With school in session for a few months now, it’s a good time to check with pediatric patients and their parents to see if they have any binocular vision issues.

The public may not know the link between vision problems and academic performance, so patients may not mention these issues to an eye doctor. Use the following advice to make sure a student’s education isn’t affected by undetected vision problems.

Starting the conversation

To start the conversation about how well a child is reading, try this patient script: “What’s your favorite subject and your least favorite subject? Do you read for fun?” If the patient picks reading class as his least favorite and recess or lunch as the favorite, probe more into their school performance. During the examination, ask if they lose their place when reading, and if the words on the page move, become double, or blurry.

You can also explain to the parent the effect of vision on education using the following script: “Academic success can be influenced by several visual skills involving motor, sensory, and thinking abilities. Binocular vision contributes to a third of these visual skills,¹ so any issue with binocular vision can interfere with the efficiency of the visual system and delay learning. Eyes are not supposed to hurt, see double, or blur when reading. Such eyestrain can result in avoidance, headaches, eye pain, or myopia. When a child has a visual condition that affects the ability to learn, some children might try to endure the discomfort. Others might avoid academics when they have discomfort and blurry vision. Consequently, they experience fewer symptoms, but can also have potential learning delays. A compete visual evaluation will determine if there are vision difficulties affecting learning.”

Examination techniques

At my clinic, we assess patients by using the following:

• A survey of different symptoms, indicating whether further evaluation is needed. Some patients complete this survey before they enter the exam room.
• Visual tracking tests to determine whether a child has an issue, and the types of symptoms that occur at the beginning vs. end of the day. These are simple, brief chairside tests that identify issues with eye movements, convergence, and accommodation.
• Visual thinking evaluations (e.g., asking a child with eyes closed to think of an ice cream cone. Ask if he can actually see it, or does he see black.) This is important because visualization helps comprehension and memory.

Also, to demonstrate eyesight versus other visual skills to the parent, we ask the parent to try to read without moving their eyes. Another good demonstration is to hold a loose prism in front of one eye while mom or dad are trying to read. Slowly rotate it slightly and notice how reading becomes more difficult. Finally, demonstrate how much more difficult it is to read when the material is held at 8 inches versus 26, even though the text is clear in both cases.

After identifying a potential vision problem, the treatment plan may include special lenses to relieve symptoms. These lenses may have a low plus prescription and incorporate a micro prism. Finally, the patient should return for further testing to get age-related normative data on binocular vision disorders and visual perceptual delays. This will determine if you should prescribe optometric vision therapy.

Yearly checks

Before the student and the parents leave, inform the parents their child’s binocular vision should be evaluated annually because a student’s visual demands increase as grade level advances. Print size gets smaller until about fifth grade, so visual issues that don’t play out in the first grade with large print begin to show up later, during elementary school, and this can make reading more difficult for the child. Additionally, increased digital device use in children has been linked to poorer binocular vision, adding another reason to test regularly.² OM

REFERENCES

1. Montecalvo B. Visual Secrets for School Success: Read Faster, Write Better, Master Math and Spelling. Author Academy Elite; 2020.
2. Maharjan U, Rijal S, Jnawali A, et al. Binocular vision findings in normally-sighted school aged children who used digital devices. PLoS One. 2022 Apr 7;17(4):e0266068. doi: 10.1371/journal.pone.0266068.