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Leanna M Dudley, O.D.1 life, saccades, special populations, vision ered visual efficiency disorders such as
oculomotor dysfunction (OMD), accom-
Terri Vasch, O.D.2 therapy
modative insufficiency and binocular co-
1. Private Practice, Golden, CO INTRODUCTION ordination. Some visual efficiency disor-
D
2. Private Practice, Silverton, OR Developmental Delay ders have been documented in subgroups
evelopmental delay (DD) is of DD, including cerebral palsy, Downs
Abstract characterized by a late onset of syndrome, low birth weight children and
Individuals with developmental delay motor, speech, behavioral and/or genetic anomalies. Individuals with ce-
(DD) have a higher incidence of visual cognitive skills.1 There are many causes rebral palsy have a markedly higher in-
problems including visual efficiency dis- of DD including, but not limited to: ge- cidence of visual efficiency disorders
orders. Ocular motor dysfunction (OMD) netic syndromes, acquired brain injury, such as accommodative insufficiency
is one such disorder that can negatively cerebral palsy, autism, seizures, central (42%-100%) and oculomotor dysfunction
impact an individuals quality of life. nervous system malformations, low birth (100%).8,9 Downs Syndrome patients also
Gross motor control and coordination weight, hypoxic-ischemic encephalopa- have a high occurrence of accommodative
are the foundations for fine motor con- thy, abnormal movement pattern and insufficiency (80-92%), although the inci-
trol, especially for eye movements. In- abnormal muscle tone.2 The prevalence dence of OMD has not been reported.10,11
dividuals with DD tend to have poorly of DD in the general population varies Children born prematurely have difficulty
developed gross motor skills.It follows depending on the criteria used. Studies with voluntary control of saccades as in-
that they frequently will have delayed fine based on parent surveys vary from 3.3% fants.12 Aside from these reports, there is
motor skills including ocular motor per- to 17%.3,4 A more objective study by little evidence in the literature that gives
formance. A 10-year-old white male pre- Rosenberg et al was based on a sample of an accurate picture of the visual function
sented with developmental delay and very young children, representative of the en- of children with DD. Regardless of the
poor oculomotor control. He was treated tire United States, eligible for Part C early patients individual level of function, visu-
with 20 sessions of vision therapy (VT) intervention services.1 Part C service is al efficiency conditions such as OMD and
resulting in significant improvements in an interagency program for coordinating accommodative insufficiency can have a
visual efficiency skills. VT is very effec- early intervention through speech and oc- significant negative impact on daily life
tive in the treatment of OMD in the gen- cupational therapy for children ages nine and learning capabilities of the patient.
eral population. This case demonstrates months to three years and identified as Oculomotor dysfunction
that individuals with DD can benefit from having DD. Determination of DD is based As toddlers, children are primarily mo-
VT as well. Often bilateral coordination on testing cognitive and motor skills, or tor-driven.13 Normal oculomotor control
and body awareness are critical building the presence of diagnosed conditions that develops as a result of using vision to
blocks for accurate eye movements. Such confer high risk for developmental delay. replace motor exploration of the environ-
activities should be integrated into the VT Almost 14% of all children were qualified ment. This process can only occur once
program. as DD, although only 10% of the 14% re- gross motor coordination develops ap-
ceived Part C services. propriately. Gross motor control includes
Key Words bilateral coordination, visual motor inte-
The prevalence of visual conditions found
bilateral integration, body awareness, de- gration and body awareness. Bilateral co-
in the DD population is not well reported
velopmental delay, eye movements, ocu- ordination allows the child to differentiate
but seems to vary depending on the etiol-
lomotor dysfunction, pursuits, quality of right from left and gain an inherent knowl-
ogy of the delay. Although some studies
describe an increased incidence of high edge of midline and laterality. Visual mo-
Dudley LM, Vasch T. Vision therapy for a patient
with developmental delay: Literature review and refractive error and reduced visual acuity tor integration enables the child to transi-
case report. J Behav Optom 2010;21:39-45.. in these populations,5-7 few have consid- tion from motor to vision as the primary
Journal of Behavioral Optometry Volume 21/2010/Number 2/Page 39
learning modality. The child must also be Table 1. Symptoms associated with OMD
aware of where their body is in space be-
fore they can accurately localize targets.14 General signs and symptoms Signs and symptoms while reading
These gross motor elements are critical Poor fixation, locating or tracking objects Loss of place
for the development of fine motor control. Head or body movement while tracking Skipping words or skipping lines
Eye movements are the pinnacle of fine Difficulty copying from far to near Excessive head movement
motor control given the high demand for Short attention span Eyestrain or headache
accurate, coordinated movements. Conse-
Poor performance in sports Slow reader
quently, deficits in gross motor coordina-
Motion sickness or dizziness Uses finger to keep place
tion can lead to OMD. The same types of
gross motor deficits can cause problems Poor visually-guided coordination Poor comprehension
with laterality, directionality, and visual Adapted from Scheiman M, Wick B. Eye Movement Disorders. In: Scheiman M, Wick B, eds. Clinical
spatial skills resulting in delays of visual Management of Binocular Vision,15 and Applied concepts in Vision Therapy.16
perception. For this reason it is common
based on age. (Appendix) Low scores, es- 20/20 visual acuity at distance OD, OS
to find OMD concurrently with visual
pecially in the categories of head and body and OU. Monocular near visual acuity
perceptual dysfunctions.15,16
movement, indicate OMD. Reading-re- was reduced to 20/40 OD, 20/30 OS, but
The clinical definition of OMD is the de-
lated eye movements can be assessed was 20/20 OU. Pupils were round and re-
lay or inability to control the eyes while
using the DEM,24,25 a well established, active to light without afferent pupillary
making pursuits, saccades or maintaining
reliable scoring system. Once OMD has defect. Anterior segment ocular health
fixation. This results in a decrease in vi-
been identified, vision therapy (VT) is the was unremarkable. Posterior segment
sual efficiency that can affect reading and
traditional treatment approach.26,27 health was evaluated with dilated fundus
learning significantly.17 A list of typical
CASE REPORT exam and was also unremarkable.
symptoms of OMD can be found in Table
A 10-year-old white male of Eastern Eu- While ocular motilites were full, pursuit
1.
ropean descent presented for a compre- movements were severely deficient re-
Many children will not actively offer
hensive eye exam at Silver Falls Eyecare sulting in NSUCO score age equivalent
complaints since they may not be aware
in March of 2007. The chief complaints of less than 5 years of age. Pursuits were
of the problem. In the absence of pathol-
from his mother included poor visual at- characterized by significant head and
ogy, OMD is typically found in school-
tention, trouble seeing the computer, los- torso movement, profound inaccuracy
age children and is the result of incom-
ing his place often and poor eye contact. and inability to complete a single rota-
plete development of the internal spatial
His teacher was concerned that he had not tion. Saccadic eye movements were also
map and is thought to be a problem
made any progress recently and suspected very poor resulting in NSUCO score age
within the higher levels of neurologic
a visual problem. Delays in gross and fine equivalent of less than 5 years old. Sac-
function.15(p.246-262)
motor coordination were also reported. cades required head and torso movement
The prevalence of OMD in the general
His mother revealed concern at some of to initiate the saccade and were grossly
population has not been established, al-
these unusual behaviors she observed. inaccurate with very poor ability to com-
though most clinicians would agree it is
The patient was adopted at age 7 and plete a single cycle between targets. A
not uncommon to find the condition in
consequently much of his medical his- complete description of the NSUCO pro-
children and some adults. Studies have
tory was unknown. A recent neurologi- cedures, scoring criterion and age norms
found that good readers tend to have good
cal and physical examination revealed are listed in the Appendix. Fixation was
eye movements and a low prevalence of
overall developmental delays including of very short duration (<2 seconds) with
OMD. Preliminary reports by Maples
mental retardation, poor gross motor de- significant latency of initiation, frequent
and Ficklin indicate that the incidence of
velopment and speech delays. The cause large saccadic intrusions and large fixation
OMD in good readers ranges from 6-19%.
of the overall DD was suspected to be a errors up to 15 degrees. The patient had
Conversely, individuals with learning dis-
hypoxic event prior to or during birth and/ little ability to control his eye movements
ability were found to have OMD in 24-
or an alcohol related neurodevelopmental and often could not move his eyes to the
40% of the population.18 Some specific
disorder. However, the facial features of desired target, even with concentration
populations have increased prevalence of
the patient were not characteristic of fetal and effort. Binocular findings including
this condition, as well as other visual ef-
alcohol syndrome. At one month prior to phoria and vergence ranges were border-
ficiency disorders. OMD is found more
his initial visit to clinic he was diagnosed line. Stereoacuity at near was reduced to
often in individuals with traumatic brain
with Attention Deficit Disorder for which 70 seconds of arc with Wirt circles. Nega-
injury,19 learning disabilities,20-22 cerebral
he was prescribed Atomoxetine HCl tive relative accommodation (NRA) was
palsy, premature births12 and other special
(Straterra) for one month. He was en- +0.50 and positive relative accommoda-
populations.5
rolled in grade 3 at a public school special tion (PRA) was -0.25, both very reduced.
There are a number of subjective and
education program. Speech therapy was The DEM was very poor with many errors
objective tests to diagnose OMD.18 The
provided by the public school, but neither resulting in an age equivalent below test
Northeastern State University College of
occupational therapy nor physical therapy norms. The DEM recording form in Fig-
Optometrys (NSUCO)a oculomotor test
had been initiated. ure 1 illustrates the difficulties the patient
and the Developmental Eye Movement
The pertinent examination findings are had with horizontal eye movements.
Test (DEM are two such tests.24,25,b Using
summarized in Table 2 under pre-VT. Tests of visual perception were admin-
a scaling system of 1-5, eye movements
The refraction revealed emmetropia with istered to assess the patients ability to
can be quantified and compared to norms
Volume 21/2010/Number 2/Page 40 Journal of Behavioral Optometry
Table 2. Clinical Findings Pre- and Post-Vision Therapy process visual information. The follow-
Diagnostic Test Pre-Vision Therapy (6/07) Post-Vision Therapy (12/07) ing tests were administered to assess the
corresponding visual skills: Piaget Left/
Near Visual Acuity 20/40 OD, 20/30 OS, 20/20 OU 20/20 OD,OS, OU
Right Awareness28 (laterality/directional-
NSUCO Pursuits15 Ability 2 Age Ability 5 Age ity), Jordan Left/Right Reversal29 (direc-
Accuracy 2 <5 yr Accuracy 2 8 yr tionality), Beery Developmental Test of
Head Movm 1 equiv Head Movm 3 equiv Visual Motor Integration (VMI)30 (visual
Body Movm 1 Body Movm 4 motor integration), Monroe Visual Three31
NSUCO Saccades15 Ability 2 Age Ability 5 Age (visual memory), Visual Manipulation
Accuracy 1 <5 yr Accuracy 3 8 yr Test by Getman-Henderson-Marcus32 (vi-
sual spatial skills), and the Motor-Free
Head Movm 1 equiv Head Movm 3 equiv
Visual Perception Test (MVPT)33 (over-
Body Movm 1 Body Movm 4 all visual perceptual skills). Severe defi-
Fixation Duration <2 sec, significant Duration 7-8 sec, no latency ciencies were noted in all areas of visual
latency of initiation, frequent of initiation, 1-2 small saccadic processing. The patients average perfor-
large saccadic intrusions, large intrusions, good accuracy
fixation errors mance on tests of visual perception was at
a 5 year age equivalent. Moderate speech
Stereo Vision 70 sec of arc 20 sec of arc
delay was observed but the patient could
NRA/PRA +0.50/-0.25 +2.75/-2.50
adequately express himself and follow in-
DEM24,25 Vert 84s Age Vert 81s Age <6 yr structions. Attention was often poor but
Horiz 155s <6 yr Horiz 87s Age 7 yr the patient responded well to verbal re-
Err 31 equiv Err 16 Age 7 yr direction. The following diagnoses were
Ratio 1.84 Ratio 1.07 Age >14 yr made: profound oculomotor dysfunction,
Piaget L/R 28 Age 6 equivalent Age 11 equivalent severe accommodative insufficiency and
overall visual processing deficits.
Jordan L/R Reversal29 Part 1&2: 23 errors Part 1&2: 2 errors
VT was recommended with an estimate of
Below age 5 equivalent Age 10 equivalent 20 sessions consisting of weekly 45 min-
Beery VMI30 Age 5.3 equivalent Age 5.7 equivalent ute in-office sessions combined with daily
Monroe Visual Age 4 equivalent Age 9 equivalent home activities. The VT components are
Three31 listed in Table 3. The goal for therapy was
Visual Manipulation32 Age 4 equivalent Age 4 equivalent improvement of oculomotor control and
MVPT 33
Age 6.8 equivalent Age 6.11 equivalent gross motor coordination. The patient
See Appendix A for NSUCO scoring criterion and age norms was not a visually guided learner; he was
still relying heavily on reinforcement from
auditory and motor input. An occupa-
tional therapy evaluation was also recom-
mended but due to the familys financial
limitations it was not presently affordable.
VT was initiated in June 2007 and the rec-
ommended 20 sessions were completed
over a period of six months. There was
good attendance to office sessions and
moderate compliance with home therapy
activities. Emphasis was placed on bilat-
eral integration, body awareness, lateral-
ity, visual motor integration, pursuit and
saccadic eye movements, accommodation
and vergence. Visual perception skills
were addressed, but given a more guarded
prognosis.
At the conclusion of therapy, the patient
showed progress in many areas and his
parents were both thrilled with the dra-
matic transformation at the end of thera-
py. Increased ability to make eye contact
was observed as well as improvement in
his behavior and attention. He no longer
had problems seeing the computer and
had better visual attention. His mother
expressed that he seemed like a different
Figure 1.
child altogether; he was more observant,
Journal of Behavioral Optometry Volume 21/2010/Number 2/Page 41
independent and aware of his surround- shown to be quite effective for a number counteract gravity and maintain stability.
ings. The clinical findings after comple- of visual dysfunctions.36,37 However, the The visual-motor experiences that are ac-
tion of VT are summarized in Table 2. efficacy of VT in the DD population is quired will then enable the child to accu-
Marked improvements in ocular motility not well established. Consequently, many rately localize targets. Bilateral integra-
control were seen at the end of therapy, practitioners may not consider individuals tion and coordination are essential parts
showing an overall developmental gain of with moderate to significant DD as candi- of this process and enable a child to sense
three years. Near visual acuity improved dates for VT.38 This case demonstrates the right from left and fluidly move through
to 20/20 OD, OS and OU. Pursuit eye error of that assumption. space. Once the child can use vision to
movements showed profound improve- There are very few reports in the literature guide their movements, when the body
ment with NSUCO score age equivalent regarding the efficacy of VT in special is centered and stabilized, fixation and
of roughly eight years. The full pursuit populations. Duckman documented im- accurate eye movement can develop. If
rotations were able to be completed with provement in nine patients with cerebral the child has not adequately progressed
moderate accuracy with very few head palsy after VT for OMD, accommoda- through these stages, they will have dif-
movements and no torso movements. Sac- tive insufficiency, and visual perceptual ficulty remediating poor eye movements.
cadic eye movements also improved with skills.39 All patients showed improved Since DD typically includes delays in mo-
NSUCO score age equivalent of approxi- eye movements and most showed im- tor development, these patients frequently
mately eight years. The patient was able provement in other visual skills. Aside benefit from gross motor activities inte-
to complete the NSUCO cycles with mod- from this study, there is little evidence in grated into the VT program. The patient
erate accuracy, minimal head movements the literature that represents the potential was observed to have poor coordination
and no torso involvement. The DEM test for improvement in patients with DD. and balance, especially during eye move-
was significantly better; although the ver- Some practitioners think that individu- ments. If he was standing and asked to
tical time component did not change, the als may simply outgrow their poor visual make a slow pursuit, he would recruit his
horizontal component and the number of skills and catch up with their peers; this is whole body such that he almost fell over.
errors made was reduced by almost half. not the case. Tassinari conducted a retro- After it was recognized that this patient
This gives evidence that while the ocular- spective study showing that OMD did not had severely deficient gross motor coor-
motor skills were improved, the automa- improve if left untreated.40 Woodhouse dination and body awareness, these skills
ticity problem remained. The resulting et al showed that in young Downs syn- were addressed as a foundation for reha-
age equivalent on the DEM was age six to drome patients, accommodative skills do bilitation of his oculomotor system. A list
seven years. Fixation duration increased not improve with age.10 The search of the of gross motor and oculomotor activities
to seven to eight seconds and initiation literature indicates that the best method to utilized to encourage bilateral integration,
latency was no longer seen. Fixation ac- address these visual problems in the gen- body awareness and visual motor integra-
curacy was very good with minimal small eral population is through VT. There is tion can be found in Table 3.
saccadic intrusions. Stereoacuity reached no evidence that patients with DD would Vision Therapy for Individuals
20 seconds of arc. The NRA and PRA nor- not benefit from VT as well. If the patient with Developmental Delay
malized to +2.75 and -2.50 respectively. is not a good candidate for VT because of In general, VT has been shown to be ef-
While some of the tests of visual percep- physical or mental limitations, lens pre- fective for a variety of conditions in a
tion improved, others did not. The tests scriptions (e.g. bifocal for accommoda- wide range of different populations.27,36,37
that improved were: Piaget Left/Right tive insufficiency) should be considered VT has also been shown to improve
Awareness (age 11 equivalent), Jordan to provide them the best vision for their quality of life.41,42 There is no reason to
Left/Right Reversal (age 10 equivalent) daily activities.5 Treatment of these visual believe that patients with DD cannot de-
and the Monroe Visual Three (age nine conditions can make a significant impact rive the same benefits from VT as other
equivalent). For all of these tests he im- on the quality of life of the individual and patients. Modifications to accommodate
proved to near age equivalent. There were their learning potential.41,42 the patients specific needs are often nec-
no significant improvements with the Motor Control in Visual essary. Also, progress in therapy may be
Beery VMI, Visual Manipulation and the Development slower depending on the physical limita-
MVPT. Moderate progress was observed Many optometrists recognize the im- tions (motor and cognitive) of the patient
in bilateral coordination and arm/leg coor- portance of motor development in vi- in question.
dination during therapy, although this area sion.14,43-45 Often, in order to treat the fine Treatment of OMD and other visual dys-
will need continuing rehabilitation. These motor component, poor gross motor coor- functions in a patient with DD may require
results correlate well with the behavioral dination must first be addressed. Ideally some slight modifications to traditional
and functional changes reported by his this is done through co-management with therapy methods. Each patient is unique
parents at the conclusion of therapy. At- an occupational therapist, but visual mo- in their disability and often creativity is
tention, visual awareness, tracking and tor activities can also be incorporated into employed to alter activities or invent new
visual perception improved dramatically the VT program.46 ones. OMD activities should focus on
both subjectively and objectively. Taub et al indicates the relationship be- accuracy, eye-hand-body coordination,
DISCUSSION tween motor development and eye move- rhythm and automaticity. Starting thera-
VT for the treatment of OMD has been ments as follows.47 Motor coordination py with monocular activities often results
shown to be an effective form of reha- starts as the child learns to stabilize his in better control with gradual transition
bilitation in children and often improves body in space with basic muscle control. to binocular therapy. Age appropriate
reading skills.26,34,35 Overall, VT has been Then balance and centration is learned to elimination of head and body movements
Normal pursuit eye movement criterion by age Normal saccadic eye movement criterion by age
and gender and gender
Ability Accuracy Head Mvmt BodyMvmt Ability Accuracy Head Mvmt BodyMvmt
Age M F M F M F M F Age M F M F M F M F
5 4 5 2 3 2 3 3 4 5 5 5 3 3 2 2 3 4
6 4 5 2 3 2 3 3 4 6 5 5 3 3 2 3 3 4
7 5 5 3 3 3 3 3 4 7 5 5 3 3 3 3 3 4
8 5 5 3 3 3 3 4 4 8 5 5 3 3 3 3 4 4
9 5 5 3 4 3 3 4 4 9 5 5 3 3 3 3 4 4
10 5 5 4 4 4 4 4 5 10 5 5 3 3 3 3 4 5
11 5 5 4 4 4 4 4 5 11 5 5 3 3 3 4 4 5
12 5 5 4 4 4 4 5 5 12 5 5 3 3 3 4 4 5
13 5 5 4 4 4 4 5 5 13 5 5 3 3 3 4 5 5
>14 5 5 5 4 4 4 5 5 >14 5 5 4 3 3 4 5 5