Vision, Reading, and Dyslexia Evaluation

Detailed Description of Evaluation

CASE HISTORY 

Your first step is to complete a case history form to provide the doctor with clues on ways vision may be impacting reading.

EYESIGHT

Acuity  (See Chapter 2 of When Your Child Struggles)

“20/20 acuity” means that you can see at twenty feet what you are supposed to see at twenty feet.  At reading distance, “20/20 acuity” means you can see clearly long enough to read a half-a-dozen letters.  It does suggest that seeing remains clear during the effort needed to decode words.  It says nothing about clear seeing during sustained reading. 

Refractive Error (See Chapter 3 & 4 of When Your Child Struggles) 

“Refractive Error” is a term to describe the strength of the glasses needed to see clearly and comfortable when looking far away. 

EYE-MUSCLE COORDINATION (See Chapters 6 and 7 of When Your Child Struggles)

There are fourteen eye muscles that are used to keep things clear and single and stable.  Poor coordination between these fourteen muscles can dramatically increase the effort needed for reading and cause eyestrain, double vision, blurred vision despite 20/20 acuity, headaches, loss of concentration, trouble remembering what is read, loss of place, having to reread sentences.

The more difficult reading is, the more important good eye coordination becomes.  Compare, for instance, the fatigue experienced reading a best-selling novel written at fifth grade level compared to the fatigue experienced reading near the edge of your reading level: the higher the thinking demand, the more critical you visual skills become.  Thus eye coordination becomes especially critical for children with reading disabilities.      To evaluate eye coordination, we perform up to fifteen different tests, many of which are not normally included in routine eye exams.  The tests are selected from the following:

• Cover Test—a procedure to determine if effort is required to keep the eyes from turning inward or outward (phoria) or if crossed or wall eyes are present (strabismus).
• Near Point of Convergence—how close to your nose can you correctly coordinate your eyes
• Stereopsis—two-eyed depth perception
• Worth Four Dot—a test using red-green glasses to determine if double vision exists or if the patient ignoring (suppressing) information from one or both eyes
• Stereoscope—an instrument that assesses subtle misalignment of the eyes or loss of information from the eyes (suppression).
• Computer-Generated Randot Stereograms—an instrument which tests convergence and divergence.
• Prisms and Lenses—provide a measure of visual flexibility, a measure of how much extra stress can be applied before the visual system breaks down and confusion occurs.  The technical names for such tests of flexibility (names which need not be understood, include the following
  • Positive relative convergence,
  • Negative relative convergence,
  • Positive relative accommodation
  • Negative relative accommodation
  • Accommodative facility
  • Vergence Facility

VISUAL ATTENTION: EYE MOVEMENTS 

(See Chapter 8 of When Your Child Struggles)

Visual attention is the ability to accurately aim the eyes at what is being viewed.  If a child doesn’t aim the eyes accurately, and instead uses peripheral seeing, visual information is poor.  We measure visual attention by the child’s ability to maintain fixation on a moving light.  The following performance is expected:

• Below age 5—Difficulty maintaining fixation with or without head movement.
• Age 5—Maintains fixation, but needs to move the head or muscles of the face.
• Ages 6-7—Can maintain fixation without head movement, but full attention is required.
• Ages 8 and above—vision is now dominant.  Can maintain fixation while simultaneously doing simple math problems or answering questions.

VISUAL TRACKING (See Chapter 8 of When Your Child Struggles)

Visual tracking is the ability to move the eyes along a line of print.  We evaluate the skill with the King Devick Visual Tracking Test.  The test uses numbers rather than words so we can tell how much of a tracking problem is due to eyes and how much is due to language skills.  In other words, we are trying to determine if poor spatial awareness is causing loss of place when reading and decoding or if there a language problem causing confusion and loss of place.  Some readers suffer from one problem or the other.  Some suffer from both. 

VISUAL PERCEPTION (See Chapter 9 of When Your Child Struggles)

Vision perception can be defined as the ability to make sense of things, to tell how they appear alike and different.  How does a “b” appear to be different than a “d”?  How does “was” appear to be different from “saw”?  How does “they” appear to be different than “the” or “them”?  How does “law” appear different than “saw” or “lawn”? 

When a child is young, the world is made of two directions: “out away from me” and “in toward me.”  For such a child a b and a d are the same: both have an up-and-down line and a half circle, and the half circles go “out away from me.”  Children first learn right and left on themselves and then in space.  Right and left must be understood in space before memory tricks (such as constructing “bed” with two fists and two thumbs) can be used and b’s and d’s drilled to the point of recognition.  

To evaluate vision perception, we adapt a test from Piaget to informally test if the child understands right and left concepts.  We may also use the 1968  version of the Beery Test of Visual Motor Integration to screen for visual perception.  For younger children we may use subtests from the Gardner Test of Visual Perception, Non-Motor to determine if the problem exists when only the eyes are used and the hands are taken out of the act. 

HAND-EYE COORDINATION (See Chapter 10 of When Your Child Struggles)

How well do your child’s eyes guide his hands and body?  If the eyes do not properly guide the hands, then learning to write is difficult despite proper instruction.  Catching a ball or learning to ride a bike may be difficult.

If hand-eye coordination is difficult, one step is to insure that good visual attention, perception, and eye-muscle coordination allow the patient to use vision to guide the hands.  Another step is to insure that the eyes and hands are coordinated with one another.  We evaluate fine motor coordination using the Motor Speed and Precision Subtest of the Detroit Test of Learning Aptitude.  We evaluate visual motor integration using the Beery Test of Visual Motor Integration.

VISUALIZATION (See Chapter 11 of When Your Child Struggles)

Visualization is the ability to create images in the mind.  Here are some examples:

1. Picture a four or five letter word in your mind such as HOUSE.  Close your eyes and keep picturing the word.  Spell the word backwards.

2. Manipulate the parts of a word in your mind: for instance, picture the word C A T in your mind. By picturing, replace the C with a F.  What word do you now see in your mind?  Replace the T with an N.  What would do you see?  Replace the A with an I.  If you were able to picture the letter changes, then you should now have the word   F I N in your mind. 3. Imagine that you find the following words in a paragraph: COWBOY, HORSE, ROPE, COW.  Picture in your mind what is probably happening.  Did you picture a cowboy on a horse, roping a cow?  Now add some details: Does the cowboy have a hat?  What color is the horse?  What color is the cow?  Is all this happening on grass or dirt?

Whether we are learning to spell, read, or understand words, visualization can open the door to success.  Visualization may also open the door to the past and allow you to see your goals for the future.  If certain language skills are difficult, visualization can be used to help get around the problem, to match the pictures in the reader’s mind to the pictures in the readers mind to the scene the author had in mind. 

We evaluate visualization either informally or using the Monroe III Visual Memory Test. 

READING SCREENING   

We do not assess which exact decoding skills are missing.  We will not, for instance, determine if your child knows that the eigh in neighbor and weigh makes the “long A sound.”  We will not assess the exact vocabulary skills of your child. If your child easily understands when being read to, vocabulary is less likely a problem.  If your child does not understand when read to, you will need a language evaluation as well.  We will instead look at some skills commonly missing in children who do not “teach themselves” to read during a standard reading program. 

Phonemic Awareness

Phonemic Awareness the ability to break down a stream of sound into its parts.  If you cannot recognize the sounds in a word, it is difficult to match symbols (letters) with those sounds.  Test questions for this area may include such commands as “Say ‘steamboat.’  Now say it again but don’t say ‘boat.’” “Say ‘pick.’  Now say it again but don’t say ‘p’ [make p sound].”   Or “Say ‘scat.’  Now say it again but don’t say ‘C’ [make k sound].”  We assess phonemic awareness using the Rosner Test of Visual Analysis Skills. The test examines the basic types of phonemic awareness skills necessary for learning phonics.  Different skills are expected in kindergarten, first, second, and third grade.  

Automatic Naming

Automatic Naming is a measure of how quickly the child can look at a symbol, remember what to call it, and produce the sound.  If deficient, automatic naming makes eading out loud more difficult.  Difficulty with automatic naming often accompanies language-based reading disability (sometime called dyslexia).  Automatic naming may be improved but sometimes does not respond fully to therapy, whether visual or academic.  If automatic naming is difficult, phonics (“sounding out words”) is often difficult and the child’s ability to picture images in the mind (visualization) can be used to allow improved sight vocabulary and less demand for phonics.  It is important to know how to sound out a new word once.  If you need to sound out the same word in the next line there is a problem with either perception, poor eye-teaming causing visual confusion, or not using visualization. 

To evaluate automatic naming we use the first section of the King-Devick Tracking Test, a section in which the numbers read are all connected by lines, reducing the need for tracking ability and highlighting the ability to rapidly name symbols.  

Informal Oral Reading

Dr. Cook listens to paragraphs read from the Gates Oral Reading Test.  He looks for an approximate word-calling level and for what types of errors are made.  Sometimes he checks how using a pointer to maintain accurate fixation helps.  He checks how covering one eye affects reading: does the child’s reading improve when not having to coordinate two eyes?  He is interested in gaining a feel for both basic reading skills and how vision is affecting reading.

Summary

When the evaluation is complete, Dr. Cook will go over the results with the parent or parents.  If vision therapy is likely to improve reading performance, he will suggest that a consultation be arranged during which both parents, if possible, to go over a written report and get their questions answered.

Is there an undetected visual perceptual or eye-coordination problem contributing to the reading issue? Could your child’s struggle be related to amblyopia vision therapy or need targeted amblyopia exercises? For those with convergence insufficiency, sustaining focus on text can be a challenge despite interest. Visual processing difficulties, such as letter reversals or poor eye-hand coordination, may also play a role.

At Cook Vision Therapy Center, we address these questions and more, aiming to improve both visual skills and reading comprehension.