The Use of Orthoptics in Dyslexia

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

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 ~ impfOtled with orthoptic exershycises designed to augment the Jusional amplitudes The treatment did not affect the perceptual deject associated with dyslexia

Dyslexia is a perceptual disorder which literally means reading diffishy

culty (Money 1966 Public Law 91230 Title VI) There are cases however whose reading difficulty may not be asshysociated with a perceptual defect Dysshylexia was first described by ophthalmoloshygislS 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 shOWed 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 (dysshylexia) with reading difficulty with or without fusional amplitude defect

Material and Methods

The cases included in this study were children referred from private or public schools children referred by special edushycational teachers and children referred by learning disability specialists or speech

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 undershystanding or recall of what was read by the child

Every child had a complete ophthalshymological examination which included distant and near vision refraction and cycloplegic retinoscopy (for objective reshyfraction) funduscopic and slit lamp exshyaminations 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 instrushyment for phoria testing subjectively)

Orthoptic exercises were aimed at 1 Correction of the near point of conshy

vergence CNPC) when present 2 Correction of the fusional amplishy

tudes Cat near in particular) using framshying exercises

3 Anti-suppression exercises (when monocular suppression existed) using red filter tracing or cat stereograms

4 Relaxation exercises and physiologshyical diplopia training to imprcM on any degree of accommodative spasm or esoshyphoria which might aggravate the fusional amplitudes

S Fusional exercises using the troposhyscope when indicated and when home

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 inshycluded in the study

RESULTS

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 hyshyperopia--refractive errors causing near vision blurr andor 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 175 and +

150 Of thes~ 24 were d~xic and 13 showed no perceptual defect 21 had exophoria with convergence insufficienshycy 12 had esophoria with convergence excess and four were orthophoric

Tabe 1

1078-1078 Age

MaJFmale Refractive Error Alone Dyslxla (Perceptual Defect)

Alone Poor Fusional Amplitudes

With Dyslexia Without Perceptual Defect

73 Children with Reading Difficulty 61013

years 649 18 18

37 24 13

~pists-AIL -easesJNefe-lefene(Lbe exercises wereJlOl-sufficientlyJle1pfuL___~uslonal amplitudes were~o~idcrcd cause of reading difficulty Except for the latter all orthoptic ex- nonnal at the range of four to six A

The reading evaluation was done by a ercises were done at home under th~ _ (ptism diopters) base-in (81) at distance

Journal of Lornin~ DlSobililifJ 142

Table 2

37 C~lIdren with Poor Fusional Amplitudes 21 X 12 S 4 0

20 Both Convergence and Divergence Poor 13 4

Table 3

Rate of Reading Improvement Modified Monroe Method

Length of Uninterrupted Reading Attentiveness l Recall--Understanding Subjective

Amplitudes 16 o to 2 Months 15 2 to 4 Months 4 4 to 6 Months 2 Over 6 Months

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) baseshyout (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 imshyprovement 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 apshypeared as if daydreaming especially those with convergence insufficiency

Discussion

It should be emphasized I That even though dyslexia is not an ophthalmologishycal disease the process of reading may be affected by the fusional amplitudes of the child especially if there is intermitshytent diplopia as a result of convergence

Volume 7 umber 3 March 1984

(Convergence Insufficiency) (Convergence Excess) (Orthophoric)

Only Convergence Poor Only Divergence Poor

Reading Improvement

o to 2 Months 29 2 to 6 Months 4 Very Slow 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 readshying difficulty is not accompanied by pershyceptual defect 3 That children with dysshylexia and reading difficulty with normal ophthalmological examination and fushysional amplitudes do not benefit from orthoptic exercises or any other ophthalshymological 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 affcct only the fusional amplishytudes 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 supshypression amblyopia or alternation Howshyever if fusion is relatively well estabshylished but the f~sional amplitudes are disturbed especially at near then a struggle will efsue when the child atshytempts to maintain fusion especially durshying the reading process The difficlilty y

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 convershygence and accommodation are faulty to some extent but not severe enough to produce exotropia or esotropia ie 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 Alshyternately he will have to go back from one word to the other in order to mainshytain fusion The second step results from image confusion during reading which particularly develops as a result of crossed diplopia as in convergence inshysufficiency 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 (KrausshyMackiw Muller-Kuppers amp Rabetgc 1978)

Even though this study is directed to the orthoptist there is no reason why the ophthalmologist who examines preshyschool and school age children may not be able to institute such orthoptic exershycises 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 ophshythalmic student should be trained to do the same when he does not have access to an orthoptist

REFERENCES

Benton J D Jr Ophthalmological approach to

the problem of retarded readers among elemenshy

43

tary sclwel child~n Journal of th~ Florida M~dical Association 47 1123 1961

E~s T H Comparison of ~~ conditions among Ofl~ lhousand r~ading failuns flw hund~d ophshythalmic 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 9 I 230 Tit~ VI

Kraus-Mackik E Mulla-Kuppu3 M de Rab~g~

G Binocularity in Tul-to-Ttwlvt Y~ar Old Chilshydnn with Poor Writing and R~ading Ability Proshycudings of Ihe 761h Cong~ss of Ih~ G~rman Ophthalmological Society Dusulldorf Volum~

17 1978 p IJ5 Monq J Th~ Disab~d ampada Education of th~

Dysluic Child Ballimon Md Johns Hopins 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 ophmiddot

thalmology at Ih~ N~ York M~dical ColI~g~ in OpJuhalmowgy H~ is also th~ ~dilorinmiddotchi~f of M~tabolic P~diatric and Sysumic Ophthalmology Nancy ~ Isaacs MS is an ~ducational psycholoshygist in privau proctia Karin Onghena is an onhoptis Ayala Mazor is also an orthoptist AdshydIYss 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

J 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 beautishyful 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 Gods 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 hes in their presence How did this fiveshyfoot 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~ksshycould 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 couldnt 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

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 locashytion 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 scientists sacrifice in the cause of humanity

John Middlebrooks wasnt 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 capashybility to bring out in other people that which they held most sacred most ennobling The chameleon could not only undershystand the poets exotic ideas and overburdened analogies but he had some sort of knack which helped the poet sharpen and clarify her own work He had away to convince the moralist that he was good that his pasewasnt a pose (which he would have otherwise believed) and that his righteousness wasnt 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 11jdli~ebrooks gave himself to his fellow man

Journal of uarning Disabilitin 44

tary sclwel child~n Journal of th~ Florida M~dical Association 47 1123 1961

E~s T H Comparison of ~~ conditions among Ofl~ lhousand r~ading failuns flw hund~d ophshythalmic 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 9 I 230 Tit~ VI

Kraus-Mackik E Mulla-Kuppu3 M de Rab~g~

G Binocularity in Tul-to-Ttwlvt Y~ar Old Chilshydnn with Poor Writing and R~ading Ability Proshycudings of Ihe 761h Cong~ss of Ih~ G~rman Ophthalmological Society Dusulldorf Volum~

17 1978 p IJ5 Monq J Th~ Disab~d ampada Education of th~

Dysluic Child Ballimon Md Johns Hopins 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 ophmiddot

thalmology at Ih~ N~ York M~dical ColI~g~ in OpJuhalmowgy H~ is also th~ ~dilorinmiddotchi~f of M~tabolic P~diatric and Sysumic Ophthalmology Nancy ~ Isaacs MS is an ~ducational psycholoshygist in privau proctia Karin Onghena is an onhoptis Ayala Mazor is also an orthoptist AdshydIYss 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

J 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 beautishyful 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 Gods 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 hes in their presence How did this fiveshyfoot 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~ksshycould 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 couldnt 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

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 locashytion 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 scientists sacrifice in the cause of humanity

John Middlebrooks wasnt 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 capashybility to bring out in other people that which they held most sacred most ennobling The chameleon could not only undershystand the poets exotic ideas and overburdened analogies but he had some sort of knack which helped the poet sharpen and clarify her own work He had away to convince the moralist that he was good that his pasewasnt a pose (which he would have otherwise believed) and that his righteousness wasnt 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 11jdli~ebrooks gave himself to his fellow man

Journal of uarning Disabilitin 44