Use Of Orthoptics In Dyslexia

The Use of Orthoptics in Dyslexia

Haskel M. Haddad, MO, Nancy S. Isaacs, MS, Karin Onghena, and Ayala Mazor'

supervision of a parent. a relati ve. or a teacher. Follow up was on monthly or bimonthly intervals. Tropia. including esotropia, exotropia and hypertropia. alternate suppression, and all monocular cases were not in­ cluded in the study.

RESULTS

In 73 children with reading difficulty, ophthalmological evaluation show-ed that 18 had ~rt refractive errors. 18 had dyslexia and no ocular anomalies, and 37 had impaind Jusional amplitudes. 24 oj whom wen dyslexic. In all patients with poor fusional amplitudes the reading mechanism could ~ impf'Otled with orthoptic exer­ cises designed to augment the Jusional amplitudes. The treatment did not affect the perceptual deject associated with dyslexia.

D

yslexia is a perceptual disorder which literally means reading diffi­ .culty (Money 1966, Public Law 91230 Title VI). There are cases, however. whose reading difficulty may not be as­ sociated with a perceptual defect. Dys­ lex.ia was first described by ophthalmolo­ gislS, yet the role of ophthalmology and orthoptics in the management of reading difficulties is not well defined (Eames 1948, Benton. 1961). In the past decade. the author in his capacity as a pediatric ophthalmologist examined many children referred because of reading difficulty (as a symptom or complaint). The study of these children and their follow up by learning disability specialists shOW'ed that they fall into three basic categories: ( 1) Refractive error contributing to reading difficulty. (2) Poor fusional amplitudes either in the fonn of convergence insufficiency or convergence excess causing confusion at near and thus contributing to reading difficulties. (3) An actual perceptual problem (dys­ lexia) with reading difficulty with or without fusional amplitude defect.

During the school years of 1976-1978. 73 children ranging in age from six to 13 years, with a male to female ratio of seven to one, were referred with reading difficulties (Table 1). Eighteen children had overt refractive errors (Primarily astigmatism, high myopia and high hy­ peropia--refractive errors causing near vision blurr and/or confusion) with no other ophthalmological or orthoptic disor~ ders. With the prescription of glasses the reading difficulty was soon ameliorated . Eighteen other children had dyslexia with no abnonnal ocular manifestations either in the fonn of refractive error or in the fonn of orthoptic defect. Thirty-seven children (Table 2) had impainnent of the fusional amplitUdes with occasional small degree of myopia or hyperopia ranging between maximums of 1.75 and + . 1.50. Of thes~, 24 were d~xic and 13 showed no perceptual defect. 21 had exophoria with convergence insufficien­ cy, 12 had esophoria with convergence excess, and four were orthophoric.

modified Monroe method CMonroe 1932) which consists of: 1) the evaluation of the time span of unintelTUpted reading by the child before the learning disability specialist, 2) delineating the degree of attentiveness during a period of reading, and 3) detennining the degree of under­ standing or recall of what was read by the child. Every child had a complete ophthal­ mological examination which included distant and near vision. refraction and cycloplegic retinoscopy (for objective re­ fraction). funduscopic and slit lamp ex­ aminations, orthoptic analysis with phoria testing (ability of sustaining binocularity) including the measurement of fusional amplitudes at distance and at near, and troposcopic evaluation (using an instru­ ment for phoria testing subjectively). Tab'e 1. Orthoptic exercises were aimed at: 1. Correction of the near point of con­ 73 Children vergence CNPC) when present. with 2. Correction of the fusional ampli­ Reading tudes Cat near in particular) using fram­ 1078-1078 Difficulty ing exercises. Age 61013 3. Anti-suppression exercises (when years MaJ.:F.male 64:9 monocular suppression existed) using red Refractive Error Alone 18 filter tracing or cat stereograms. Dysl.xla (Perceptual Defect) 18 Material and Methods 4. Relaxation exercises and physiolog­ Alone ical diplopia training to imprc:M: on any Poor Fusional Amplitudes 37 The cases included in this study were degree of accommodative spasm or eso­ With Dyslexia 24 Without Perceptual Defect 13 children referred from private or public phoria which might aggravate the fusional schools, children referred by special edu­ amplitudes. S. Fusional exercises using the tropo­ cational teachers. and children referred by learning disability specialists or speech scope when indicated and when home ~pists.-AIL -eases..JNefe-.l'ef.ene(L..be.". . exercises ..were.JlOl-.sufficientlyJle.1pfuL.._._._~uslonal .. amplitudes. were..~o~.idc:rc:d. Except for the latter, all orthoptic ex- nonnal at the range of four to six A cause of reading difficulty. The reading evaluation was done by a ercises were done at home under th~ ,,_ (ptism diopters) base-in (81) at distance 142

Journal of L,ornin~ DlSobililifJ

will be much further aggravated when ,he child has an added perceptual problem as in dyslexia. When the neuro-muscular and innervational factors involved in the fusional process, especially in conver­ gence and accommodation, are faulty to some extent, but not severe enough to produce exotropia or esotropia, i.e., not severe enough to cause monocularity, then the child will attempt to fuse at all costs. This impulse to fuse will fatigue the child, especially when he has to maintain and sustain fusion for a long period of time as is the case during reading. When such a difficulty develops during reading, the first manifestation will be that of focusing difficulty, since the child cannot sustain binocularity for a long period of time and thus will keep trying to focus each word separately. Al­ ternately, he will have to go back from one word to the other in order to main­ tain fusion. The second step results from image confusion during reading, which particularly develops as a result of crossed diplopia, as in convergence in­ sufficiency. Thus the child will begin to see the words shifting backwards, and thus he will shift his gaze from right to left as he tries to continue to read. The child will complain that tnt letters appear to move . from right to left. The learning disability specialist often mentions that while reading, the child appears to be unable to follow the reading material on the line in a continuous fashion and will make stops at each letter, a process which becomes very tiring. This was recently corroborated by electro-oculographic studies of the eye movements (Kraus­ Mackiw. Muller-Kuppers, & Rabetgc 1978). .Even though this study is directed to the orthoptist, there is no reason why the ophthalmologist who examines pre­ school and school age children may not be able to institute such orthoptic exer­ cises for the child without having to have the help of an orthoptist in his office. An orthoptist might be better equipped for follow up and for training, but the oph­ thalmic student should be trained to do the same when he does not have access to an orthoptist.

Table 2.

37 21 12

4

C~lIdren

with Poor Fusional Amplitudes: (Convergence Insufficiency) (Convergence Excess) (Orthophoric)

X S

0

20 Both Convergence and Divergence Poor 13 4

Only Convergence Poor Only Divergence Poor

Table 3.

Rate of Reading Improvement Modified Monroe Method Length of Uninterrupted Reading Attentiveness Recall--Understanding \ Subjective

l

Amplitudes

o to 2 Months

16 2 to 4 Months

15 4 to 6 Months

4 Over 6 Months

2

and eight Ll to 12 Ll (prism diopters) base-in (81) at near for divergence, and 18 Ll (prism diopters) base-out (80) for distance and 30 Ll (prism diopters) base­ out (80) at near for convergence. In the 37 children studied and found to have poor fusional amplitudes, even those with dyslexia. orthoptic exercises resulted in improvement in the attention span (Table 3). The rate of improvement was faster in the group without perceptual defect, and in the group with divergence instead of convergence insufficiency. The learning disability specialist usually. reported im­ provement in the reading ability as a result of improved focusing. Prior to orthoptic treatment, the child was noted to stop his gCize at each word read, and often lost it, eventually losing interest in continuing to read. Often the child ap­ peared as if daydreaming, especially those with convergence insufficiency.

Discussion It should be emphasized: I. That even though dyslexia is not an ophthalmologi­ cal disease, the process of reading may be affected by the fusional amplitudes of the child especially if there is intermit­ tent diplopia as a result of convergence Volume /7. ."umber 3. March 1984

Reading

Improvement o to 2 Months 2 to 6 Months Very Slow

29 4 4

insufficiency or convergence excess. 2. That reading difficulties may not only be related to perceptual defects and dyslex~ ia, because there are children whose read­ ing difficulty is not accompanied by per­ ceptual defect. 3. That children with dys­ lexia and reading difficulty with normal ophthalmological examination and fu­ sional amplitudes do not benefit from orthoptic exercises or any other ophthal­ mological attention. 4. That parents, orthoptists, learning disability specialists and ophthalmologists should accept the proposition that Qrthoptic exercises given to the child with dyslexia do not affect the perceptual problem of the child, and that the ophthallllologist or orthoptist are not treating dyslexia or the perceptual problem of dyslexia, and that orthoptic exercises affc:ct only the fusional ampli­ tudes and thus help the reading process, and not the perceptual process. In a child, if there is a frank fusion disturbance, he will either qevelop sup­ pression, amblyopia or alternation. How­ ever, if fusion is relatively well estab­ lished, but the f~sional amplitudes are disturbed, especially at near, then a 'struggle' will ef!sue when the child at­ REFERENCES tempts to maintain fusion, especially dur­ Benton. J. D. Jr. Ophthalmological approach to the problem of retarded readers among elemen­ ing the reading process. The difficlilty y

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tary sclwel child~n. Journal of th~ Florida Association. 47. 1123. 1961. E~s, T. H. Comparison of ~~ conditions among Ofl~ lhou.sand r~ading failuns. flw hund~d oph­ thalmic pati~nts and Ot1~ hundr~4 fifty unsd~('Ud childnn. Amaican Journal of OpJuhalmology. 31. J7IJ. 1948. "Education of tlu Handicapp~d Act", Public Law M~dical

9 I 230

Tit/~

VI.

Kraus-Mack.ik'. E .. Mulla-Kuppu3. M. de

Rab~/g~.

G. Binocularity in Tul-to-Ttwlvt Y~ar Old Chil­ dnn with Poor Writing and R~ading Ability, Pro­ cudings of Ihe 761h Cong~ss of Ih~ G~rman Ophthalmological Society. Dusulldorf. Volum~ 17. 1978. p. IJ5. Monq. J. Th~ Disab/~d &ada. Education of th~ Dysluic Child. Ballimon. Md: Johns Hop;;ins p~ss. 1966. Monrw. M. Cnildnn Who Cannot R~ad, Chicago. /II: Uniwrsity ofCnicago !,~ss. /932.

ABOUT THE AUTHORS Hesk~1 M. Haddad is clinical prof~ssor of oph· thalmology at Ih~ N~ York M~dical ColI~g~ in OpJuhalmowgy. H~ is also th~ ~dilor.in·chi~f of M~tabolic. P~diatric. and Sysumic Ophthalmology. Nancy ~. Isaacs, MS, is an ~ducational psycholo­ gist in privau pro.ctia, Karin Onghena is an onhoptis./, Ayala Mazor is also an orthoptist, Ad­ dIYss: H~st~1 M, Haddad. MD. 9 East Y6th 51,. N~ York. NY 10128,

~eMOJt

~uwm~~~

by Burton Blatt, EdD

THE CHAMELEON WHO WOULD

LIGHT UP THE WORLD

ohn Mid~lebr~ks was a cham~leon., but ,also a professor of Amencan history at Methodlst Umverslty. He was also the ugliest of human beings, but nevertheless the most beauti­ ful. He would be shunned on first sight, but those who knew him would not leave his presence. He repelled the unaware and pulled the knowing. That is. there were people on earth who would rather be with the devil himself than with him; yet there were others who might rather risk God's wrath than John Middlebrooks' dismay. He was a physical misanthrope with an inner radiance, at once the most unappealing and appealing person on earth. Have you ever known a person who lights up the room with his entrance, causes people to smile without telling the joke. and makes everyone feel good to be alive when the only thing to cheer about is that he's in their presence? How did this five­ foot. four-inch, iII-shapen, too heavy around the middle and to skinny around the neck and the legs, man with bad skin and worse teeth, with too few hairs where they belongeq and too many around the ears and on the back of his hands. ~o it? Speak of inner beauty and inner grace. he proved such lofty notions actually exist outside of the meanderings of wild romantics and wilder still revolutionaries. How did he do it? Better, what did he do? The colleague who saw himself as a great literary scholar knew that John Middlebrooks-cnly John Middlebr~ks­ could understand his work, could not only unders~d but could discuss and clarify, could not only discuss an~ ~larify but could interpret in ways that almost none but he-the would-be literary scholar-could, that is if he really could, which he couldn't. The colleague who saw herself as a poet surrounded by technicians who spent their time doing things, but would never waste their time merely trying to understand

J

/44

things, had a confederate in lohn Middlebrooks, a man who valued her poetry. her sensitivity, her good fight against the philistines. The moralist who would save the world' for God if not His people knew for certain that lohn MiddlebrOOks "played the heathen" to turn them to the right path, the patch that only John and he--the doomed prophet-knew the loca­ tion of and how to travel it. The scientist could talk with John Middlebrooks for hours about everything from t1irtnite atoms to black holes to entropy to human sacrifice in the name of science, and the scientist's sacrifice in the cause of humanity. John Middlebrooks wasn't all things to all people, not by any accounting. lohn Middlebrooks had that rarest of all gifts, that most precious of all attributes, an uncanny capa­ bility to bring out in other people that which they held most sacred, most ennobling. The chameleon could not only under­ stand the poet's exotic ideas and overburdened analogies, but he had some sort of knack which helped the poet sharpen and clarify her own work. He had a. way to convince the moralist that he was good, that his pase',wasn't a pose (which he would have otherwise believed) .and that his righteousness wasn't Self-righteous (which it would otherwise have been). John Middlebrooks both listened to what a man appreciated in himself and helped tum the boast from an illusion to the truth, from hypocrisy to understatement. John Middlebrooks saw in people hot what they were but what they wanted to become, and then he convinced them that th~ were right. that this one could be a great scientist, and that one couJd be a great, scholar. and the other one could be that single person on earth who would save die world from itself. . John Middlebrooks was a chameleon. But unlike the reptile who would change to become invisible and. thus, to hide from the world. John Middlebrooks changed to meet the world. lohn Middlebrooks was both the chameleon and the catalyst. He changed so others would change. It couid truly be ~aid that lohn 1'1jdli~ebrooks gave himself to his fellow man. Journal of uarning Disabilitin