Vision Referral: Developmental Optometrist & Occupational Therapy

Anna Baker M.A., OTR/L BCP SIPT
Anna Baker M.A., OTR/L BCP SIPT

LKS & Associates
Occupational Therapist

Vision Referrals

  In the LKS and Associates blog: “Vision versus eyesight, Knowing the Difference” there is a distinction between eyesight and vision. For a more in-depth perspective on vision and visual processing, this blog will have information from both a developmental optometrist and an occupational therapist to review specific difficulties in vision that can affect a child’s participation in a variety of areas.  There will also be information on when to refer to these disciplines for additional support.  

Developmental Optometrist

Areas of concern–  It’s possible to have  “20/20,” EYESIGHT and still have functional VISION problems. Vision is one of the most important sensory systems that dominates the brain more than all the other senses. Severity of the deficits may vary, but if vision does not work well, it can handicap a person in school life, social and business. Many signs, symptoms, and behaviors associated with learning disabilities are similar to those caused by vision problems. If those vision problems are not diagnosed and treated, children may struggle in school and often go on to be adults with the same vision problems– children do not “grow out of” these difficulties. This is why it is so important that a comprehensive eye exam (need good hardware- healthy eyes, retina, refraction)  is done along with a full Functional/ developmental exam (need good sofware) that goes beyond checking for 20/20 EYESIGHT.  This should be part of the interdisciplinary evaluation of all children who are failing to succeed in school. School screenings that look at a Snellen chart to read the 20/20 acuity letters are not complete and many vision problems can be missed completely or misdiagnosed as other conditions like ADHD. 

Vision is the intake of information, processing of information in the brain, and the motor action that comes from that.  Our vision guides our movement in space, helps us play sports, guides our handwriting, and allows us to get meaning from our world whether it has to do with reading comprehension at school or work, solving puzzles (perceptual/ cognitive abilities) or simply riding a bike. In other terms, we see with our brain through our eyes! There are about 40 visual skills that coordinate almost simultaneously to allow vision to perform optimally, and 17+ of those can be broken down to our binocular skills in eye teaming, depth perception,  tracking, focusing, and the rest in perceptual skills. 

It is important to note that vision is pervasive in our brain. As Gesell has described in child development, “Not one of the major fields of behavior, motor, speech-language, and personal-social is normally devoid of visual content or visual controls. To understand vision we must know the child, and to understand the child we must know the nature of his Vision.” 

Some of the signs or behaviors that may indicate an area of concern are: 

*Difficulty to maintain eye contact

*Child rubbing the eyes or holding the head as if having a headache when playing with Legos or trying to write. (Note that allergies are not an explanation, because allergies don’t just come on when working up close.) 

* A diagnosis of ADD and/or ADHD

* Children are a bit clumsy, spilling food, getting paint or glue everywhere when doing art. 

* Inconsistent / poor sports performance 

* The child does not lack effort, but the product does not show. If this becomes a long-term issue it may lead to eventually getting more frustrated and the child may stop putting forth the effort, even though it doesn’t start that way.  

* The child will sit still while you read several stories and will retain what is read. However, if you ask the child to look at the words in the book, the child will hold their head, refuse, and no longer wants to sit for storytime.

*Headaches with near work

*Words run together while reading

*Burning, itchy, or watery eyes

*Skipping/repeating lines while reading

*Tilting head when reading

*Closing one eye when reading

*Difficulty copying from a chalkboard

*Avoiding near work or reading

*Poor reading comprehension- may have to re-read to understand what was read

*Holding books or near work very close to eyes

*Short attention span with near work

*Omitting small words when reading

*Writing uphill or downhill

*Misaligning digits/columns of numbers

*Difficulty completing assignments on time

*Saying “I can’t” before trying something

*Clumsiness and knocking things over

*Poor use of time

*Losing belongings or misplacing things

*Forgetting things

When to Refer

Dr. Charlotte Newman advises referral any time there could be a learning-related vision problem, lazy eye, eye turns, visual disturbances from strokes, or head trauma. If parents are noticing issues with any of the symptoms listed above, even if the child has had an eye health exam to look into a comprehensive functional vision exam. 

How to Contact

To schedule your first Eye Health Evaluation and/or Functional Eye Health Evaluation call Dr. Newman Optometry at (323) 653-4078. You may also visit us at DrNewmanOptometry.com

Occupational Therapist 

   Sensory processing is the ability of the brain to process information received through our senses, including vision, hearing, taste, touch, and smell as well as the body sense (proprioception), the movement sense (vestibular), and the internal body sense (interoception).  For general information about sensory processing, please look at the sensory processing blog here. Vision is closely related to both the vestibular and proprioceptive sensory systems in that each sensory system supports and guides typical daily activities such as play, academic skills, and self-help skills.  

  Visual processing consists of recognizing the significance of objects in our environment, or “what” we are looking at (referred to as object vision), as well as the location and position of objects relative to ourselves, or the “where” of yourself and objects (referred to as spatial vision).  Knowing where we are in space is called spatial processing and it is largely unconscious. Under that process, we need to look at how the vision and vestibular system affect play and development.  The initial job of a baby is to go from being carried by a parent to moving independently within 1 year.  The visual, vestibular and proprioceptive systems are a large part of that transition.  A baby has to learn to move from a flexed position with limbs and body curled together in the womb to a more extended position in response to gravity.  An infant learns to move to the side, turn onto the stomach, roll, crawl, and pull the body to stand.  In each of these positions, the movement pattern directs the head which in turn directs the vision.  Each of these position changes are registered by the vestibular system and trigger reactions in the visual system to support sustained engagement in the activity. The ability to determine the position of the head in space is vitally important to the visual information received in the brain.  As an example, if someone blew bubbles from a wand and asked you to pop the bubbles, you would first turn your head to the bubble, focus your vision on that bubble and then extend your finger to pop the bubble.  If you were asked to rotate your head side to side and try to pop the bubble at the same time, could you do it?  It’s possible that you could, but the movement of the finger would not be very controlled at all! Children that have difficulty with vestibular processing can also present with problems with oculomotor control which affects overall vision as well as motor skills. 

  The proprioceptive or muscle sense is the ability to interpret information from the muscles and joints in response to their position.  This sense is integral for an unconscious body schema, which is how a person knows where their body is relative to the environment.  As an example, when a 6-year-old child sees a tunnel on the playground, the child will use visual information about the size of the tunnel as well as knowledge of body size and position to know if it is possible to duck into the tunnel or if it is necessary to crawl on all fours to move through the tunnel.  Efficient movement patterns depend upon vestibular, proprioceptive and visual-spatial processing.  Knowledge of how to change your grasp based on whether you are holding a fork or pencil depends upon efficient processing in the vision, vestibular and proprioception systems.

  In addition to the unconscious processing that occurs, there is a cognitive component to visual spatial input that is called spatial cognition.  Spatial cognition is the process of manipulating objects or images mentally to determine relationships between and among objects.  An example of this is handwriting, as letter formation involves the understanding of the use of lines and curves to create specific letters on a repeated basis and with consistency.  Spatial cognition is also necessary to create a Lego project.  On a more advanced level, spatial cognition also allows a child to find their way around a new playground without getting lost.  

  Other cognitive components of vision that can be of concern include:

  • Visual memory difficulties: problems recalling information about an object from memory such as difficulty matching an object previously presented.  
  • Visual discrimination difficulties: where a child has a problem identifying, pairing, and classifying objects such as matching the same shape when presented with an array of similar shapes.  
  • Form constancy difficulties: problems identifying objects of varied size, orientation or detail as when attempting to recognize the letter “A” in different fonts such as “A”. 
  • Visual closure difficulties:  problems identifying an object based on seeing only a part of it, as when attempting to read a partially hidden book title on a table piled with lots of books.  
  • Figure-ground difficulties: problems separating the object from the surroundings such as inability to select a specific toy from a box of toys.  

  Visual motor integration is the combination of the visual cognitive components and motor performance which results in the brain, hands and eyes all working together.  Visual motor integration occurs when a child is able to write legibly and within the boundaries of the page.  Visual motor integration difficulties can be present due to problems in the visual cognitive system, the motor system, or both with compounding difficulties in processing vestibular and proprioceptive information.  

  Visual processing problems can present in diagnoses including developmental disabilities and language delay.  Often the ability to use language to identify objects comes from the visual perception skills first needed to categorize and identify the objects.   

When to Refer to an Occupational Therapist

  An occupational therapist may be able to provide assistance if a child is showing difficulties with:

  • Orientation of letters in handwriting
  • Spacing in handwriting
  • Orientation of clothing
  • Left and right directionality
  • Reversals of letters
  • Orientation of drawings on paper
  • Copying accurately from white board
  • Management of clothing fasteners
  • Coordinated use of utensils
  • Ability to locate toys or objects at home or in school
  • Using a dominant hand for tasks such as eating and writing 

  You can find out more about how occupational therapists can assist with visual processing by contacting the LKS office at 310-739-9337 or by email at scheduling@lksandassociates.com. 

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