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An Interview with Dr. Linda Lipstein

Most learning delays are caused by delays in auditory processing, rather than visual processing. However, a number of our students also live with visual processing struggles. I recently had an opportunity to speak with Dr. Linda Lipstein. We discussed vision disorders, vision therapy, and the impact each has on learning.

Dr. Lipstein is a Doctor of Optometry. She also has a Masters of Education in the Visual Function of Learning. She has spent the last twenty years studying and applying her knowledge to help children and adults with vision and learning challenges.

On the challenges that lead most people to schedule a vision exam

Often, parents don’t equate their child’s learning problems with a vision problem. They think that vision is truly just acuity, how clearly we see. When, actually, there’s a lot more to vision than that. For instance, when there is a learning problem, the first question I ask is Do the eyes work together as a team? This needs to happen when we read. As a developmental optometrist, during the vision exam I ask a few more extra questions that you may not hear during the traditional eye exam.  I ask How’s your child doing in school? And often a parent tells me Well you know, my child is in remedial reading class, and they’re not doing as good as we think they could be doing in school. This starts the conversation about vision and learning.

On common symptoms

The most common symptom of a vision problem is blurry distance vision after the child has been reading up close. Headaches are often reported when this happens because the eyes are so strained. In fact, headaches are probably the most common thing I hear from young people in the exam room. And it’s due to a strained focusing system or eye alignment problem that causes the eyes to fatigue. Often, there will be red rings around the eyes because the child is rubbing their tired, strained eyes.

On the cause of most vision disorders

The most common vision disorders are what we refer to as General Binocular Disorders. This involves convergence insufficiency, where the muscles around the eyes fatigue when reading and one of the eyes moves out relative to the other. The eyes don’t point to exactly the same place, causing vision to blur and sometimes go double. When this happens, it is difficult to read and comprehend what we are reading. Focusing disorder occurs when the focusing muscles inside the eyes become strained causing blurry vision and headaches. Convergence insufficiency and focusing disorder share many of the same symptoms and in vision therapy we tend to train them together. Also, we must be able to maintain fixation as we look around at different objects in front of us; the eyes must be able to track together. To avoid double vision, we train eye movement skills in vision therapy.

It is important to note that the General Binocular Disorders of convergence insufficiency, focusing disorder and tracking disorders can be treated and problems can usually be eliminated with vision therapy.

Strabismus occurs when the two eyes do not point to the same place most or all of the time. The person may experience double vision and often there is little or no depth perception. Strabismus can often be controlled with vision therapy. In some cases, surgery is more appropriate.

There are also vision disorders that affect how we process visual information. Our visual processing skills allow us to get meaning out of what we are reading.  Therefore, poor visual processing skills can affect our ability to learn. Remediation of visual processing disorders takes a bit longer in vision therapy, but most times great gains can be made.

On testing for vision disorders

Occasionally,  I get a child in my exam chair who has 20/20 vision, in other words, they see clearly at distance. They may be getting headaches when they read or perhaps the parent reports that the child is in a remedial reading class. In the exam room, I have the ability to measure how well the eyes work together.  I can also measure how strong the focusing system is. I can then compare the results of my tests with a set of guidelines and if the results of the child’s tests fall outside of the guidelines, I may determine that the child has a vision disorder.  It’s a bit more complicated, and the testing is  more in-depth than I make it sound, but this is the basic idea of how the testing goes.

Why a standard school eye exam may not identify most vision disorders

The major purpose of the school screenings is to catch those kids who have problems seeing far away or up close. And so, the school screenings are basically testing for visual acuity. There has been a real push to get other visual skills tested in the school screenings. Some schools do better than others in incorporating other testing.

It’s important to understand that you can have a vision disorder that impacts your ability to read and learn and still have 20/20 vision. So when the schools only test how clear a child can see, they may be missing visual problems that affect the child’s ability to read and learn. That is why it is important to have vision exams with a developmental optometrist. This is important if your child is getting headaches at school or if they are falling behind in their studies. There may be a reason for this and testing will help identify the problem.

On what to expect from vision therapy and what occurs during the sessions

A traditional vision therapy program has kids in the office anywhere from 1 to 3 times a week. A usual session lasts from 40 to 60 minutes. Twelve to sixteen weeks is usually scheduled for the first segment of therapy. And further need for therapy is determined at the end of this first segment. The child typically is assigned therapy to do at home so that eye exercises are being done about 6 days a week. In-office therapy involves activities where we train the eyes how to move together as a team.

Keeping vision therapy fun

A good therapist will attempt to make therapy fun and keep the child moving around in engaging activities. We always start therapy in  tasks that the child will find easy and then we begin to increase the complexity. For instance, one activity involves reading a card with letters on it that is held up close. The child then looks at a chart on the far wall, reading the letters on that chart; then looking back at the chart they are holding in their hand and back and forth and back and forth. This change in eye fixation exercises the focusing muscles causing them to relax when reading the chart on the wall and then contracting the focusing muscles when reading the chart held up close.

When the child is able to accurately and clearly read the letters on the wall and also up close, we change the distances between the charts to put a load on the system. We also use lenses to make it more difficult until the child can see clearly at distance and at near. By doing this, we build up the strength and flexibility of the focusing muscles allowing the child to see clear at all distances. Also, the eye strain and fatigue have been eliminated.

On training the brain

Once we get the vision clear at different distances, we need to develop a guidance system so it will stay that way.  In the big picture what we’re really doing in vision therapy is training the brain to maintain clear vision. The brain learns to modulate the system using clarity of vision as it’s set-point. Once the brain is guiding the visual system to see a single and clear image, good vision becomes automatic. Good vision should be an unconscious process and this is what we are training in vision therapy.

On the potential impact of vision therapy

It’s incredible and so rewarding to be a part of! After a segment or two of therapy,  the child’s visual skills begin to work properly allowing them to read without strain.  Their ability to learn from what they are reading escalates. And they begin to catch up to their grade level in school. In my clinic, a remedial reading teacher is available to tutor those kids who need it. In the end, the main goal for vision therapy is to provide the child the necessary skills to succeed in school. And that contributes to success in life.

On how early can someone be assessed for vision disorders

By about 4 or 5 year’s old, we can start getting some very good information on how well a child sees and processes visual information. Now, I’m referring to the general binocular disorders. You can see strabismus (a mis-alignment of the eyes) sometimes at birth. Identifying strabismus early is important because it may accompany a high prescription that the child needs to wear at an early age in order for vision to develop normally. Parents, if you see that your child has an eye turn, take them to a developmental optometrist early in their life to be evaluated. The optometrist will tell you if the eye turn can be controlled with glasses and/or vision therapy. Sometimes, you may be referred to a strabismus surgeon.

On what she’d like to make sure parents understand about vision therapy

The biggest mistake we make as parents is waiting to see if the vision/learning problem will just go away. If a parent sees that there child is having difficulty in school, the  tendency is to find plausible explanations for it.  For instance, perhaps it’s a poor dynamic with the child’s teacher. There’s other kids in the class who are disruptive, or there is a problem at home that we feel will be resolved soon.

My recommendation to parents is to get help for your child now. Don’t wait to see if it gets better in the next school year. Studies show that for every year a child falls behind in school, it takes two years for them to catch up. The child’s self-esteem can suffer and sometimes, they never get it back. When your smart kid is having difficulty reading and learning, find the proper professional to find out why. Get the help you need to change things for the better.  And there’s no better time to start than today

Dr. Lipstein, O.D., M.Ed has an educational website that answers our most important question:  My Child is Smart * So Why is Reading So Hard?  Learn about the 4 most common reading and learning disorders and take the Learning Assessments to find out if your child has one of them. You can visit her website here.