Vision and Development: What's Old is New Again Within Vision Therapy

I recently stumbled upon old Optometric Extension Program (OEP) books that detailed vision development and perceptual assessments of children, and realized that there is so much value in old literature and theories.

As new graduates, we are so focused on learning new technology and using computers as diagnostic tools, that we often forget the value of observation, and good old pen and paper testing to learn about our patients.

With the school year just starting, and October being "Learning Disability Awareness Month," I think it is a great time to review how to examine children who can see 20/20, but are still struggling visually.

This article will chronicle perceptual areas that we must observe in our patients when doing a complete visual workup and the testing to go along with it.

Before we move forward, I’d like to share a few clinical pearls from Dr. Homer Hendrickson from “Visual and Perceptual Aspects for the Achieving and Underachieving Child,” to remember:

It was found that the eyes weren’t at fault as much as how the eyes operated, how they worked with each other and together with the brain, and in turn with the whole child.
The human is a total being, never segmented.
Movement is the key to learning.

Visual information processing: things to look out for

Keeping these clinical pearls in mind, you can appreciate the reason behind making perceptual testing part of our visual work-up. We must understand the child as a whole to understand how they are visually functional. Here are some of the areas that I test for in my visual information processing work-up:

Perceptual speed:

This is a skill that translates into a child’s ability to observe and comprehend things visually in a succinct amount of time. A paper written by L. Bender in 1938 found that “slow visual processing produces an incomplete perception of the stimulus, resulting in a more primitive response.”

Motor skills:

The development of motor skills in children has been well documented with the age-appropriate milestones laid out. It is crucial to make sure that a child has not skipped any steps in their motor development, as this can then translate into poor oculomotor function and spatial/body awareness.

Visual form perception/recognition:

These skills are essential in building the foundation to read, write, and comprehend.

Auditory perception/processing/memory:

Vision and auditory processing are intertwined entities that are crucial in learning. It is good practice to toggle out any signs of auditory processing issues in your patient.

Visual memory

Memory is an integral portion of learning and maintaining our skills.

Visual motor integration

We must understand the patient’s ability to use his/her eyes to guide his/her motor movements. VMI is key in developing gross and fine motor skills for visually demanding tasks.

Laterality/directionality:

These skills are pervasive throughout a child’s life, giving rise to body awareness and letter/word recognition.

For more information on perceptual testing, I encourage you to read Mindsight, the COVD Blog, for great articles. A few of my favorites are the following:

A blog I wrote a few years back about perceptual testing here called “The Rare Beast: The Simple Convergence Insufficiency.”

What I can tell you is that the mastering of prescribing a vision therapy program takes time and practice, but is an essential part to guarantee your success.

Check out these COVD resources:

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The following should be considered during your vision therapy and perceptual workup:

Perceptual Speed
Motor Skills
Visual Form Perception/Recognition
Auditory Perception/Processing/Memory
Visual Memory
Visual Motor Integration
Laterality/Directionality

Below you will find a list of tests that I have used in many of my vision therapy and perceptual work-ups:

Perceptual speed:

PMA Perceptual Speed Test: this is a pencil and paper test that tests the patient's ability to 'rapidly perceive subtle differences in similar forms.' It has two different levels with a five minute time limit.
PTS II Tachistoscope: you can find the diagnostic testing through Home Therapy Solutions.

Motor skills: oculomotor skills

Developmental eye movement test
Visagraph/ReadAlyzer

Visual motor integration

Beery VMI
Wold Sentence Copying Test

Visual form perception/recognition

Test of Visual Perceptual Skills (TVPS): covers many different areas of visual perceptual testing in one succinct test. It includes testing for the following areas that are critical within your vision therapy and visual perceptual workup:

visual discrimination
memory (simultaneous/sequential)
spatial relations
form constancy
figure/ground
visual closure

Auditory perception/processing/memory

Birch-Belmon Auditory-Visual Integration (AVIT) test cards: this test requires the provider to tap out a sequence and the patient has to visualize the auditory sequence and pick out the pattern.

Visual memory:

PTS II (again): Tachistocope (Simultaneous Visual Memory) & Visual Span (Sequential Visual Memory)

Laterality/directionality:

Piaget's L/R Awareness
Jordan Reversals
Gardner Reversal Frequency Test

A few things about vision therapy and perceptual work-ups:

This testing is NEVER covered by insurance; make sure you bill the patient appropriately for your time.
Set aside approximately 1-1.5 hours for the testing.
Keep the room quiet and free of distractions. Sometimes that even means removing the parents from the room!
Consider writing a full report at the end detailing all of your findings to be shared with other professionals (OT/ST/School/PCP).

And there you have it! The major things to look out for when it comes to vision therapy. What are your top tips for those looking to enter the VT field?