The Children’s Hospital of Philadelphia
July 20, 2016

Problems are especially worrisome considering importance of near visual work in an education setting.
New research from doctors at The Children’s Hospital of Philadelphia’s (CHOP) Sports Medicine and Performance Center finds children may suffer from abnormal near point of convergence (NPC) following a concussion. The study was published in the journal Optometry and Vision Science on July 6, 2016. Abnormal NPC may be a sign of convergence insufficiency, the inability to focus on objects up–close, which can cause problems for schoolchildren who are recovering from concussion. The biggest concern is that children may not report or recognize their symptoms, and current concussion symptom scales may not detect vision problems like abnormal NPC. Binocular visual disturbances, such as convergence insufficiency, affect nearly half of concussion patients. Children may be especially affected by vision problems due to the heavy visual workload involved with school, such as reading, writing, and focusing on a smartboard. Although most symptoms resulting from concussion appear to resolve within two weeks, there is growing concern that children may have prolonged visual symptoms, which may require at least one month to recover. Of the 275 patients in the study, 67 suffered abnormal NPC after concussion. Out of those 67 patients, 89 percent recovered from their vision problems at a median of 10 weeks.

Eye-tracking study first to suggest connection between caregiver focus and key cognitive development indicator in infants

BLOOMINGTON, Ind. — Caregivers whose eyes wander during playtime — due to distractions such as smartphones or other technology, for example — may raise children with shorter attention spans, according to a new study by psychologists at Indiana University.

The work appears in the journal Current Biology and is the first to show a direct connection between how long a caregiver looks at an object and how long an infant’s attention remains focused on that same object.

“The ability of children to sustain attention is known as a strong indicator for later success in areas such as language acquisition, problem-solving and other key cognitive development milestones,” said Chen Yu, who led the study. “Caregivers who seem distracted or whose eyes wander a lot while their children play appear to negatively impact infants’ burgeoning attention spans during a key stage of development.”

“Historically, psychologists regarded attention as a property of individual development,” Smith said. “Our study is one of the first to consider attention as impacted by social interaction. It really appears to be an activity performed by two social partners since our study shows one individual’s attention significantly influence another’s.”

Head-mounted cameras were worn by both caregivers and infants in the study. Parents and children played together in an environment that closely resembled a typical play session at home or day care. The technology also allowed the parents and children to play with physical toys. A typical eye-tracking study of children would involve manipulating objects on a screen.

Caregivers were given no instructions before engaging with children to ensure the psychologists got an unfiltered view of their interactions.
Generally, Yu said, caregivers fell into two major groups: those who let the infants direct the course of their play and those who attempted to forcefully guide the infants’ interest toward specific toys. The caregivers who were most successful at sustaining the children’s attention were those who “let the child lead.” These caregivers waited until they saw the children express interest in a toy and then jumped in to expand that interest by naming the object and encouraging play.

“The responsive parents were sensitive to their children’s interests and then supported their attention,” Yu said. “We found they didn’t even really need to try to redirect where the children were looking.” The gains in attention for children in this group were significant. In cases where infants and caregivers paid attention to the same object for over 3.6 seconds, the infant’s attention lingered 2.3 seconds longer on average on the same object even after the caregiver’s gaze turned away. This extra time works out to nearly four times longer compared to infants whose caregivers’ attention strayed relatively quickly.

A number of other studies tracking the influence of sustained attention in children from ages 1 through grade school show consistently that longer attention spans at an early age are a strong predictor of later achievement. “Showing that what a parent pays attention to minute by minute and second by second actually influences what a child is paying attention to may seem intuitive, but social influences on attention are potentially very important and ignored by most scientists,” said Sam Wass, a research scientist at the University of Cambridge whose commentary on the study appears in the same journal. “Chen Yu and Linda Smith’s work in this area in recent years has been hugely influential.”

The shortest attention span by children were observed when caregivers displayed extremely low engagement with children while playing. These distracted caregivers tended to sit back and not play along, or simply look elsewhere during the exercise. The point of the study is: “When you’ve got someone who isn’t responsive to a child’s behavior,” Yu said, “it could be a real red flag for future problems.”
This research was supported by the National Institutes of Health.

Some parents are very concerned about how quickly their children are becoming more nearsighted and look for a more pro-active preventative approach to address this. Some parents are content to simply increase the eyeglass prescription each year. This re-active approach compensates for the amount the child has become more nearsighted but does not correct the problem. These are simply two different approaches.

Myopia (nearsighted) is more than just a mild inconvenience. It actually increases the risk of serious eye diseases such as glaucoma, cataracts, and retinal detachments. In the US, the rate of children becoming more nearsighted has increased dramatically within this past generation.

What can you do?

1. Become more educated – each person can become more nearsighted based on (1) how their visual system works and (2) on genetics. .
2. Gain the ability to handle visual stress – Working on electronic devices and spending more time indoors increases visual stress. This can causes children to become more nearsighted. Vision Therapy is often the best way to learn how to deal with visual stress and helps the person build a visual system that is better suited to handle that stress. Vision is learned, similar to learning how to ride a bike, or drive a car, or play the piano. Developing the ability to use the visual system effectively is the best way to prevent a child from becoming more nearsighted. Vision Therapy is like having a personal trainer for an exercise program.
3. Find the right eye doctor – Some eye doctors have specialty training in myopia control. This goes beyond the basic ability to prescribe eyeglass and contact lenses to see clearly. Credentials such as FCOVD mean the doctor has taken post-doctoral education and has demonstrated additional expertise in understanding methods of myopia control.
4. Start early – The best way to control myopia is to prevent it. The first examinations should be at age1, 3 and 5. Every year a child is in school they should have a full eye examination. A vision screening by the school nurse or at the pediatrician’s office is not an eye examination. The earlier we take action, the earlier we can address the problem, especially if parents are nearsighted. Don’t wait until your child fails a school or pediatrician vision screening.
5. Orthokeratology – has been shown to effectively reduce myopia progression. Ortho-K is FDA approved for children and adults. It gives patients clear daytime vision without glasses or contacts and has the added benefit of reducing or eliminating myopia progression.

 

Vision plays an important role in sports. Concussions, caused by injury while playing sports, can lead to vision problems that affect both athletics and academics. It is important to identify student athletes who sustain concussion when playing organized sports.

Young athletes are reluctant to acknowledge or admit that their function has been compromised because they want to continue to play. Athletes often think they have “just had their bell rung” and don’t realize the seriousness of the injury. It is common for student athletes who have had a concussion to then have problems with orientation, dizziness, and headaches. Those who sustain a first injury are at risk of suffering a second concussion because they have not yet recovered from the first. This ultimately affects their sports performance and more importantly, it affects learning and school success.

Student athletes who sustain a concussion can become confused with regard to time, space, and their orientation. Professional athletes who have sustained multiple concussions and brain injury have lifelong impacts that have been implicated in causing Parkinson’s Disease, Dementia, and Alzheimer’s Disease. Concussion has been termed “mild” brain injury but the cumulative effects are considerably more than just “mild”. The effects are exponential rather than just additive. It affects the athlete’s visual function (double vision, blurred vision, dizziness, etc.) and therefore it affects cognition.

Baseline eye movement testing should be established in the pre-season so these same eye movement tests can be measured should there be an injury during play. This can be considerably more diagnostic than an MRI, since the injuries are often not apparent in imaging testing and may not be readily apparent at the time of injury. These tests can quickly and effectively determine if an athlete should be removed from play. The effects of a concussion may become apparent only well after the injury, similar to a muscle injury or a whiplash after a car accident that is noticed only days later. Eye movement testing can also serve as a gauge for return to play.

Student athletes are also at risk for learning problems after they sustain a concussion or brain injury. The vision system is compromised, but can be re-built through a program on neuro-optometric rehabilitation. This often has an even greater affect because it can then facilitate improvements from other therapies such as cognitive therapy, physical therapy, occupational therapy, neuro-psychology, etc.

Just as it is important to be able to determine if an athlete is physically ready to continue play, it is important to evaluate visual competence to learn after a sport-related injury, or even non-sports related injury. Athletic trainers and coaches, guidance counselor and teachers should be aware of the impact sports-related injuries have on academics as well as sports.

Sports vision therapy prior to competitive play enables the athlete to be more visually aware, react faster, and conceivably reduce injuries. It then helps athletes play better and be even more effective in sports.

 

The International Keratoconus Academy of Eye Care Professionals (IKA) was recently established to promote ongoing professional education and scientific development in the area of keratoconus and other forms of corneal ectasia. Its mission is to promote and develop the knowledge base and awareness of the state-of-the-art pertaining to the diagnosis and management of keratoconus and other forms of corneal ectasia, and further to promote the awareness and understanding of the most appropriate and effective treatment strategies for the management of these diseases. IKA. will accomplish its mission by providing an array of educational initiatives which will include live events, web-based education, social media activities and publications in the professional literature. It will also be dedicated to supporting ongoing clinical research. IKA will function as a complementary entity to other organizations that support patients with these diseases such as the National Keratoconus Foundation (NKCF). These organizations will work cooperatively to establish a comprehensive effort to advance knowledge, awareness and quality of care.

Amblyopic Children Read More Slowly Than Controls Under Natural, Binocular Reading Conditions

Presented at the 41st Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, New Orleans, Louisiana, March 25-29, 2015.

TAKE-HOME MESSAGE

• Eye movements while reading grade-level text at the habitual reading distance were recorded in a small cohort of school-aged children with amblyopia (lazy eye), with or without strabismus (an eye turn in or eye turn out). Compared with normal controls and strabismic children without amblyopia, children with amblyopia had a significantly slower reading rate and made significantly more forward saccades. (a saccade is a jump eye movement when moving from one thing you are looking at , to another. When we read, we look at one word and then jump to the next word. When we reach the end of a line of print, we saccade, jump our eyes, from the end of that line to the start of the next line. If we cannot do that accurately, then reading is labored and not smooth. We spend energy on the eye movement part of reading and do not have enough for understanding what we are reading.
• The authors conclude that amblyopia rather than strabismus is responsible for slower reading rates and suggest that this could be due to oculomotor dysfunction (increased number of saccades) or to the visual acuity deficit. They further suggest that children with amblyopia (even with binocular 20/20 acuity) should be given academic accommodations such as increased time to complete assignments.

This study is very important because it further points out the false sense of security that when a child has 20/20 with both eyes together there is no significant visual impediment to reading.

The studies before this one had concentrated on strabismic amblyopia, whereas this study focused on amblyopia without strabismus.

The authors used the ReadAlyzer device, a device we have in our office, that enabled them to document eye movement reading patterns objectively.

Poor eye movement deficits were not a secondary manifestation of poor comprehension. Rather, it is the reason for the poor comprehension.

The authors of the study stress the importance of recognizing amblyopia as a potential reason to request accommodation in school or on standardized testing for a student to receive additional time for completion of assignments.

They also note the importance of treating amblyopia because of the implications for improved transfer effects to reading.

BACKGROUND

Recent evidence suggests that amblyopia results in fixation instability and atypical saccades. Reading is a vision-reliant ability that requires sequential eye movements, including forward and regressive saccades. This study investigated reading and associated eye movements in school-age amblyopic children.

METHODS

Amblyopic children with strabismus and/or anisometropia (n = 29) were compared to nonamblyopic children treated for strabismus (n = 23) and normal control children (n = 21). While fitted with the ReadAlyzer, an eye movement recording system, children silently read a grade-level paragraph of text during binocular viewing. Reading rate, number of forward and regressive saccades per 100 words, and fixation duration were determined. Comprehension was evaluated with a 10-item quiz; only data from children with at least 80% correct responses were included.

RESULTS

Amblyopic children read more slowly and had more saccades compared with nonamblyopic children with treated strabismus and normal controls. Fixation duration did not differ significantly for amblyopic children versus normal controls. Treated strabismic children without amblyopia did not differ significantly from normal controls on any reading measure. Amblyopic eye visual acuity was not correlated with any reading measure.

CONCLUSIONS

Amblyopia was associated with slower reading in school-age children. Treatment for monocular amblyopia visual acuity impairment could improve reading speed and efficiency.