorders” diagnosed?
•
Were the subjects receiving other
intervention (such as reading instruction)
while receiving vision therapy?
•
Do the investigators have a financial
interest?
•
Sheryl Handler
Pediatric Ophthalmology
Controversies ?
Sheryl Handler
Pediatric Ophthalmology
Controversies ?
Sheryl Handler
Pediatric Ophthalmology
“Scotopic Sensitivity Syndrome”
 Scotopic Sensitivity Syndrome = SSS =
Irlen Syndrome = Mears-Irlen Syndrome
Not an actual medical syndrome
 Current supporters claim that it may be due to
 “Magnocellular Dysfunction”
 “Hypersensitive photoreceptors”
 “Cortical Excitability”
 Supporters relate that SSS affects:
 12-15% of the general population
 45% with learning disabilities
Sheryl Handler
Pediatric Ophthalmology
Irlen Lenses
Sheryl Handler
160
Pediatric Ophthalmology
Tinted Lenses / Filters
 Helen Irlen proposed using colored lenses
in certain types of dyslexics (1983)
 Irlen’s initial claims were based on
observations, anecdotal accounts of adults
and no formal experimentation
 Prior to any supporting research SSS was
featured twice on the television program
60 Minutes
 This national exposure led to great interest
in the treatment
Sheryl Handler
Pediatric Ophthalmology
Tinted Lenses / Filters
 Treatment with tinted lenses are used because
of presumed perceptual dysfunction causing
visual distortion & sensitivity to particular
wavelengths of light; now called “visual stress“
 Lenses are now being used to treat a variety of
non-ocular conditions: headaches, trauma,
language deficits, autoimmune disease, &
depression
Sheryl Handler
Pediatric Ophthalmology
Tinted Lenses / Filters
Color
 Color selection methods in the different
studies are highly variable
 Many methods are used:
 Yellow filters
 Blue filters
 Irlen Method – patient selection
 Wilkins Precision Tint Method using the
“Intuitive Colorimeter”
 ChromaGen Method
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses / Filters
Color
 Woerz’s study - poor test-retest
reliability on color selection
 Stone’s study - 25% needed their
color changed within a year
 Henderson’s study – 38% chose a
different color 2 weeks later
Sheryl Handler
Pediatric Ophthalmology
Tinted Lenses / Filters
 1990: Parker, Solan, Hoyt’s review of 3 studies using
tinted lenses noted serious methodological flaws –
making the studies’ conclusions invalid
 1993: Menacker’s cohort study showed no
improvement or preferred tint among disabled
readers
 Robinson - Literature Review
1993: Multiple studies showed
methodologic flaws
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses / Filters
 Hyatt, Stephenson & Carter – 2009
Review of 3 Controversial Practices
Including Tinted Lenses
 Reviewed 17 Studies on Tinted Lenses Filters from 1988-2003
 Conclusion: failed to demonstrate the
efficacy of the tinted lenses
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses / Filters
 Ritchie, Della Sala & McIntosh– 2011
Placebo controlled study
 Irlen diagnostician diagnosed Irlen
Syndrome in 47/61 below-average readers
 Irlen Syndrome children were evaluated
with an overlay of prescribed color,
overlay of non-prescribed color and no
overlay in random order
 Irlen colored overlays showed no
immediate effect on reading in children
with reading difficulties even among
those diagnosed with Irlen Syndrome
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses/Filters
JM Fletcher & D Currie 2011 – Review
 Conclusions:
 Many current studies find:
Inconsistent evidence for small and
questionably clinically significant
increases in reading rate
Little evidence of measurable effects on
accuracy or comprehension
Little evidence of specific improvement
in children with reading disabilities
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses / Filters
 Handler & Fierson - 2011
 Learning Disabilities, Dyslexia and Vision
Joint AAP, AAO, AAPOS & AACO
Technical Report
 Published studies contain serious flaws
 Many of the studies cited as proof actually
have been found to be inconclusive
 Colored filters and lenses may be ineffective
except that they act as a placebo
 The evidence does not support the
effectiveness of tinted lenses & filters in
patients with dyslexia
Sheryl
SherylHandler
Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Tinted Lenses/Filters
LM Henderson, N Tsogka, MJ Snowling - 2013
 “Visual stress”:
 Questions the value of using colored
overlays as a tool to identify visual stress
 Questions the value of using a
questionnaire to identify visual stress
 Symptoms can be attributed to visual
problems or dyslexia itself
Sheryl Handler
Pediatric Ophthalmology
Tinted Lenses/Filters
LM Henderson, N Tsogka, MJ Snowling - 2013
 Results and Conclusions:
 Both the dyslexic and control groups
read jumbled text faster with a colored
overlay than without
 Reading connected text was not
improved by colored overlays
 Comprehension was not improved by
colored overlays
 Questions the value of using colored
overlays for the remediation of reading
difficulties associated with dyslexia
Sheryl Handler
Pediatric Ophthalmology
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫כל עוד בלבב פנימה‬
‫נפש יהודי הומיה‬
‫ולפאתי מזרח קדימה‬
‫עין לציון צופיה‪.‬‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫עוד לא אבדה תקוותנו‬
‫התקווה בת שנות‬
‫אלפיים‬
‫להיות עם חופשי בארצנו‬
‫ארץ ציון וירושלים‬
‫‪Pediatric Ophthalmology‬‬
‫‪Sheryl Handler‬‬
Vision Therapy (Vision Training = VT)
 Vision therapy (VT) is a term used by optometrists
 Optometrists define VT as an attempt to develop
or improve visual skills and abilities; improve
visual comfort, ease, and efficiency; and change
visual processing or processing of visual info
 An optometric VT program consists of an
individualized progressive program of vision
procedures performed under supervision in-office
and supplemented with procedures performed at
home between office visits
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy (Vision Training = VT)
 Therapy is generally conducted once or twice
weekly in-office for 30 – 60 minutes over a
period of weeks to years
 In addition to exercises, lenses (“training
glasses”), prisms, filters, patches, electronic
targets, specialized instruments, or balance
boards may be used
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy (Vision Training = VT)
 Orthoptic techniques are used to change
specific visual functions
 Convergence
 Accommodation
 Ocular motility
 Binocular fusion capability
 Behavioral vision therapy is used to improve
visual efficiency
 Improve scanning
 Improve locating
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy (Vision Training = VT)
 Behavioral VT treats visual processing & perception defs
 Visual spatial orientation skills

Bilateral integration

Laterality & directionality
 Visual analysis skills

Visual discrimination

Visual figure-ground discrimination

Visual closure

Visual memory & visualization

Visual-motor integration

Eye-hand coordination

Auditory-visual integration
 Visual-verbal integration
Sheryl Handler
Pediatric Ophthalmology
Training Techniques - Ocular Motility
Space Fixator and
Rotating Pegboard
Sheryl Handler
Marsden Ball
Pediatric Ophthalmology
Training Techniques - Bilateral Integration
Jumping Jacks + metronome
Windshield wipers
Angels in the snow
Balance board
Chalkboard circles
Slap-tap
Bean bag toss
Sheryl Handler
Balance board
Chalkboard
circles
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Optometric Use of Training Glasses
 Skeffington’s Nearpoint Stress Model
 The model predicts that a relatively lowpowered lens is often all that is required to
permit equilibration of accommodation and
convergence
 Developmental optometrists believe that
relatively low-power plus lenses are
surprising effective in permitting more
efficient reading
 Developmental optometrists believe their
methods foster optimal development and
minimize stress on the visual system
Sheryl Handler
Pediatric Ophthalmology
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy (Vision Training = VT)
 Vision therapy has a 35% placebo rate
(in the convergence insufficiency
treatment trial)
 That means that 1/3 people will have
a positive result to VT based on the
placebo response
 There is no evidence to support using VT
for dyslexia
 Because visual problems do not underlie
dyslexia, approaches designed to improve
visual function by training are misdirected
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy (Vision Training = VT)
 American Academy of Optometry
American Optometric Association
Policy Statement 1997
 “Vision therapy does not directly treat
learning disabilities or dyslexia”
 “Vision therapy is a treatment to improve
visual efficiency and visual processing,
thereby allowing the person to be more
responsive to educational instruction.”
Sheryl Handler
Pediatric Ophthalmology
Review of Optometric Vision Therapy Studies
 Vision Therapy Studies – Poor Quality
Poor planning of study
Inadequate numbers
Inadequate control group
Anecdotal information
Failure to “mask” the investigator
Investigator with a vested interest in
the result
 Old studies






 Many of the findings have not been
reproducible in subsequent studies
Sheryl Handler
Pediatric Ophthalmology
Review of Optometric Vision Therapy Studies
L Kirkeby – 2012
Percentage of Quality Scores for Vision Therapy Articles
2.6
2.6
23.1
53.85
Excellent
Good
Moderate
Poor
Invalid
17.95
Percentage of Quality Scores for all Vision Therapy Articles Reviewed
Sheryl Handler
Pediatric Ophthalmology
Review of Optometric Vision Therapy Studies
L Kirkeby – 2012
Review of 567 VT Studies
 Only 41 of these studies were
primary research on VT
 Only 5 studies were on reading
&/or attention !!
 No study on reading &/or attention
was classified as excellent or good
 Only 2 were classified as moderate
Sheryl Handler
Pediatric Ophthalmology
Review of Optometric Vision Therapy Studies
L Kirkeby – 2012
Review of 567 VT Studies
 Shelley-Trembly examined 77 students
using the VT “reading plus program”
combined with guided reading and
word memory therapy
Found improvement in
comprehension & word knowledge
but not decoding compared to the
control group
Sheryl Handler
Pediatric Ophthalmology
Review of Optometric Vision Therapy Studies
 L Kirkeby – 2012
Review of 567 VT Studies
 Solan examined 31 reading disabled
students
 1st group had 12 sessions of eye
movement therapy (VT) combined with
guided reading therapy followed by
comprehension therapy vs 2nd group reversed order
 Both groups improved equally
 The group that had comprehension
therapy first had the same improvement
in eye movement skills as the VT group
Sheryl Handler
Pediatric Ophthalmology
See the dramatic effect of this revolutionary new treatment
Sheryl Handler
195
Pediatric Ophthalmology
IF A STUDY DOES NOT ADHERE TO
PROPER SCIENTIFIC RIGOR, YOU
CAN MAKE IT SHOW ANYTHING
YOU WANT!
Sheryl Handler
Pediatric Ophthalmology
Retracted autism study an 'elaborate
fraud,' British journal finds
Sheryl Handler
Pediatric Ophthalmology
Vision Therapy Summary
Therapy overlaps different areas
Occupational Therapy
Educational Therapy &
Special Education
Education psychology
Not evidence based treatment
Except Convergence Insufficiency
Sheryl Handler
Pediatric Ophthalmology
Financial Disclosure for Irlen and
VT advocates: They have a HUGE
financial interest
What are the costs associated with a visual exam and
therapy?
A Behavioral Vision Exam and Perceptual testing
completed by a Behavioral Optometrist to determine
visual deficiencies runs between $500-$800 dollars.
Vision Therapy plans are a lot like braces in regards to
cost and setting appropriate programs based on findings
from the exam. Once an exam has been completed,
and the full extent of the visual system challenges is
determined, a therapy plan is detailed by the
Behavioral Optometrist. Based on the patients needs
the therapy plan can last anywhere from 3 months to a
year or more. These programs cost on average $2500$8000 and include all therapy, re-evaluations with the
doctor to evaluate progress and equipment used during
therapy.
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement 2009
Joint Technical Report 2011
Learning Disabilities, Dyslexia, and Vision
 American Academy of Pediatrics
 American Academy of Ophthalmology
 American Association for Pediatric
Ophthalmology & Strabismus
 American Association of Orthoptists
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement & Technical Report
 Currently, there is inadequate scientific evidence
to support the view that subtle eye or visual
problems cause learning disabilities
 Or that correction of subtle eye or visual defects
by visual therapy is effective direct or indirect
treatment of learning disabilities
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement & Technical Report
Children who exhibit signs of LDs
should be referred as early in the
process for educational,
psychological, neuropsychological,
and/ medical diagnostic assessment
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement & Technical Report
Primary Care Physicians should
perform eye & vision screening
Children who fail screening or those
with suspected visual problems should
be referred to an ophthalmologist
experienced in children’s care
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement & Technical Report
Ophthalmologists should identify & treat
any significant ocular or visual disorder
Diagnostic & treatment approaches for
dyslexia that lack scientific evidence of
efficacy such as behavioral vision
therapy, eye muscle exercises, or
colored filters & lenses are not endorsed
or recommended
Sheryl Handler
Pediatric Ophthalmology
Joint Policy Statement & Technical Report
Children with LDs should receive
appropriate support and
individualized evidence-based
educational interventions combined
with psychological and medical
treatments as needed
Sheryl Handler
Pediatric Ophthalmology
AMERICAN ACADEMY OF PEDIATRICS
“Ineffective, controversial
methods of treatment such as
vision therapy may give parents
and teachers a false sense of
security that a child’s learning
difficulties are being addressed,
may waste family and/or school
resources and may delay proper
instruction or remediation.”
Sheryl Handler
Pediatric Ophthalmology
Resources
Education and Information on Learning Disabilities
 International Dyslexia Association
www.interdys.org
 Learning Disabilities On-Line
www.ldonline.com
 National Center for Learning Disabilities
www.ncld.org
 Schwab
www.greatschools.org/LD.topic?content=1541
 Mel Levine, M.D.
www.allkindsofminds.org
 CHADD
www.chadd.org
 “Overcoming Dyslexia” – Sally Shaywitz, M.D.
Sheryl Handler
Pediatric Ophthalmology