Vision Therapy: An Overview of Complaints and Symptoms

To kick-off our Vision Therapy discussion, let’s review the most common patient complaints that lead you down the path of investigating visual system dysfunction.  The best place to find visual system issues is during the routine eye examination.  Your patient is liking coming in to your office with a complaint (or several).   Dr. S has compiled an overview of the most common complaints from patients that raise a red flag:

Temporal headaches?  It could be convergence
issues! via

Headaches

                                                                             

     Ask your patient to show you where their head hurts.  The isolation of certain areas can be dramatic, and especially helpful to your diagnosis!  If Dr. S asks a child where their head hurts and they point directly to one area, the child almost just diagnosed themselves.  If they point to their temples she is thinking binocular issues, and if the child points to their forehead she is thinking accommodative issues.  Conversely, if the child says “all over” or is vague about their headache, talking to a parent about the symptoms can sometimes clear up confusion.  A child may have a hard time describing their symptoms, but a parent can often fill in the gaps.  A parent may observe a child rubbing a particular area, or remember a time that their child gave them more details about their headache symptoms at home.

Blurry Vision – especially that comes and goes

It's important to ask not just what distance is blurry, but if it is blurry all the time, or only in certain environments or after certain activities. A classic entering complaint for accommodative dysfunction is actually blurry vision reading the board at school.  It may seem counter-intuitive at first, but if the child's eyes are have trouble keeping focused up close (accommodation), then they also will have trouble relaxing the focusing system back out to see in the distance. The focusing system gets "locked up" if you will. This patient usually has relatively good vision at their eye exam, and will have a prescription right at zero in most cases.  If you investigate further, a lot of times even the child has noticed their vision is only blurry in the distance at school after they have been doing paper work or reading or taking a test.  Again, this one complaint almost diagnoses things without doing one extra test.

Tired Eyes

Difficulty Reading 

Ask about school performance, reading speed, and how the child reads.  Do they often lose their place when reading?  Do they sometimes start reading the same line they just finished? Are they having to use a finger to track their place?  All of these issues are commonly found in children with ocular motor dysfunction.

Difficulty copying from the board

This is a great example of a combined visual skill task.  The patient has to use their eye muscle movement to track the line, and then their focusing system to change from their paper to the board.  Challenges here could be an issue with accommodation, ocular motor skills, or both!

Try reading this artistic rendering of doouble vision,
and imagine how long it might take you to finish
a paragraph.  via

Seeing words move and bump into each other when reading

Dr. S recommends this phrasing as a better way to describe double vision to children.  If you have ever asked someone if they have double vision, you will quickly learn that even adults aren't sure what that means, much less a child.  Describing it as moving or jumbling words and letters can be a more relatable description to the patient.

Reversals of letters or numbers

General disinterest in reading or poor performance

Often times discussing these symptoms requires speaking with the parent, because it is difficult for a child to fully discuss and describe their own symptoms (especially if they are quite young).  Teachers often give parents good insight on what they witness the child doing in the classroom, and I often ask parents specifically about anything teachers might have said.  Unfortunately, many visual development issues can go undetected until a child begins struggling in the classroom, and a teacher can be a good resource as to how the child is functioning on a daily basis.

We have focused on children to this point, because their visual system is still struggling to perform the tasks required in the classroom.  For a child with a visual system issue, whether it is difficult focusing at near, keeping the eyes working together, or movement and tracking skills of the eye muscles themselves, the classroom is like an obstacle course challenging the child at every step.  The simple act of copying from a board, reading a book, or writing letters and numbers can be excessively challenging for a child with visual system issues, and that is why visual problems are often misdiagnosed as behavioral or attention issues.  Children in the classroom are not the only patients that suffer from visual efficiency problems, however.  I often see adults with binocular issues too, but on average adults tend to be less symptomatic because their eyes have been dealing with these issues for years.  Adult visual systems have typically made adjustments and compensations to deal with their visual system’s inadequacies.  These can be seen in head tilts, suppression of one eye, and even career selections!  A patient with major visual dysfunction probably isn’t going to pursue a career that requires long hours reading or in front of a computer screen. Catching visual development issues early is key to giving the eyes their best chance at working efficiently later in life, but even adults can benefit from therapy if they are symptomatic.

In Adults:

Dr. S reports that the same symptoms that affect children are often adult complaints as well.  Patients with binocular or accommodative visual issues may sometimes slip through the cracks as children with only mild symptoms, but long hours in front of a computer can make their visual system’s inefficiency rear its ugly head in serious strain and end of day fatigue at the job.  In addition to longstanding development issues, there are major traumatic events like brain injuries, concussions, and a host of systemic medical conditions that can cause new onset visual system inefficiencies that require immediate intervention.  Patients suffering from stroke, Lyme disease, and meningitis can often have issues with accommodation and binocular vision, and Dr. S has seen good success with treating these patients with prescriptive lenses and in office vision therapy.  

Common Symptoms Post-Trauma

Concussion patients can suffer from a host of visual deficiencies.  While irregular pupillary reaction is often an initial symptom, the visual processing and focusing ability of a patient can take months to recover.  The most common visual disorder after concussion is a difficulty focusing to read (or accommodation issues).  Sometimes prescription reading glasses can temporarily help relieve eye strain as the visual system recovers.  There are also a multitude of studies that show concussion sufferers may have immediate decrease in their ability to track and make reading eye movements (pursuits and saccadic eye movements).  The King Devick test is even being offered as a way to help diagnose concussions due to its ability to quickly find ocular motor issues.

Traumatic brain injury can often cause visual processing issues like new onset reversals, neglect (where the patient ignores parts of their vision even though they can functionally see), and midline shift.  These visual inefficiencies can cause severe difficulties as the patient attempts to navigate their world, and visual therapy can help patients to learn to compensate for these changes in their visual system. 

 

Asking a patient to fill out the numbers on a clock can be telling after a traumatic brain injury.  If they suffer from spatial neglect, the patient knows that the clock needs all 12 numbers, but they just cannot get their brain to process that other half of the clock, so all the numbers get crammed into just one side.  Vision therapy can help the patient learn to compensate for their neglected area of vision.  via

Interested in learning, how Dr. S uncovers her patients’ visual system inefficiencies?  The next post will outline her diagnostic routine and the tests she feels yield the best results.