Do you see what I see?

VERONICA TAY

When her seven-year-old daughter, Zoe, struggled to keep up with school work, Michelle Clarke scheduled an appointment to have her eyes checked. “Zoe was below average in class and was having a lot of trouble reading and writing. For instance, she would mix up her b’s and d’s. She didn’t like to learn at all.

“Her teacher highlighted that she was squinting a lot in class and felt that she had some eye problems that was affecting her learning,” says the 36-yearold stay-at-home mum. Mention poor grades and more often than not, learning disorders like dyslexia and attention deficit disorder come to mind. But what does your little one’s vision have to do with those persistent Band 3 or 4 scores?

Plenty, it seems. Vision and learning are closely related. For children to reach their full academic potential, good vision is important, says Yap Tiong Peng, a senior consultant optometrist trained in behavioural optometry at Igard Group Singapore with 18 years of clinical and research experience. Behavioural optometrists look at how the eyes and brain function as they process visual information, and how that may affect development in children.

Yet, vision is an oftneglected aspect in childhood. About one in 10 children are at risk of an undetected vision problem, according to the American Optometric Association.

Studies show that nearly half of children who struggle to read and learn in school complain about vision-related issues, Tiong Peng explains. At Igard’s centres, about seven in 10 patients seen are children with suspected vision problems. Optometrist Titus Wu of Titus Eye Care, who has been in practice for nine years, estimates that as many as one in four children he sees in his practice may have learning difficulties linked to their vision woes, which are mostly due to undetected myopia and binocular vision-related issues.

Binocular vision refers to the ability to process information when both eyes work together at the same time. This is as important as having clear vision in each individual eye, he says. For instance, if your eyes do not coordinate well, you may have trouble reading or maintaining focus on an object, explains senior consultant optometrist Rachel Kelly of Igard.

According to Tiong Peng, there is growing evidence based on UK-based optometrist Bruce Evans’ research to suggest that binocular vision problems contribute to reading difficulties and spelling errors. Prof Evans is from the UK Institute of Optometry and City University. These children tend to feel fatigue and have headaches when reading and studying. They may also skip small words when reading, reread sentences and insert words that do not exist in the text, says Kelly.

She adds: “The child may appear inattentive in class, avoid reading and studying, make careless mistakes and have difficulty completing assignments. Sometimes, the symptoms only show up intermittently when the child has to read a larger volume of text, especially when running up to the school examinations.” As such it is not unusual for parents and teachers to dismiss the child’s complaints as a behavioural issue, when he might be struggling with poor vision.

HOW GOOD IS GOOD EYESIGHT?

A common misconception parents have is that their kid has perfect vision which allows him to read and write well, just because he aced his cursory eyesight test during school check-ups, say the optometrists. Titus reckons that about 15 per cent of children who pass a vision screening test actually have a vision problem that requires intervention.

In Singapore, the Health Promotion Board (HPB) conducts yearly eye tests for preschoolers. Routine eye checks are also conducted in primary school. The screening test involves reading off an eye chart from a distance to check for myopia. Children also undergo three-dimensional vision tests to screen for squint and other eye conditions.

Tiong Peng says while these routine vision screenings pick up refractive errors like myopia, they may not detect other vision problems that can hinder learning. Sometimes, the more subtle symptoms may also elude some eye-care professionals using standard eye examinations, he adds. “Optometrists trained to address learning-related vision issues use diagnostic techniques to check if the child’s eyes are functioning well. For example, whether both eyes can sustain or switch focus easily, which is important for reading.”

“However, these functional vision issues are often trivialised especially when eye doctors do not find any obvious physical abnormality,” he says. While it might be tempting to blame Junior’s learning difficulties on poor vision, the experts emphasise that not all children struggling in school have vision problems.

It is also important for parents to identify any learning disability so that their child gets the right type of help, says Titus. In Zoe’s case, she was found to suffer from an alignment problem of the eyes, which gave her double vision and affected her ability to focus. Her optometrist prescribed bifocal spectacles to alleviate some symptoms and Zoe underwent thrice-weekly vision therapy.

RETRAINING THE EYES

Vision therapy is a set of techniques used by optometrists to improve a person’s vision and the way they process what they see. Depending on the specific problem, the intervention programme may involve the use of eye exercises and devices such as lenses, prisms and coloured filters. “The aim of the treatment is to allow the child to gain control of his binocular vision by encouraging the two eyes to work together properly and for the whole visual system to work efficiently,” explains Tiong Peng, who was part of the team that treated Zoe’s vision problems.

Children who have problems with convergence and accommodation (these help us to see near and far objects clearly without double images) tend to have high success rates using vision therapy, with over 90 per cent seen at Igard resolving their vision problems and symptoms within a few months of therapy, he shares.

He believes that vision therapy should form part of a multidisciplinary approach to support a child with learning disabilities or special needs to help prepare him for lifelong learning. Equally important is to see an eye doctor or optometrist trained to address learning-related vision issues. “Not all eye doctors, ophthalmologists or optometrists are adept in these diagnostic techniques and parents may be referred to another optometrist,” he says.

HELP OR HYPE?

But adjunct associate professor Audrey Chia, deputy head of the paediatric ophthalmology and strabismus department at Singapore National Eye Centre, cautions: Be sure to have a healthy dose of scepticism before buying into treatment options not backed by strong scientific evidence. “Some parents seeking a second opinion come into the clinic with a five-page report on what is wrong with their child’s vision. But when we examine the child, they don’t have any pressing problems,” shares Prof Chia, who also heads the Eye Clinic at KK Women’s and Children’s Hospital. While it is important to ensure a child has no major eye issues, over-diagnosis can be a double-edged sword.

She says: “When you do 101 tests, you are bound to find something wrong. The question is, will the child’s learning really improve even when you try to resolve that one problem? “Even when symptoms seem to go away after doing eye exercises, what might have really improved might be the child’s mental capacity to cope with learning over time.” Still, Michelle says the optometric intervention methods have done her daughter a world of good. Zoe recently completed her course of supervised vision therapy at the centre and is currently on a homebased programme.

“The teacher remarked that her school work has improved dramatically. From being below average in class, her school performance is now considered above average,” Michelle says. “More importantly, Zoe actually enjoys learning now.” Ultimately, Prof Chia urges parents not to lose sight of what is most important for their child. “Many of these programmes often make parents feel like they are doing something for their child. But whether they are needed or whether a kid’s learning could benefit equally from quality time spent with their parents, is debatable. “Sometimes, we need to accept that our child will have strengths and weaknesses. No one is perfect,” she says.

Does he have a vision problem?

While certain vision conditions like a crossed or turned eye are easy to recognise, others are less obvious. Telltale signs of learning-related vision problems include:

• Frequent headaches or eye strain

• Poor depth perception

• Double vision

• Poor hand-eye coordination

• A tendency to cover or close one eye

• Avoiding near work (less than 40cm) or other visually demanding tasks

• Blurring of vision (both distance and near), particularly after reading or other types of near work

• Tilting or turning the head when looking at an object Watch for signs of your child’s binocular vision problems affecting his learning:

• Poor reading comprehension

• Diffi culty judging sizes and shapes

• Diffi culty copying from one place to another

• Able to respond orally, but unable to get the same information down on paper

• Loss of place, repetition or omission of words while reading

SOURCE OPTOMETRIST TITUS WU OF TITUS EYE CARE