an ophthalmologist’s approach to visual processing learning differences harold paul koller

Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences

In the past, most ophthalmologists read orwere told that treatment of the disordersaffecting children with dyslexia and otherlearning disabilities fell outside the field ofophthalmology because the brain, and not theeyes, is the main organ active in the processof thinking and learning (Hartstein, 1971;Hartstein & Gable, 1984; Miller, 1988).Because dyslexia, for example, implied aninability to understand the written word, thedefinitive diagnosis and therapy was in thehands of the educators and clinical psycholo-gists, not the ophthalmologist. The role of anophthalmologist, thus, was to rule out diseaseas the first step in determining the reason fora learning difference before referring thechild back to the pediatrician or family doc-tor for further evaluation and referral.

This limited role for ophthalmologists intreating children with learning disorders isnow being displaced by a move toward aninterdisciplinary approach. The ophthalmolo-gist is often the first expert to whom the pedi-atrician refers a child suspected of having alearning disorder. Educating ophthalmolo-gists in the medical and nonmedical condi-tions and situations that could affect learningin a child or older individual will help ensurethat a patient receives appropriate, effective,and timely remedial treatment.

The first step in educating ophthalmolo-gists is to introduce psychiatry, educationaland neuropsychology, physical and occupa-tional therapy, and educational science in allits forms relating to learning differences inchildren and adults to the ophthalmologycommunity (Koller & Goldberg, 1999). (Anappendix to this chapter outlines briefly whatan ophthalmologist in general practice shouldknow about learning disorders.) The secondis to make the diagnosis and treatment ofchildren more efficient by developing a sys-tem for classifying disorders that is orientedtoward ophthalmologists. This chapterdescribes such a classification system forlearning disorders. It then goes on to describecauses and treatment of medically based oph-thalmic problems affecting learning, as wellas other conditions affecting learning that arenot purely ophthalmic but which ophthalmol-ogists can help diagnose (Koller, 1999a).

AN OPHTHALMOLOGIST’SCLASSIFICATION APPROACH TO

LEARNING DISORDERS

Children with learning disabilities can beclassified into two main groups: (1) thosewith purely medically and surgically treatedophthalmic disorders that temporarily or

243

11

An Ophthalmologist’s Approach to VisualProcessing/Learning Differences

Harold Paul Koller, M.D., F.A.A.P., F.A.A.O.

ICDL Clinical Practice Guidelines

chronically affect learning efficiency inschool (DSM-IV: Axis III – general medicalconditions), and (2) those with conditions notpurely ophthalmic that traditionally have fall-en into the243 fields of the cognitive sciencesand education (DSM-IV: Axis I). The secondgroup of conditions can be subdivided into thefour traditional types of learning differences:(1) developmental speech and language disor-ders, (2) nonverbal learning disorders, (3)attention disorders, and (4) pervasive develop-mental disorders (PDD). Many of these haveobservable ophthalmologic findings. Thesocial reasons for deficient learning in school,such as dysfunctional family environment,poor instruction, foreign first language, andsevere psychiatric disease are not directlyassociated with eye abnormalities (DSM-IIand IV). The next section discusses the causesand treatment of disorders within the firstmain group; that is, medical conditions thattemporarily or chronically affect learning.

Ophthalmic Causes of Learning Difficulties

There are several purely ophthalmic caus-es of temporary or chronic learning difficul-ties. Many times these conditions causeintermittent blurry vision in school and athome, itchy eyes, redness, foreign body sen-sation, various visual phenomena, doublevision, tearing, light sensitivity (photopho-bia), and ocular pain and headache. All ofthese symptoms can affect children’s concen-tration in the classroom and at home and theirability to learn efficiently (Koller, 1997). Themain categories of ophthalmic causes affect-ing learning are refractive errors, strabismusand amblyopia, nystagmus, systemic diseasesaffecting the eyes, local ocular diseases, andneuro-ophthalmic disorders.

Refractive errors are optical refractiveimperfections due to the size and shape of the

focusing structures of the eyeball (globe)itself. Refractive status is inherited, with theeyeballs of children shaped like the eyeballs oftheir parents. A nearsighted eye (myopia) islonger, and the light is focused in front of theretina. A farsighted (hyperopia) eye is shorter,and the light is abnormally focused in back ofthe retina, not on it. An astigmatic eye is one inwhich the cornea in front or the lens in themiddle of the eye is misshapen microscopical-ly like a lemon or football, more curved in onedirection than the other, 90 degrees away. Ablurry image results from all three refractiveabnormalities (Reinecke, 1965). A correctivespectacle lens is necessary to refocus the lightrays coming from the objects observed to cre-ate a sharp focused image on the retina, whichis then transmitted to the brain so a person caninterpret what is seen clearly.

Strabismus is the condition of misalignedeyes in which the eyes are not aimed in thesame visual direction. The eyes may be diver-gent (exotropia or walleyes), convergent(esotropia or crossed eyes), or vertically apart(hypertropia). They also can be cyclotropic, ormisaligned around an anterior-posterior axisthrough the pupil, which can cause significantvisual confusion and image “tilt” or torsion.Most acquired strabismus can cause doublevision (diplopia), which is most annoying toschool-aged children. Less frequently, thesudden onset of strabismus with diplopia in aschool-aged child or younger may be of para-lytic etiology as a result of a virus infection,or even a brain tumor. The paralysis in the lat-ter case is due to one of the three cranialnerves innervating the six extra-ocular mus-cles in each eye being affected. A thoroughmedical evaluation is mandatory (Parks,1975).

Treatment for exotropia is usually surgi-cal, although for small deviations and thoseless severe cases in which the eyes go outmore at near (convergence insufficiency) than

244


in the distance (divergence excess), eyeexercises in the form of classic orthoptics oroptometric vision training is quite acceptable.The idea is to train diplopia awareness toimprove fusional convergence amplitudes.This enables the individual to see and focussingly over a broader area of viewing and for alonger duration (Bedrossian, 1969). Treatmentfor nonparalytic esotropia (the eyes arecrossed in but move normally in all directionsand to the extreme gaze positions) is usuallysurgical or optical (eyeglasses) if there isexcessive farsightedness. In such a case, theeyes over-focus and turn in too much. Thehyperopic power of the glasses assumes thefocusing function and, when the lenses areworn, the eyes do not have to focus to seeclearly and the eyes remain straight. If theeyes turn in more at near than in the distance,bifocal eyeglasses are required to cause morefocusing relaxation close up. There are cases,however, involving both esotropia mecha-nisms that require both glasses and, for theportion of deviation not controlled by the eye-glasses alone, surgery. If left untreated, theweaker eye may develop suppression in orderto avoid double vision and become ambly-opic. Paralytic as well as restrictive esotropiapatients often present with face turns to pre-serve use of their eyes together away from theside of the paralyzed eye muscle. This cansometimes interfere with efficient reading.Treatment is often surgical.

Hypertropia or vertical strabismus comesin a variety of forms but often it presents tothe pediatrician or ophthalmologist as a headtilt, chin depression, elevation or face turn, orcombinations of these abnormal head pos-tures. These can all interfere with normalnavigation as well as with reading and learn-ing. The treatment is usually surgical. Onecommon such condition is congenital fourthnerve palsy; head tilt is the presenting sign.One should also be aware of the so-called

“A” and “V” syndromes in which the eyes go“in” or “out” more in one gaze than in anoth-er. For example, a “V”-pattern esotropia isone in which the eyes go in more when look-ing down than when looking up, which couldcause double vision when reading. Treatmentis either with bifocal eyeglasses or surgery ifspectacles are ineffective.

Amblyopia is the term applied to dimin-ished vision without an obvious physical orstructural abnormality present to account forthe vision loss (Simon & Calhoun, 1998). Itis called “organic amblyopia” when thevision loss is due to a structural defect suchas an abnormal optic nerve. The lay term foramblyopia is “lazy eye,” which people oftenconfuse with strabismus or “a weak eye mus-cle.” A more appropriate term for amblyopiawould be “lazy vision.” There are three typesof amblyopia: (1) refractive, due to the eyeshaving different refractive errors and focus-ing ability; (2) strabismic, in which the eyesare not aimed at the same object, causingdiplopia to occur; and (3) occlusion ambly-opia, in which one eye has unclear or opaquemedia inhibiting light from being clearlytransmitted from the environment to the reti-na, such as a cataract.

For vision to develop normally, both eyesmust be in focus, see clearly, be alignedstraight ahead, and maintain coordinated eyemovements in all fields of gaze. If this doesnot take place, the lateral geniculate body inthe brain develops ganglion cell degenerationand a subsequent decrease in visual acuity.The cause of this in the refractive type is oneblurred retinal image in the affected eye andone clear image in the more normal eye. Thebrain automatically shuts off the blurryimage and the cells in the lateral geniculatebody atrophy. Giving these patients the cor-rect eyeglasses and covering the better eyewith a patch to cause the cells to regenerate isthe best therapy. The earlier this is done, the

245


easier it is for the cells to regenerate and thebetter the results. The brain becomes lessplastic after age six and often does notrespond to occlusion therapy after puberty. Inthe strabismic type, eyeglasses or surgery toeliminate the malalignment of the eyes, pre-ceded and followed by occlusion therapy overthe better eye, is the best treatment. In occlu-sion amblyopia, surgical therapy to removethe cause of the obstruction is performedfirst, followed by appropriate optical correc-tion. A contact lens, or intraocular lens in thecase of a unilateral cataract in a child, is cur-rently the best therapy. Amblyopia isreversible if diagnosed early. However, treat-ing school-aged children is frequently achallenge due to peer ridicule and the child’slack of compliance with eye patching.Schoolwork and learning can be affectedbecause the patch covers the better eye.Alternatives to patching include cycloplegiceyedrops, such as atropine and cyclopento-late, to blur the vision in the better seeing eyeas well as oral levodopa. L-dopamine seemsto improve amblyopic vision in some individ-uals, even after adolescence, although thisdrug is not yet in widespread use in theUnited States (Leguire, Rogers et al., 1998).

Nystagmus is repetitive movements ofthe eyes, usually horizontally to-and-fro witha fast jerk in one direction (Reinecke, 1997).The movement may be only horizontal orvertical and rarely torsional, but more oftenit is a mixture. Nystagmus is typically stablein any specific field of gaze, which is termedthe “null point.” There are many types ofnystagmus based on description of the pat-tern and on the etiology. Examples includevestibular nystagmus, latent and manifestlatent nystagmus, amaurotic or “blind” nys-tagmus (which is more a searching, thanjerking movement), and idiopathic infantilenystagmus. The latter is seen in patients withalbinism and various retinal disorders.

Occlusion amblyopia can cause deprivationnystagmus, which decreases or is entirelyeliminated when the obstacle to normalfocusing is removed. Many types of nystag-mus are associated with less than normalvision and often a null point exists in onefield of gaze, causing a head tilt or face turnin order to achieve optimal visual acuity thatexists in the field of least nystagmus activity.Treatment in some cases is surgical in orderto move both eyes and the null point awayfrom the extreme gaze position of the nullzone and to the primary straight-ahead posi-tion. Reading can be labored for children andadults with nystagmus, and learning is there-fore sometimes compromised.

Systemic disease affecting the eye and dis-rupting normal visual learning processes mostcommonly include (1) juvenile rheumatoidarthritis; (2) metabolic and endocrine disor-ders, such as juvenile diabetes or pituitarydisorders; (3) blood dyscrasias affecting theeye and brain, such as leukemia; and (4)metastatic neoplastic disease to the eye and/orbrain, such as neuroblastoma. All of these dis-eases are treated medically and surgically, asrequired. Disruption of schooling oftenoccurs for significant periods of time in themore serious cases. Learning is thus second-arily compromised even if no basic learningdisorder was present before the child becameill. If the brain becomes structurally involvedin the disease process, the various learningcenters can be directly affected, causing a pos-sible permanent learning disorder.

Local ocular causes of decreased visioninclude: • Ocular media opacities, such as opaque

corneal lesions and cataracts.• Congenital and infantile glaucoma (high

intraocular pressure frequently causinglegal or complete blindness).

246


• Significant unilateral and bilateral oculartrauma causing moderate to severe visionloss, such as rupture of the globe afterfalling on a sharp object.

• Ocular and adnexal neoplasms withsecondary disfigurement and/or visionloss, such as retinoblastoma and rhab-domyosarcoma of the muscles of theglobe or eyelids.

• Severe chronic ocular infections, such asHerpes Simplex Virus–I, with vision lossaffecting the cornea.

• Congenital and degenerative retinal oroptic nerve diseases affecting the maculaor optic nerve, such as toxoplasmosis andoptic nerve hypoplasia (small, poorlyfunctioning optic nerve).

These are frequently seriously urgentconditions, often requiring surgery, chemo-therapy, or other medical treatments to cureor control. Schooling and learning invariablysuffer (Miller, 1988).

Neuro-ophthalmic causes of temporary orintermittent learning impairment and ineffi-ciency include two broad categories frequent-ly seen in the pediatric ophthalmologist’soffice: (1) primary brain diseases and tumorscausing personality and behavior changes and(2) the vast variety of vascularly mediatedpediatric migraine syndromes.

Classic migraine involves a vascular-mediated headache, often preceded by vari-ous visual auras, photophobia, and nausea. Itis usually followed by the desire to sleep,after which the headache often is gone.Children frequently present with a variationtermed “acephalgic migraine.” Headachesare not usually a part of the presenting symp-tom complex. This fact often confuses theparents and many professional caregiverswho expect migraine to always be aheadache. Children who complain of blurryvision in school but who are found to have a

normal eye evaluation may merely be experi-encing the pediatric equivalent of adult, con-stricting visual fields and the typical“scintillating scotoma.” These aura are oftentermed “ophthalmic migraine” when headachesymptoms are minimal or absent in adults.Children have a number of associated signsand symptoms of pediatric migraine. Thesepara-migraine entities include infantile colic,lactose intolerance, sleep disturbances(including night terrors and nightmares), andmotion sickness. They also include frequentfebrile seizures; unexplained abdominal dis-comfort; allergic predisposition; unusual sen-sitivity to light (photophobia), noise, andsmell; and a type-A personality resistant tochange with occasional obsessive/compulsivebehavior. Para-migraine entities may also becharacterized by various other visual phenom-ena, such as micropsia (things looking small-er or farther away), macropsia (things lookinglarger or closer), and metamorphopsia (thingslooking distorted, as in a fun house mirror).The classic description of the latter is the so-called “Alice in Wonderland” syndrome.

Children complaining of any of thesesymptoms, either as a single symptom or incombination, sometimes are not believed orare misunderstood, leading to a misdiagnosisor no diagnosis at all. A pediatric examinermust ask the parents of children with learningdifferences and difficulty with schoolwork ifthese symptoms occur to ascertain whether ornot para-migraine complaints exist. A pedi-atric neurologist is best for advising thesefamilies about acephalgic pediatric migrainetherapy. More severe pediatric vascularmigraine can result in the syndrome of oph-thalmoplegic migraine, which is manifestedby paralysis of one or more extraocular mus-cles with resultant strabismus and diplopia.In these cases, a pediatric ophthalmologistshould be consulted. More serious conditionssuch as a brain tumor must be ruled out. A

247


migraine predisposition must be consideredin any child with a learning problem.Migraine is definitely familial and inheritedin a multi-factorial mode with various familymembers having different combinations ofsymptoms (O’Hara & Koller, 1998).

The following section discusses condi-tions that are not purely ophthalmic, butsome of which may have ophthalmologicfindings. These include receptive languagedisorders, a nonverbal learning disorder, andsome pervasive developmental disorders.

COGNITIVE AND EDUCATIONALCLASSIFICATIONS IN

LEARNING DISORDERS

Speech and Language Disorders

Articulation and expressive language dis-orders (Koller, 1999b) can be grossly diag-nosed by taking a history of the child fromthe parents and observing the child speakingor not speaking while seated in the examchair. If the parents have not yet sought pro-fessional help, the child can be referred backto the pediatrician, an ear, nose, and throatspecialist, or a speech and language patholo-gist for further evaluation and therapy withthe primary care physician’s knowledge andconsent. The ophthalmologist is not directlyinvolved in the specific diagnosis or treat-ment of children with these disorders.

Receptive language disorders, in contrast,involve visual processing and perception andshould be more thoroughly analyzed by thepediatric ophthalmologist. Realizing thatdevelopmental dyslexia is now thought to be aresult of a genetically inherited deficiency(Shaywitz, 1998) in cerebral phonetic analysis,the ophthalmologist can deduce the likely pres-ence of dyslexia from the family history and byasking the child a few questions about simplewords, such as “cat” and “bat,” in an attempt to

bring out the inability of such children to iden-tify the components of “bat” as “bu,” “aah,”and “teh.” A history of letter reversals in schooland difficulty reading may not really point to areceptive language disorder alone because non-verbal learning disorders and attention disor-ders can also cause these symptoms in certaininstances. Early preschool identifying charac-teristics include unusual difficulty learningnumbers, letters, and colors without evidenceof eye disease. The ophthalmologist shouldrefer these children to a knowledgeable neu-ropsychologist or speech and language pathol-ogist for further testing to identify all thespecific language disorders existing in eachindividual case and then to recommend diag-nosis-specific therapy. A licensed readingteacher and a homework tutor may both berequired, with additional therapy and monitor-ing by the speech and language pathologist andthe neuropsychologist as necessary.

Auditory processing disorders are in therealm of ear, nose, and throat specialists, as wellas speech and language pathologists, and shouldbe referred to those professionals for appropri-ate, specific diagnoses and therapy (Welsch,1980; Welsch & Healey, 1982). A tutor is oftenhelpful to teach auditory interpretation andattention in the classroom environment.Auditory processing disorders are receptive lan-guage dysfunctions and the “hearing” equiva-lent of “visual” developmental dyslexia. Oneremedial method in reading disorders is to havethe child simultaneously listen to a recording ofthe written text while following the printedmaterial in the book in the presence of a readinginstructor. This therapy is effective if only visualor auditory processing is abnormal, not if thechild suffers from both disorders.

Nonverbal Learning Disorders

Appropriate diagnostic studies establishthis all-too-often missed learning disorder.

248

The ophthalmologist can suspect a nonverballearning disorder (NVLD) by giving theyoung patient a simple visual memory test inthe office. It takes only 1 to 2 minutes to per-form. (See Figure 1.) NVLD is thought to beassociated with right hemisphere white mat-ter dysfunction (Bannatyne, 1974; Foss,1991; Johnson & Myklebust, 1967). The frontallobe may also be involved. The main deficits ofthis disorder include visual-spatial perception,visual memory, psychomotor coordination,complex tactile-perceptual skills, reasoning,concept formation, mathematical abilities, andpsychological/behavioral difficulties.

Well-developed verbal and reading skills,however, are frequently observed in these

children and adults. Occupational therapy isthe treatment path that is most efficient forindividuals with NVLD. At times, therapymust be coordinated with a homework tutor,reading specialist, and/or a physical therapistif other, more complex aspects of NVLD areidentified. Numerous treatment strategieshave been tried over the years but utilizingcurrent repetitive, standard rehabilitation sci-ence techniques seem, at present, to be best.

It is in this category of learning differ-ences that some optometric vision trainingtechniques appear to be effective. These tech-niques are partially based on occupationaland physical therapy principles as well asstandard rehabilitation science. Adults, after

Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 249

Figure 1a-1e. – A Diagnostic Toolfor Categorizing NonverbalLearning Disabilities in School-aged Children 6 to 12 Years Old

(A simple pattern [1a] is presented toa child for 15 seconds. The child isthen asked to draw the pattern frommemory. Figures 1b and 1c areexamples of acceptable normalvariations in children’s drawings.Figures 1d and 1e representvariations that indicate a possiblenonverbal learning disorder.)

Figure 1a

Figure 1b Figure 1c

Figure 1d Figure 1e

strokes, as well as all-aged individuals afteraccidental closed head trauma, are taught toutilize the uninjured functioning parts of theirbrain to compensate for loss of normal use ofan injured or damaged brain area, despite thefact that the area of the brain assuming thenew function was never intended to do so.Stroke patients thus learn to read, write, talk,and navigate once again despite permanentbrain damage to the area previously pro-grammed to maintain those particular func-tions. A similar model exists for childrenwith naturally occurring brain dysfunction,such as the one for nonverbal learning dis-abled individuals. These children are bornwith inefficient or inadequate brain program-ming and processing. Laterality training, eyemovement coordination strategies to helpcreate smooth pursuits (saccades), and hand-eye coordination exercises all help improve,to some extent at least, performance of thosefunctions. To what direct extent learningitself, in a classroom or at home, is enhancedin all cases has yet to be shown via evidence-based science using a masked or doublemasked controlled study. Published studiesreviewed by the author to date are anecdotalor retrospective/prospective reviews of meas-urement parameters or performance, oftenwhile other remedial methods are carried outsimultaneously (Atzmon et al., 1993).

Piaget’s theory stating that “intelligence is themost important instrument of learning” and thatenvironmental interaction is equally importanthas been used as the basis for utilizing games andplay as a medium to enhance the process of think-ing and learning. This was tried in a West Virginiaschool setting by Furth and Wachs more than 25years ago (Furth & Wachs, 1974). Developmentaloptometry has adopted some of Piaget’s theoryfor vision training. The idea is to think before youcan actually learn a fact or concept.

Some optometric exercises (Scheiman,1994) are designed to improve developmental

visual information processing. The first goalof therapy is to develop the patient’s motor-awareness ability by performing isolated,simultaneous, and sequential movementsinvolving both sides of the body. The treatingoptometrist wishes to develop motor memoryof the differences between the right and leftsides of the body. This is typically accomplishedusing balance activities, ball bouncing, chalk-board squares, and other gross eye-hand coordi-nation activities such as beanbag tossing or ballplaying. The second goal of therapy is to developthe patient’s motor-planning ability. This isaccomplished using numerous other techniques,including jumping jacks, the Randolf shuffle, andslap-tap, among others. These strategies seem towork by repetitive, positive psychological rein-forcement and one-on-one patient-therapist inter-action as much as by direct influence on thecerebral academic learning process itself. SinceNVLD involve higher cognitive learning centersin which abstract thinking, visual memory, andspatial recognition are the main deficits, repetitivetraining makes it possible for a child to learn toperform certain tasks more efficiently. “Practicemake perfect” is a commonly accepted theme. If achild with NVLD is taught by optometrictechniques to enhance motor memory, motorawareness, and motor integration—and thisimprovement can be transferred to the academicarena—then the claimed benefits of optometricvision training can be realized. Those who professbenefits from vision training in cases of speechand language disorders, attention disorders, andpervasive developmental disorders (includingclassic autism) are simply not reporting the othertherapies for these individuals being carried outsimultaneously by other professionals, includingpediatric neurologists, psychiatrists, psycholo-gists, language therapists, occupational therapists,physical therapists, educators, and pediatricians.NVLD account for less than 15% of all learningdisabled individuals (Koller, 1999b). Vision

ICDL Clinical Practice Guidelines250


therapy is but one of many interdisciplinary inter-ventions necessary for these individuals.

Attention Deficit/Hyperactivity Disorders

The diagnosis of attention deficit/hyperac-tivity disorders (ADD/ADHD) is establishedby the criteria listed in the DSM-IV, withbehavior repeated over time. Some controversystill exists concerning the real existence anddefinition of these two diagnoses as a separatecategory of learning disorders (Carey, 1999).The pediatric neurologist, pediatric develop-mental specialist, family pediatrician or physi-cian, or psychiatrist usually provides treatment.It is necessary for the ophthalmologist to iden-tify the behavior by listening and observingwhile the child is in the examination chair andreferring appropriately. Pharmacological thera-py is the treatment of choice, with ancillaryremediation from homework tutors, certifiedreading specialists, and, occasionally, occupa-tional therapists. Teaching a child to concen-trate quite often appears to be easier when thepatient is on stimulant therapy such as Ritalinor Adderal. Nonetheless, many pediatric neu-rologists and pediatric developmental special-ists now prefer to reserve drug therapy formore persistent cases.

The Committee on Quality Improvement(Subcommittee on Attention Deficit/Hyper-activity Disorder) of the American Academy ofPediatrics (2000) recently published its clinicalpractice guidelines, Diagnosis and Evaluationof the Child with Attention Deficit/Hyper-activity Disorder, which emphasizes to pedia-tricians the DSM-IV criteria for diagnosingADHD and observing the typical behaviors inmore than one setting, location, and situationover time. Research involving the study of aca-demically efficient individuals with ADHDcompared to those afflicted who are scholasti-cally inefficient was suggested.

Pervasive Developmental Disorders

The ophthalmologist can frequently iden-tify an individual with Asperger’s syndrome orRett syndrome by history and observation ofthe patient’s behavior in the examination chair.Lack of eye contact is often the initial com-plaint and reason for referral to the ophthal-mologist (Koller & Goldberg, 1999). Lack ofsocial relatedness and peer interaction isobtained by the ophthalmologist from thefamily and patient history. The history canalso provide information concerning anintense area of interest or other behavior pecu-liar to individuals with autistic spectrum dis-orders. Definitive diagnosis and treatmentshould be in the hands of a qualified psychia-trist and knowledgeable pediatricians, as wellas occupational and physical therapists, whoare well schooled in diagnosing and treatingchildren with pervasive developmental orautistic spectrum disorders (PDD/AS)(Greenspan & Wieder, 1998). The role of theophthalmologist is to suspect the diagnosisand refer appropriately, noting the high indexof suspicion.

“Vision training” techniques have yet tobe shown to directly influence the maindeficits of autistic individuals. However, somevision training techniques and occupationaltherapy are appropriate for nonverbal learningdisorders that are part of an autistic individ-ual’s component disabilities. Since the autisticspectrum involves people with difficulties insocial relatedness and social skills, use of lan-guage for communicative purposes, and a lim-ited but intense range of interest, manydifferent professionals must become involvedin ongoing therapy. Any eye abnormality pres-ent should be corrected by the ophthalmolo-gist, just as an appropriate specialist shouldtreat any medical condition. If the patient issufficiently functioning and can concentrateon occupational and/or vision therapy tasks,

these tasks should be provided for those com-ponent disorders the PDD/AS patient mani-fests. There is much to be learned in the futurefrom studying these remedial methods withevidence-based science. Optometrists, oph-thalmologists, occupational therapists, andspeech and language pathologists should worktogether to bring about this research.

OTHER DISORDERSAFFECTING LEARNING

Other disorders affecting learning that anophthalmologist frequently sees includeTourette syndrome and some purely mentaldisorders such as anxiety disorder, opposi-tional defiant disorders, and personality dis-orders (Axis-I). Idiopathic sleep disorderscan also affect learning, as can social andfamily dysfunction or poor school instruction(Axis-IV). All these conditions can besuspected from a social and family historytaken by an ophthalmologist in the office.Tourette syndrome is often treated by a pedi-atric neurologist or psychiatrist, whereas apediatric psychiatrist most effectively han-dles the other conditions mentioned.

Several serious genetic disorders are fre-quently associated with learning differences,including familial dysautonomia (Reilly-Daysyndrome) (Groom, Kay, & Corrent, 1997)and mitochondrial cytopathy (Phillips &Newman, 1997). Both these conditionsinvolve multiple systems within the body. Thebrain is a high oxygen/energy uptake organand the mitochondria are the oxygen genera-tors of our cells. Any disease of the mito-chondria affects most organ systems. Theautonomic nervous system is almost non-functional in familial dysautonomia, andbrain processing is also affected. Much more

research in the area of mitochondrial (notnuclear) inheritance must be done to correlatelearning disabilities with these conditions.Familial dysautonomia may also be a partialmitochondrial disorder, as might many othertypes of learning differences and disabilities.

CONCLUSION

As noted previously, having the ophthal-mologist aware of all of the medical and non-medical conditions and situations that couldaffect learning in a child or older individualincreases the potential for a child with learn-ing disabilities to receive appropriate, effec-tive, and timely remedial treatment. It isimportant for one professional to take theresponsibility of coordinating all the special-ists actually involved in the care of any patientwith a learning difference. It doesn’t matterwhat that person’s specialty is, so long as heor she is knowledgeable in the general fieldand has the motivation, passion, and resourcesnecessary to coordinate the efforts ofnumerous physicians, psychologists, educa-tors, and allied health professionals, such asoccupational therapists, physical therapists,optometrists, and speech and language thera-pists. Social workers and attorneys often areinvolved, too. Given the desire, an ophthal-mologist can assume this task easily. The oph-thalmologist is often the first expert to whomthe pediatrician or family physician refers thechild suspected of having a learning differ-ence. However, the pediatric psychiatrist, neu-rologist, or developmental specialist could beequally effective. True multidisciplinary sci-ence and coordination of effort is mandatoryif optimal benefit is to be achieved for allindividuals with learning disorders. ■



American Academy of Pediatrics (2000).Clinical practice guideline: Diagnosis andevaluation of the child with attentiondeficit/hyperactivity disorder. Pediatrics,105(5), 1158-1170.

Atzmon, C. O. et al. (1993). A randomizedprospective masked and matched compar-ative study of orthoptic treatment versusconventional reading and tutoring treat-ment for reading disabilities in 62 children(including pro and con editorial commentsby Drs. Hardenbergh and Cibis Tongue).Binocular Vision & Eye Muscle SurgeryQuarterly, 8(2), 91-106.

Bannatyne, A. (1974). Diagnosis: A note onrecategorization of the WISC scaled scores.Journal of Learning Disabilities. 7, 272-274.

Bedrossian, E. H. (1969). The surgical andnonsurgical management of strabismus.Springfield, IL: Charles C. Thomas.

Carey, W. B. (1999). (in commentaries).Problems in diagnosing attention andactivity. Pediatrics, 103(3), 664-667

Foss, J. M. (1991). Nonverbal learning dis-abilities and remedial interventions.Annals of Dyslexia, 41, 129-131.

Furth, H. G., & Wachs, H. (1974). Thinkinggoes to school, (Piaget’s theory in prac-tice). Toronto: Oxford University Press.

Gable, J. L. (1984). Visual disorders in thehandicapped child. San Mateo, CA: MacelDekker.

Greenspan, S. I., & Weider, S. (1998). Thechild with special needs. Reading, MA:Perseus Books.

Groom, M., Kay, M. D., & Corrent, G. F.(1997). Optic neuropathy in familialdysautonomia, Journal of Ophthalmology,17(2), 101-102.

Hartstein, J. (1971). Current concepts indyslexia. St. Louis, MO: Mosby.

Johnson, D., & Myklebust, H. R. (1967).Nonverbal disorders of learning. In LearningDisabilities Educational Principles andPractices. New York: Grune and Stratton.

Koller, H. P. (1997). How does vision affectlearning? Journal of Ophthalmic Nursing& Technology, 16 (Vol. I), 7-11.

Koller, H. P. (1999a). Visual perception andlearning differences: An ophthalmologist’sview. American Orthoptic Journal, 49.

Koller, H. P. (1999b). How does vision affectlearning? Journal of Ophthalmic Nursing& Technology, 18(1), 12-18.

Koller, H. P., & Goldberg, K. B. (1999). A Guideto visual and perceptual learning disabilities,Current concepts in ophthalmology, 24-28.Pennsylvania Academy of Ophthalmology.

Leguire, L. E., Rogers, G. L., et al. (1998)Occlusion & Levodopa-Carbidopa Treat-ment for Childhood Amblyopia. Journal ofAAPOS, 2(5), 257-264.

Miller, N. R. (1998). Neuro-OphthalmologicTopographic Diagnosis of Tumors andRelated Conditions. In Walsh & Hoyt(Eds.), Clinical Neuro-Ophthalmology(pp. 1137-1242).

O’Hara, M. A., & Koller, H. P. (1998).Migraine in a pediatric ophthalmologypractice. Journal of Pediatric Ophthal-mology & Strabismus, 35, 203-208.

Parks, M. M. (1975). Ocular motility and stra-bismus. Hagerstown, MD: Harper & Row.

Phillips, P. H., & Newman, N. J. (1997).Mitochondrial diseases in pediatric ophthal-mology. Journal of AAPOS, 1(2), 115-122.

Reinecke, R. D. (1965). Refraction: A pro-grammed text. New York: AppletonCentury-Crofts.

Reinecke, R. D. (1997). Idiopathic infantilenystagmus: Diagnosis & treatment. Journalof AAPOS, 1, 67-82.

REFERENCES


Scheiman, M. M., & Rouse, M. W. (1994).Optometric management learning-relatedvision problems. St. Louis, MO: Mosby.

Shaywitz, S. E. (1998). Dyslexia: Currentconcepts. New England Journal ofMedicine, 338(1), 307-312.

Simon, J. W., & Calhoun J. H. (1998).Amblyopia: A child’s eyes. Gainesville, FL:Triad.

Welsh, L. W., Welsh, J. J., & Healey, M. P.(1980). Central auditory testing anddyslexia. Laryngoscope, XC(6), 972-984.

Welsh, L. W. et al. (1982). Cortical, subcorti-cal, and brainstem dysfunction: A correla-tion in dyslexic children. American Journalof Otolaryngology, Rhinolaryngology andLaryngology, 9(3), 310-315.


Appendix

VISUAL PERCEPTION AND LEARNING DIFFERENCESIN PEDIATRIC OPHTHALMOLOGY:

What the Ophthalmologist Needs to Knowabout Learning Disabilities in Clinical Practice

I. Ophthalmic Causes of Temporary Learning Impairment and InefficiencyA. Strabismus, amblyopia, and refractive errors

1. Decompensated accommodative esotropia with secondary diplopia2. Secondary ocular cranial nerve palsies (n. III, IV, VI)3. Uncorrected congenital vertical strabismus with abnormal face and head positions4. Bilateral very high ametropias, such as bilateral amblyopia of high hyperopia5. Bilateral occlusion amblyopia, such as after congenital cataract surgery6. Associated untreated “A” and “V” syndromes7. Convergence insufficiency exotropia/phoria in certain individuals

B. Nystragmus of moderate to severe degree causing significant vision lossC. Pediatric ocular diseases that can affect learning via visual and emotional effects

1. Severe juvenile rheumatoid arthritis and related ocular inflammations2. Congenital glaucoma with vision loss3. Congenital cataracts and major corneal opacities with vision loss and nystragmus4. Significant unilateral and/or bilateral ocular trauma with vision loss5. Ocular and adnexal neoplasms with secondary disfigurement and vision loss6. Severe chronic ocular infections such as HSV-I with vision loss7. Congenital and degenerative retinal diseases affecting the macula

II. Neuro-ophthalmic Causes of Temporary or Intermittent Learning Impairment andInefficiencyA. Brain tumors causing a change in personality and behavior in a pediatric patientB. Migraine syndromes

1. Acephalgic pediatric migraine with visual disturbances and variable vision inschool

2. Ophthalmic migraine in childhood3. Ophthalmoplegic migraine4. Classic migraine in the older student

C. Optic nerve disease with significant visual impairment

III. Systemic Diseases Associated with Vision and Neurologic Dysfunctions PotentiallyAffecting LearningA. Metabolic and endocrinic disordersB. Blood dyscrasias affecting the eye and brainC. Metastatic neoplastic disease to the eye and/or brain

255


IV. The Ophthalmologist’s Role in Examining a Child and Advising the Family of a Defectin visual processing and/or learning is to rule out the presence of eye disease or related sys-temic disorder and to refer the pediatric patient to the proper professionals for more defin-itive diagnoses and subsequent treatment(s). In order to effectively do this, a classificationof non-ophthalmic learning disorders will now be outlined.A. Learning disabilities (differences)

1. Developmental speech and language based disorders (epidemiology)a. Articulation disordersb. Expressive language disordersc. Receptive

(1) Dyslexia—phonologic processing disorder(a) genetics(b) pathophysiology(b) remediation(d) early preschool identifying characteristics

(2) Other receptive language disorders2. Nonverbal learning disabilities (epidemiology)

a. Definitionb. Characteristics and affected areas of learning

(1) visual-spatial perception(2) visual memory(3) psychomotor coordination(4) complex tactile-perceptual skills(5) reasoning(6) concept formation(7) mathematical abilities(8) psychological behavioral difficulties(9) good verbal and reading skills

c. Early identification traitsd. Differential diagnosise. Methods of treatment. What exactly is optometric vision training?f. Rationale of therapy based on the traditional closed head trauma/stroke

rehabilitation model3. Attention deficit hyperactivity disorder (epidemiology)

a. Definitionb. Characteristics (DSM-IV) and diagnostic criteria observable during an

eye exam(1) squirms in seat, fidgets with hand and/or feet(2) unable to remain seated when required to do so(3) easily distracted(4) blurts out answers before a question is finished(5) difficulty following instructions(6) unable to sustain attention in work activities(7) interrupts or intrudes on others

256


(8) does not appear to listen(9) loses items for tasks such as toys, pencils, and books(10) often engages in dangerous activities without considering the

consequencesc. Subclassification

(1) inattention(2) impulsivity(3) hyperactivity

d. Differential diagnosis(1) Tourette’s syndrome(2) conduct disorder(3) oppositional defiant disorder(4) other tic disorders

e. Treatment and community support(1) pediatric neurologist(2) pediatric developmental specialist(3) pediatric psychiatrist(4) special education teacher or tutor(5) various support groups

4. Pervasive developmental disorders/autistic spectrum disorders (PDD/ASD)a. Definitionb. Characteristics: defects in social relatedness and language/

communication skillsc. Subclassifications

(1) Asperger’s syndrome (chief eye symptom is “lack of eye contact”)(2) Rett syndrome(3) classic autism(4) unclassified PDD/ASD

d. Referral and treatment optionse. Micro and primary dyskinetic strabismus as a presenting sign of PDDf. Hyperlexia

V. Patient Support Groups for Learning Disabled (LD) IndividualsA. CHADD (Children and Adults with ADD)B. CEC (Children’s Educational Counsel)C. ASLHA (American Speech, Language and Hearing Association)D. LDAA (Learning Disabilities Association of America)E. PERC (Parents Educational Resource Center)F. The Orten Dyslexia SocietyG. AHA (American Hyperlexia Association)H. HALO (Health Achievement Learning Opportunities Centers)

257


VI. Role of the Pediatric and Comprehensive Ophthalmologist Concerning Individualswith Learning DisabilitiesA. Identify and treat any eye or eye-related systemic disease or abnormality.B. By observation and careful history, identify which broad category of learning differ-

ences the patient likely has and convey that impression to the pediatrician, the family,and any other interested parties. These children have often been through manypsychological tests, tutoring, and other attempts at remediation without a definitivediagnosis or combination of diagnoses. Suggest a comprehensive neuropsychologic/educational evaluation from a qualified, credentialed neuropsychologist when all inter-ested parties agree.

C. Help the family by giving them a direction in which to proceed so that the child withnon-ocular learning differences can start to achieve his full potential. Not every indi-vidual with learning disabilities requires every possible specialist. These professionalsinclude:1. Pediatric neurologist2. Pediatric psychiatrist3. Pediatric developmental specialist4. Pediatric endocrinologist5. Pediatric geneticist6. Pediatric otolaryngologist7. Pediatric ophthalmologist8. Speech and language pathologist (audiologist)9. Neuropsychologist10. Educational psychologist11. Educator with special education credentials12. Reading tutor13. Physical therapist14. Occupational therapist15. Pediatric social worker16. School placement expert (educator)17. Disabilities attorney18. Family physician or general pediatrician

D. A specialized attorney is often beneficial for helping families receive federal LD ben-efits to which they are entitled under the terms of the Individuals with DisabilitiesEducation Act (IDEA) and Americans with Disabilities Act (ADA).

E. When the answer the question, “Is the child’s reading and/or learning problem in schooldue to his eyes?” is “No,” the ophthalmologist must explain why it is not and offer apositive and constructive method to direct those families toward obtaining the properand appropriate care. The public still believes that eye specialists are knowledgeable inthe field of visual perception as well as visual function.

258

an ophthalmologist’s approach to visual processing learning differences harold paul koller

Health & Medicine