Introduction

Education plays a pivotal role in the development of personality of every person by

providing a better quality of life, in terms of health, income and prospects. The major
goals of primary education are achieving basic literacy and numeracy amongst all
children, along with an establishment of strong foundations in science, mathematics and
social sciences. Academic performance is the outcome of education, the extent to which
a student has achieved his/her educational goals. The academic performance has been
linked to difference in intelligence and personality of each child by previous literatures.

A child needs good reading and writing skills to perform well at academics. To facilitate
academics they will require accurately functioning visual system. When we change our
fixation from distance to near, our eyes converge and change the focus by the
mechanism of accommodation in order to maintain single clear binocular vision. When
these mechanisms fail, affected individual may develop symptoms like headache,
blurring of vision, diplopia, fatigue or loss of concentration while doing near work.

Schiemann et al studied a clinical pediatric population of 2023 patients and their results
showed that the most common disorders recorded after refractive errors were binocular
(14.3%) and accommodative(5.4%) anomalies.1 In fact, 30-60% of a child’s school
activities involve near point tasks.2 These anomalies may result in a child developing
visual symptoms which can have a negative impact on the academic
performance.3These children may often experience unnecessary frustration and poor
self esteem due to these undetected eye problems, which may eventually result in
avoidance of near work.4,5

Children with poor academic performance include those with and without dyslexia, as
well as children with a lower intellectual ability or other problems. Once the child is
found to have dyslexia or low IQ, clinicians will be working on those for improving their
performance. But the role played by non-strabismic binocular vision anomalies in a
normal child with low academic performance remains a great concern as this is the
population which will be left undetected as they are considered as children with good IQ
and without dyslexia. Although prevalence of these conditions may vary according to

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the diagnostic criteria/clinical methods used, these functions were found to be much
better predictors for academic achievement.6,7

Although numerous studies done in western countries have suggested that efficient
visual functions play a role in ensuring appropriate academic performance, we don’t
have such data on our Indian population. So the main objective of the current study is to
analyse the impact of non strabismic binocular vision dysfunctions on academic
performance in primary school children, adjusting for IQ level and socio-economic
status of all children.

A study done by Vaughn et al has shown that children with more visual symptoms had
lower academic achievement than those with fewer visual symptoms. 8These authors
used the COVD-QOL questionnaire, which is used to measure subject’s visual symptom
score using nineteen questions regarding the difficulties faced by these children in
performing near tasks. In this questionnaire each question is given a numerical score
(never=0, seldom=1, occasional=2, frequently=3, always=4) and a total score of ≥20 is
suggestive of concern and further evaluation indicated.9 Though the previous study by
Lara et al has shown good test-retest reliability of this questionnaire in 3rd-4th grade
children, it was found that the sensitivity and specificity of this questionnaire alone to be
used as a screening tool for non-strabismic binocular vision anomalies (NSBVA) is low.
Also in the past, studies have shown that children from 4th standard onwards get used
to these visual symptoms and may not really complain of these problems.

After considering the need of a screening tool for non-strabismic binocular vision
anomalies in this school population, the secondary purpose of our study was to
determine the sensitivity and specificity of COVD-QOL-19 questionnaire for the
screening of NSBVA in higher primary school population and also to identify addition of
which clinical test along with the questionnaire improves the sensitivity and specificity,
making it a useful clinical tool for screening of non-strabismic binocular vision
anomalies.

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 Aim of the study

To estimate the impact of non-strabismic binocular vision anomalies on academic

performance in a primary school children of Udupi, Karnataka

Objectives

To perform a complete orthtoptic procedure and estimate the diagnosis of non-

strabismic binocular vision anomalies (NSBVA)

To find the Sensitivity and Specificity of COVD-QOL-19 questionnaire as a screening

tool for NSBVA in higher primary school children

To identify a clinical test which can improve the sensitivity and specificity to screen for
NSBVA along with COVD-QOL questionnaire

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 Review of literature

Conditions related to learning problems have always been associated with general
binocular dysfunctions. Several studies have indicated that children with reading and
learning problems show a higher incidence of non-strabismic binocular vision disorders
than normal readers.10,11,12Hoffman has reported that more than 85% of learning
disabled children who were referred for optometric evaluations had non-strabismic
accommodative and vergence dysfunctions. Though the ocular dysfunctions are having
contributions with one of these conditions, it is not the primary factor responsible for
poor academic performance.13

A study by Grisham D has shown a large number of high school-age children with poor
reading skills were found to show an increased risk of visual skill dysfunction, with poor
reading students being deficient in binocular fusion range.14 The study done by Palomo-
Alvarez et al have analysed the binocular abilities of population of non-dyslexic primary
school children with reading difficulties using accurate methods in an optometrist’s office
and have shown that poor readers show reduced distance base in vergence as has
been found in children with dyslexia.15 In that study, they have taken only reading
difficulties as the selection criteria for the study, but when it comes to academic
performance will have to consider all subjects and skills in each subject. So we have
thought it would be better to consider academic performance as a whole having
language, mathematics and combination of science & social science subjects rather
than just the reading skills. Hence all children who complain of visual symptoms related
to near work or have academic difficulties should be tested for accommodative and
vergence dysfunctions.

A study in the past has shown other than refractive anomalies, the most common
conditions optometrists are likely to encounter in a pediatric population are binocular
vision(starbismic and non-strabismic) and accommodative disorders. The prevalence of
accommodative and binocular (strabismic and non-strabismic) vision disorders is 9.7
times greater than the prevalence of ocular disease in children 6 months to 5 years of
age, and 8.5 times greater than the prevalence of ocular disease in children 6 to 18
years of age.1 It has been suggested that improving visual skills associated with

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vergence and accommodation by vision therapy should allow children to perform to their
maximal learning potential.16,17 Although numerous studies have suggested that efficient
visual function plays a role in ensuring appropriate academic performance 18,19other

studies have contradicted this.20 These studies have used different research methods
and this must have led to the controversies in their results.

The study done by Hoy et al on relationship between academic performance and

accommodative and vergence dysfunctions in primary school children has shown that
these anomalies have a negative impact on academic performance in this population.
But they did not adjust for IQ and socio-economic status of each child which plays a
major role in the performance of all children at school. In the past, poor school
performance has been documented to be high among children from poor socio-
economic background.21 This has been attributed to poor motivation, unsatisfactory
home environment and neglect. Other factors contributory to poor school performance
include poor housing and nutritional inadequacies. So these factors need to be
considered while assessing factors influencing the academic performance.

It is very well known that intelligence which is measured as the intelligence quotient or
IQ is one of the important prognostic variables in the academic performance of a child. 21
Children with borderline intelligence or poor IQ, irrespective of the etiology, are known
to present with poor school performance. 22 So only we have also included the
measurement of IQ of all children using Seguin Form Board to rule out the impact of
poor IQ on academic performance.

When children develop visual symptoms, they often find ways to avoid or reduce this
symptoms.8 Inappropriate behavior from a vision problem can lead to an inappropriate
diagnosis of a learning disability or attention deficit. Children diagnosed with attention
deficit disorder or attention deficit hyperactivity disorder (ADD/ADHD) exhibit more
visual quality-of-life symptoms than similar groups of non-ADD/ADHD children.23 The
early detection and prevention of vision problems is important. Usually vision screenings
done at schools are to rule out only refractive error not for other visual functions. The
reason for not testing other functions of eyes may be that a complete orthoptics
assessment being more time consuming.
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Questionnaires are a quick, easy, and cost-effective way to collect meaningful data.24,25
The College of Optometrists in Vision Development(COVD) developed a committee in
1995 to address the changes in quality of life as a result of vision therapy. Quality of
Life(QOL) Outcomes Assessment Committee devised a 30-item questionnaire to
administer to patients before, and after the completion of vision therapy. This
questionnaire addresses symptoms associated with vision anomalies from four broad
categories of quality of life: somatic, physical/occupational, social, and psychological.
The somatic sensation symptoms in the questionnaire include headaches, asthenopia,
pain, diplopia, dizziness, nausea and blurry vision. The physical-occupational category
addresses mobility, job, school, self-care, and ability to manage life without assistance.
Symptoms associated with social interaction are addressed by asking about personal
relationships with friends, family, peers, and community. Lastly, the psychological well-
being section includes overall satisfaction with life, anxiety, memory, and self image.26
The 30-item questionnaire [COVD-QOL] allows clinicians to better describe visual
symptoms and quantify changes attributed to optometric intervention, specifically with
lenses and vision therapy. A shorter version was developed as the original version
being criticized by patients as being too lengthy, consisting of 19 of the most attributable
quality of- life symptoms. Each question is marked as “Never” 0 points, “seldom” 1 point,
“occasional” 2 points, “frequently” 3 points, and “always” 4 points. A total score is
calculated by adding all question scores. The short form was found to have acceptable
test–retest reliability in 3rd and 4th grade children.27 A total score of 20 and above is of
concern, and further evaluation is indicated.

A study done by Bleything et al has shown a sensitivity of 71% and specificity of 54%
for COVD-QOL questionnaire in identifying children with vision problems.28In their study,
the visual symptoms due to vision, accommodative and vergence problems all together
was taken into consideration without classifying them into normals, with uncorrected
refractive error and NSBVA group. But in the current study we have analysed the
sensitivity and specificity of this COVD-QOL-19 questionnaire to screen specifically for
NSBVA.

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 Methodology

Study population: Students of 5th, 6th & 7th standard from Z.P. Government Higher

Primary School, Volakadu, Udupi, Udupi District, Karnataka, India.

Study design: Prospective Cross sectional study

Study setting: Z.P. Government Higher Primary School, Volakadu, Udupi

Study duration: December 2013 to March 2014

Sample size calculation:

n = 2(Z1-α/2+Z1-β/2)2σ2/d2

= 2(1.96+0.84)(2.648)2/(1.122)2
= 2(7.84)(7.02)/1.259
= 110.074/1.259
n = 87
Where, for 95% Confidence Interval Z1-α/2= 1.96

Keeping 80 as the Power, Z1-β/2 = 0.84

σ (standard deviation) and d (mean of difference of academic performance between

normal children and children with non strabismic binocular vision anomalies)
These data have been taken from the previous similar study, so minimum of 87 children
were expected to have non strabismic binocular vision anomalies out of all children from
5th to 7th standard.
So the final sample size calculated for the study was 87 subjects with non-
strabismic binocular vision anomalies out of all subjects.
Sampling technique: Purposive sampling method was used for the selection of school
to be screened for non strabismic binocular vision anomalies and its impact on
academic performance. Investigator recruited all subjects of 5th, 6th & 7th standard for
the study who met the inclusion and exclusion criteria set for the study.

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Inclusion Criteria:
 Students of 5th, 6th & 7th standard
 Presenting visual acuity of more than or equal to 20/20

Exclusion Criteria:
 Subjects presenting with strabismus/amblyopia
 Presence of systemic or ocular pathology
 Subjects with dyslexia/learning disability

Materials:
 Seguin Form Board for IQ assessment
 COVD-QOL 19 questions questionnaire to evaluate symptom score
 Students from 4th standard to 7th standard
 Log MAR Visual acuity chart for distance and N notation chart for near
 Balleywala and Homy trial set and trial frame
 WelchAllyn Retinoscope and Ophthalmoscope
 Binocular vision assessment kit having,
o Modified Thorington for quantification of phoria
o Titmus Fly stereo test
o ±2.00 accommodative flipper lenses
o 3Δ BI/12∆BO Prism flippers
o Prism Bar for fusional vergence measurement
o Torch light for anterior segment evaluation and for NPC assessment
o Gulden Fixation stick
 Academic performance : Total of all modes of examination conducted during first
half of academic year i.e. in first semester grades in Language (Kannada),
Mathematics and Average of Science & Social Science.

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Methodology:
Once the study population and study setting was decided, permission was taken from
School Authorities of Z.P.Government Higher Primary School, Volakadu, Udupi and an
official meeting was conducted for the class teachers of 5th, 6th and 7th standard,
explaining them about the purpose and methodology of the study. The detailed
information sheet regarding the study was provided to all parents and their consent was
taken for their child’s participation in the study which was circulated through the
respective class teachers. All procedures were done in the same staff room throughout
the study, provided by the School Authority which was a well lit room.
The class teachers of 5th, 6th and 7th standard were requested to collect information
about each subject’s parental profession. As this has an impact on academic
performance of each child, it was used as a controlling factor in seeing the impact of
NSBVA on academic performance. The professions were categorized under White
collar, Blur collar and Pink collar. White collar included any professional, managerial
and administrative work where as blue color was mainly of manual labor and pink collar
consisting of all service oriented works like customer interaction, entertainment and
sales. The examiner was masked about this information until the analysis stage.
A brief history was taken regarding the presence of ocular or systemic pathology,
significant family history of learning disability and also regarding the previous history of
any vision therapy to decide on whether the subject meets the inclusion criteria or not.
All subjects were examined for presenting visual acuity of 20/20 or better with Log MAR
visual acuity chart at distance and N6 with N notation chart at near.
An objective refraction was done using retinoscope to estimate the refractive status. In
cases of latent hypermetropia, subjective acceptance was done by fogging technique
and lenses were retained in the trial frame for further evaluation. Following this was the
anterior segment evaluation with hand held slit lamp and posterior segment evaluation
with direct ophthalmoscope to rule out any ocular pathology.

Sensory and motor evaluation

First sensory evaluation was done following which rest of the orthoptics assessment
was done. Titmus Fly test was used for assessment of stereopsis, in which the subject
was made to wear a polarizing glass over their correction if any and was asked to hold

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the test chart at 35cm. The subjects were asked to point at the circle which pops out
and were tested until subjects make more than 2 mistakes in reporting. The amount of
stereopsis present was estimated by referring to the given chart in arc seconds. Worth
Four dot test for near was performed and 10 prism diopter base down test for distance
was done to rule out suppression
To rule out manifest squint, initially simple cover test was performed following which
cover-uncover test was done to see for the presence of phoria by giving a fixation target
of 20/30 line at distance and 20/30 line in gulden fixation stick at near. The amount of
phoria was quantified by using Modified Thorington test at distance (3 meter) and near
(35cm). The test was done by placing the Maddox rod (horizontally & vertically oriented)
in front of right eye and shining the torch light through the hole present at the centre of
the Modified Thorington card. The subjects were asked to report for the number at
which the line coincides which gives us the amount of horizontal or vertical phoria
present.

Orthoptics work up
LAG: To estimate the lag of accommodation, Monocular Estimation Method was used.
The subjects were made to read the words of N8 size which was attached to the
retinoscope and the amount of lag present was estimated by neutralizing the movement
present.
Measures of accommodation: The amplitude of accommodation was estimated using
minus lens method. First the binocular amplitude was estimated following which was the
monocular amplitude estimation. The subjects were made to read the N8 line in the
chart and minus lenses were introduced in 0.25D steps at speed of 2 seconds until the
subject reported first sustained blur. The power of the lens with which subject reports
first sustained blur was noted and 2.50 D (compensating for the distance at which
reading material is kept i.e. 40cm) was added to that value to get the near point of
accommodation.
With an accommodative fixation target of N8 line in N notation chart, negative relative
accommodation was checked by placing plus spherical lenses in 0.25D steps in
2seconds of speed until the subject reports first sustained blur. Positive relative
accommodation was estimated with the help of minus lenses in the same way as NRA

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and was performed after measuring NRA to prevent excessive stimulation of
accommodation.
Accommodative facility: Monocular and binocular accommodative facility was assessed
using ±2.00D flipper lens. The fixation target of N8 was given and the subject was given
a demo of how to perform the test. Subjects were made to wear their own glasses if any
and then they were made to report immediately after clearing the reading material. The
test was started with a plus power and then moved on to minus. The number of cycles
completed in a minute was noted as accommodative facility in cycles per minute (cpm).
Measures of Vergence: NPC: PLRG method was used to estimate Near Point of
Convergence. Subject was made to wear red filter in right eye and green filter in left eye
and was asked to fixate at the torch light. The light stimulus was brought closer to the
subject until he/she reports either seeing a single color of light or two separated spots of
light. The distance was measured in centimeter (cm) and recorded as break point. Then
the recovery was identified by moving the light stimulus back until the subject reports a
single stimulus which is a mixture of both red and green and the distance was noted in
centimeter as recovery point. The procedure was repeated three times and the average
value was taken.
Vergence facility: The Vergence facility was assessed using 3ΔBI/12∆BO flipper lens.
The patient was made to fixate at the 20/30 line target which are vertically oriented for
better appreciation of diplopia and the facility was checked by first keeping the 3∆BI,
making the target single and then moved on to 12∆BO. The number of flips in a minute
was noted and the vergence facility was obtained in cycles per minute. All these tests
were carried out with a fixation material given at 40cm.
Fusional vergence: The step vergence was obtained using prism bar at distance and
near using vertically oriented letter acuity of 20/30. Negative Fusional Vergence (NFV)
was measured first by placing the prism bar, base towards nasal side, followed by
Positive Fusional Vergence (PFV). The prism was changed at a speed of 1Δ/second,
and subject was asked to report first when he notices blur and the prism power noted as
blur point. Then the prism power was increased until subject reported of appreciating
diplopia and the power was noted. From that prism power it was decreased until he/she
reports again of seeing single which is taken as recovery.

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Diagnosis criteria for each case
The diagnosis of each case was based on Donder’s criteria and using Schiemann &
Wick diagnosis of non strabismic binocular vision anomalies. The criteria for the
diagnosis of each anomaly are given in table 1. Diagnosis of all cases was done after
completing all the procedures of data collection, but before collecting the academic
performance reports and also before calculating questionnaire score to avoid any bias
in diagnosis.
Table 1: Diagnostic criteria for classification of non-strabismic accommodative
and vergence dysfunctions
Accommodative anomalies
Accommodative Insufficiency Accommodative Excess
Signs 1 & 2 need to be present PLUS sign 3 Signs 1-3 need to be present & one of 4
or 4 or 5
1. Decreased NPA: 2D below minimum 1. Variable objective and subjective
NPA-monocular refraction
2. Monocular accommodative facility 2. Monocular accommodative facility
with -2.00D fail≤4.5cpm ≤ 4.5cpm
3. Binocular accommodative facility 3. Binocular accommodative facility
≤ 2.5cpm ≤2.5cpm
4. Low PRA≤ 1.25 4. Low NRA ≤ 1.5D
5. Variable visual acuity
Accommodative Infacility
Signs 1-3 need to be present and sign 4
may or may not be present
1. Normal NPA
2. Monocular Accommodative facility
≤ 4.5cpm
3. Binocular accommodative facility
≤ 2.5cpm
4. Low PRA & NRA: PRA≤1.25 &
NRA≤1.50

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Vergence Dysfunctions
Basic Exophoria Basic Esophoria
Signs 1-2 need to be present and sign 3 or 4 Signs 1-3 need to be present and any of
present 4-6
1. Exophoria at Distance=Near 1. Esophoria at Distance = Near
2. Decreased PFV at near(Sheard’s 2. Decreased NFV at D & N
criterion≤ 12/15/14, atleast one of 3. Decreased vergence facility
three) 4. Low PRA
3. Normal AC/A 5. Fails Binocular accommodative
4. Binocular accommodative facility facility
≤ 2.5cpm 6. High MEM

Convergence Insufficiency Convergence Excess

Signs 1-4 need to be present and one of 5-7
1. Exophoria at near > 6∆
2. Exophoria near > distance by ≥4∆
3. Receded NPC ≥6cm break point
4. Decreased PFV at near following
Sheard’s criterion
5. Low AC/A<3/1
6. Binocular accommodative facility
≤ 2.5cpm
7. Low NRA≤ 1.5D
Divergence Insufficiency
Signs 1-3 need to be present
1. Esophoria Distance> Near
2. Low AC/A
3. Decreased NFV at distance
Signs 1-2 need to be present and one of
3-5
1. Esophoria Near > Distance ≥ 3D
2. Decreased NFV at near, failing
Sheard’s criterion ≤ 9/17/8
3. High AC/A >7/1
4. Binocular accommodative facility
≤ 2.5cpm
5. Low PRA ≤ 1.25D
Divergence Excess
Signs 1-4 need to be present
1. Esophoria Distance > Near
2. High AC/A
3. Normal NPC
4. Decreased NFV
5. Normal stereopsis at near
6. Suppression at distance

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Fusional Vergence Dysfuction
Signs 1-4 need to be present
1. Decreased NFV & PFV at D & N
2. Low PRA & NRA
3. Fails binocular accommodative
facility
4. Fails vergence facility
5. Noraml NPA, AC/A, phoria at
distance & near and monocular
accommodative facility

Description about IQ & Seguin Form Board

The academic performance of a child is affected by many factors where IQ is the prime
one. Since we wanted to find the impact of NSBVA on academic performance we
adjusted for IQ by assessing it using Seguin Form Board. Seguin Form Board is a
routine clinical test to assess the IQ of children. Once the orthoptics work up was
completed subjects were assessed for IQ level using Seguin Form board. In Seguin
Form Board, the individual is required to insert ten wooden blocks of different shapes
into the corresponding recesses as quickly as possible. The following instructions were
given to the subject: “Here are ten wooden blocks which have to be put by you in the
appropriate space. Be as fast as you can. You will be allowed only three trials”. While
administering this test these blocks were taken out by the examiner and stacked in front
of the subject who has to put them back as quickly as he/she can. The task was
repeated three times and the total time taken for all three times were added. These
tasks show the subject’s manipulation, his ability to respond to pressure for speed and
his performance when faced with difficulty. The total time taken was compared to the
age matched norms given for Indian subjects by the author J.B.Raj in the manual of
Seguin Form board. J.Bharath Raj has administered Sequin Form Board test on a total
number of 1052 subjects, the age range being 5-15years. Though Seguin Form Board
does not give us a complete picture of mental development, the test can be used as a
screening tool to find children with low IQ.

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College of Optometrists in Vision Development Quality of Life 19 (COVD-QOL-19)
The College of Optometrists in Vision Development Quality of Life Outcomes
Assessment (COVD-QOL) is a clinical survey instrument developed by a task force of
the College of Optometrists in Vision Development. COVD-QOL-19 allows clinicians to
better describe visual symptoms and quantify changes attributed to optometric
intervention, specifically with lenses and vision therapy. Each item is marked, and a
numerical score is assigned. “Never” is 0 points, “seldom” is 1 point, “occasional” is 2
points, “frequently” is 3 points, and “always” is 4 points. The minimum total score of the
questionnaire is 0 and maximum is 76. A total score greater than 20 is of concern and
suggests that further evaluation is needed.
The COVD-QOL 19 questionnaire was translated to Kannada for better understanding
purpose of children and validated before in hand by retranslating it into English by 3
qualified persons. One teacher was selected randomly out of all, to whom the mode of
instilling the questionnaire was explained and the instructions to be given. In each class
subjects were divided into a group of 10 and the questionnaire was distributed to one
group at a time. The subjects were made to sit apart for avoiding any chance of copying
from each other, while the teacher read out the questions for all subjects who were
made to mark their symptom scores. The total symptom score was calculated for each
subject by adding all the symptom scores.
Previous research with the original COVD-QOL and the COVD-QOL-19 indicated that
those subjects who scored 20 or higher would be at risk for vision problems that might
compromise the child’s academic performance. In the current study we have kept the
cut off score as 20 and have assessed for the sensitivity and specificity of the COVD-
QOL-19 questionnaire by keeping detailed orthoptic work up and diagnosis as the
standard. We have determined which of the clinical test can help us in increasing the
sensitivity and specificity of the questionnaire. Also a new cut off score was found with a
better sensitivity and specificity for the screening of NSBVA.

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Academic performance:
The academic performances of children in the following subjects were collected:
Language (Kannada), Mathematics, average of both Science and Social Science.
These details were collected from class teachers at the end of the study to avoid any
bias in the diagnosis of each case. The performance of children was graded out 100 in
all subjects based on their performance in class tests, assignments, oral and final
written examinations. The examiner conducting the study was masked from these
details until the analysis stage. The grading of children as given by school authorities
was: A+: 90-100, A: 70-89, B+: 50-69, B: 30-49, and C: 0-29. A grade of A+ and A was
taken as good performance and B+, B & C as poor academic performance.

Statistical Analysis:
Data tabulation and analysis were done using SPSS version 16 software. All subjects
were diagnosed and categorized basically into 3 groups: within normal limits,
accommodative anomalies, vergence anomalies and combine mechanism anomalies.
Impact of these anomalies on academic performance was assessed using Binary
logistic regression, adjusting for IQ and socio-economic status.
Sensitivity and specificity of COVD-QOL-19 questionnaire was analyzed using the same
software keeping the orthoptics assessment diagnosis as standard. ROC curve was
drawn and the values gave a new cut off score with improved sensitivity and specificity
for the better screening of NSBVA in this population. Also the sensitivity and specificity
of the questionnaire was calculated along with a few clinical tests like: NPC, NPA, AC/A,
NPC+NPA, NPC+NPA+AC/A, NPC+AC/A. This analysis was done to find out addition
of which of the clinical test improves the sensitivity and specificity of the questionnaire.

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 Results
A total of 236 subjects were screened out of which 27 were excluded due to the reason
of under corrected or uncorrected refractive error, refractive amblyopia and Down’s
syndrome. Out of 209, there were around 104 boys and 105 girls. Out of 209 subjects,
57% were diagnosed to have NSBVA based on standard clinical tests and the sub-
categorization of NSBVA is given in figure 1

Diagnosis of all subjects

Normals

9.2% 43%
22.9% Accommodative
24.9% anomalies
Vergence anomalies

Combined mechanism
anomalies

Figure 1: Pie diagram showing the diagnosis of all 209 subjects

Academic performance and NSBVA:

The academic performances of all 209 students in subjects like Language, Mathematics
and Science & Social Science are given in figure 2. In the subject language, among
23% (n=48) of good performers, 62.5 %( n=30) had NSBVA. Where as in mathematics,
out of 64% (n=134) good performers, 59 %( n=79) had NSBVA. Academic performance
of Science and Social Science was combined together and 54 %( n=57) had NSBVA
present among 51 %( n=106) good performers which has been shown in figure 3.

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 100
86.1
90
77
Number of students in %

80
68.4
70

60
A+ & A
50
B+, B & C
40 31.6
30 23

20 13.9

10

0
Language Mathematics Science and social
Subjects science

Figure 2 Academic performances of all 209 children in each subject

100.00
90.00
No. of students in %

80.00
70.00
60.00
NSBVA-
50.00
NSBVA+
40.00
30.00
20.00
10.00
0.00
Language Mathematics Science& social
science
Subjects

Figure 3: Diagnosis of students with good academic performance (based on

standard clinical tests)

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Binary logistic regression was performed to find the association between academic
performance and non-strabismic binocular vision anomalies. The association was also
found by adjusting for IQ and socio-economic status.

Impact of NSBVA on academic performance:

Impact of NSBVA on Language:
Without adjusting for any factors, children with NSBVA who were categorized into
accommodative anomalies, vergence anomalies and combined mechanism anomalies
performed better than the children without any anomalies, the reason being children
with anomalies performing well at academics were higher than children without
anomalies. So here, the good academic performance factor amongst NSBVA children
acts as a protective factor showing such result. When it was adjusted for IQ and socio-
economical status, it was found that the level of significance further decreased, proving
that IQ and socio-economic status has got greater impact on academic performance.
Children with normal IQ performed 0.632 times better at academics as compared to
children with poor IQ, but it was not statistically significant(p=0.505). Whereas children
of parents who are white collar grade people performed 0.221 time better than children
of blue collar, which was statistically significant (p=0.007). But there was no statistically
significant difference between children of parents from blue collar grade and pink collar
(p=0.084).

Table 2: Association between academic performance in language and NSBVA

Parameter Odd’s Ratio(95% CI) p-Value
Academic Within normal limits 1 -
performance
not adjusted Accommodative anomalies 0.555(0.254-1.214) 0.140
for IQ and Vergence Anomalies 0.664(0.293-1.506) 0.327
Family Combined mechanism 4.192(0.523-33.61) 0.177
income
Adjusted for Within normal limits 1 -
IQ and Accommodative anomalies 0.553(0.248-1.232) 0.147

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family Vergence anomalies 0.705(0.303-1.641) 0.417
income Combined anomalies 4.483(0.546-36.803) 0.162
IQ 1(poor) -
Good IQ 0.632(0.165-2.431) 0.505
Family Income 1(Blue collar) -
Pink Collar 0.532(0.261-1.087) 0.084
White collar 0.221(0.073-0.666) 0.007

Impact of NSBVA on Mathematics

In mathematics also there was no significant impact of NSBVA as children who
performed well at studies had NSBVA more as compared to poor performers. But when
it was adjusted for IQ and family income, the significance level increased suggesting the
impact of those is greater on academic performance. Children with normal IQ performed
0.554 times better than poor IQ children (p=0.344), which wasn’t statistically significant.
As compared to children of blue collar parents’, children of pink collar parents and white
collar parents had an Odd’s ratio of 0.315 [95%CI: 0.164-0.602(p=0.000)] and 0.289
[95% CI: 0.099-0.846 (p=0.023)] respectively.

Table 3: Association between academic performance in Mathematics and NSBVA

Parameter Odd’s Ratio(95% CI) p-Value
Academic Within normal limits 1 -
performance
not adjusted Accommodative anomalies 0.559(0.272-1.149) 0.114
for IQ and Vergence Anomalies 0.691(0.326-1.462) 0.333
Family Combined mechanism 1.894(0.505-7.106) 0.344
income
Adjusted for Within normal limits 1 -
IQ and Accommodative anomalies 0.556(0.263-1.175) 0.124
family Vergence anomalies 0.718(0.328-1.513) 0.408
income
Combined anomalies 1.971(0.507-0.662) 0.328

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 IQ 1(poor) -
Good IQ 0.554(0.163-1.881) 0.344
Family Income 1(Blue collar) -
Pink Collar 0.315(0.164-0.602) 0.000
White collar 0.289(0.099-0.846) 0.023

Impact of NSBVA on Science & Social Science

Subjects with accommodative anomalies performed 0.36 times better as compared to
normal subjects with a significance value of p=0.037, so there was a statistically
significant association between subjects with accommodative anomalies and academic
performance. But vergnce anomalies did not show any significant impact. Subjects with
combined mechanism anomalies performed 1.7 times poorer as compared to normal
subjects, but p value=0.998, statistically not significant. On adjusting for IQ and family
income status, the ‘p’ values of all three conditions increased, showing a significant
effect of IQ and Family income on academic performance. Normal IQ children
performed 0.76(p=0.691) times better in science and social science as compared to
children with poor IQ. The children of higher family income i.e., pink and white collar had
Odd’s ratio of 0.199 [95% CI: 0.074-0.537(p=0.001)] and 0.135 [95% CI: 0.034-0.530
(p=0.004)] respectively as compared to blue collar parents’ children.

Table 4: Association between academic performance in Science & Social science

and NSBVA
Parameter Odd’s Ratio(95% CI) p-Value
Academic Within normal limits 1 -
performance
not adjusted Accommodative anomalies 0.366(0.142-0.940) 0.037
for IQ and Vergence Anomalies 0.549(0.197-1.529) 0.251
Family Combined mechanism 1.777(0.000) 0.998
income
Adjusted for Within normal limits 1 -
IQ and Accommodative anomalies 0.354(0.132-0.948) 0.039

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family Vergence anomalies 0.565(0.194-1.650) 0.296
income Combined anomalies 1.801(0.00) 0.998
IQ 1(poor) -
Good IQ 0.761(0.138-3.721) 0.691
Family Income 1(Blue collar) -
Pink Collar 0.199(0.074-0.537) 0.001
White collar 0.135(0.034-0.530) 0.004

Sensitivity and specificity of COVD-QOL-19 questionnaire

The sensitivity of the questionnaire in detecting non-strabismic binocular vision
anomalies was found to be 37.3% and specificity was 91% keeping the 20 as the cut off
score as mentioned by the previous studies. It was also found that if we add
measurement of a clinical test like NPC and AC/A along with COVD questionnaire
keeping 20 as cut off score the sensitivity was increased to 54%, having specificity of
74%. The sensitivity and specificity of COVD-QOL-19 questionnaire along with different
clinical tests have been shown in table 5.

Table 5: Sensitivity and specificity of COVD-QOL-19 (with a cut off score of 20)
questinnaire along with different clinical tests
Sensitivity Specificity
COVD+NPC 38% 91%
COVD+NPA 90% 20%
COVD+AC/A 53% 74%
COVD+NPC+NPA+AC/A 92% 14%
COVD+NPC+AC/A 54% 74%
COVD+NPA+NPC 90% 20%

Receiver-Operating Characteristic (ROC) analysis was performed. The ROC curve plots
sensitivity (x-axis) versus 1-specificity to present area under curve (AUC) with values
between 0 and 1 (a value closer to 1 indicates better overall diagnostic ability). This
analysis provides a discriminate cut-off value of those with NSBVA compared to those

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who do not. The area under the curve was 0.739 with 95% CI (0.672-0.806), which
shows the test is fairly good enough to detect the conditions NSBVA among this
population.

Figure 4: ROC curve predicting the sensitivity and specificity of COVD-QOL-19 questionnaire
with a cut off score of 20

With the help of co-ordinates of the ROC curve which is given in table 6, a new cut off
score was found with an improved sensitivity and specifcity for identifying NSBVA. The
new cut off score found was 8.5 with a sensitivity of 69% and specificity of 66%. With
the help of this new cut off score for the questionnaire along with various clinical tests,
the sensitivity and specificity were assessed with different combinations(as shown in
table 7). It was found that along with the COVD-QOL-19 questionnaire if we add a
clnical test of AC/A ratio, the sensitivity and specificity can be improved to 79% and
53% respectively.

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Impact of Non-Strabismic Binocular Vision Anomalies on Academic Performance of Higher primary
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Table 7: Sensitivity and specificity of COVD-QOL-19 questionnaire with a new cut
off score of 8.5 along with various clinical tests

Sensitivity Specificity
COVD+NPC 70% 66%
COVD+NPA 93% 18%
COVD+AC/A 79% 53%
COVD+NPC+NPA+AC/A 96% 13%
COVD+NPC+AC/A 80% 53%
COVD+NPC+NPA 93% 18%

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 Discussion
In the current study 57% (119/209) subjects were found to have non-strabismic
binocular vision anomalies. Schieman et al study has also stated the same showing
prevalence of binocular vision (strabismic+nonstrabismic) anomalies are 8.5 times
greater in children of 6 to 18 years of age than the prevalence of ocular disease.1 Non-
strabismic binocular vision anomalies are seen in students who are high scorers or who
perform well at studies. The reason being, the more a child does near work/reading the
better will be the academic performance but near work has got a negative impact on the
eye causing non-strabismic binocular vision anomalies. So only we have seen that
children who are scoring in the category of A+ and A have more chances of having
non-starbismic binocular vision anomalies as compared to other children who are poor
at academics which is contradicting to previous studies done in the past. Also when we
adjusted for IQ and socio-economic status which have not been done by previous
studies, the NSBVA did not have any significant impact on academic performance.
Although we did not find any significant impact of NSBVA on academic performance of
any subject, the significane level increased when adjusted for IQ and socio-economic
status indicating the strong asscoiation of these two with academic performance.
A study done by Hoy et al25 on children of 9-13 years age group has shown that children
with bincoular dysfunctions had significantly lower academic score in every academic
area (reading, mathematics and science & social science) as compared to control
group(p<0.05). But in our study we did not find significant association between
academic performance and NSBVA. As IQ has got a great impact on academic
performance, a child having poor IQ may score less showing the false impact of NSBVA
on academic performance. We have also seen that children with normal IQ performed
on an avergae 0.65 times better than children with poor IQ.
Out of the three collar professions, the blue collar which includes manual labour workers
had a negative impact on academic performance of children as compared to pink collars
(service oriented workers) and white collars (professionals & administrative workers)
showing that parents educational qualification has an impact on children’s academic
performance.
As we have seen in the current study the prevalencce of NSBVA is high in the school
going population, it is very important to screen for the same. A complete orthoptics
Impact of Non-Strabismic Binocular Vision Anomalies on Academic Performance of Higher primary
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assessment consumes a long time, so as a resort the questinnaire can be used for
screening of NSBVA. So COVD-QOL-19 has been used as a screening tool for NSBVA
in this population. In the past, study done by Bleything et al has shown a sensitivity of
71% and specificity of 54% for COVD-QOL questionnaire in identifying vision problems
at the age group of 16-18years. The study basically has compared the scores pre and
post vision therapy in subjects who are socially at risk population and proven the
questionnaire as a reliable tool in comparing the symptoms pre and post vision therapy.
But in our study, the sensitivity of the questionnaire when used as a screening tool for
NSBVA was only 37% keeping 20 as cut off score and specificity was 91%. So we have
tried to increase the sensitivity of questionnaire by adding a clinical test, and it was
revealed that by adding NPC and AC/A along with the questionnaire the sensitivity can
be increased to 54% and specificity can be brought to 74%.
A new cut off score of 8.5 has been found to be used as a better screening tool among
this population having a sensitivity and specificity of 69% and 66% respectively . By
lowering the cut off score an improvement in the sensitivity has been achieved which is
supported by Bakar et al study. Bakar et al has studied the COVD-QOL-14 as a vision
screening tool in children in special eduacation classes and normal children and has
found, by decreasing the cut off score, the sensitivity can be improved in both normal as
well as special education population.

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 Conclusion

We found that the prevalence of non-strabismic binocular vision anomalies is high,

which is around 57% in the higher primary school children. Although we did not find any
negative impact of NSBVA on academic performance, we found a higher prevalence of
NSBVA among good academic performers. The reason could be good performers are
more involved in greater near work.

Our study also indicates the significance of screening for NSBVA in this school going
population. COVD-QOL-19 is a quick and good tool for screening NSBVA in higher
primary school children. Though with the previously indicated cut off score of 20, the
sensitivity of questionnaire is poor, with an addition of clinical test like NPC and AC/A
the sensitivity improves. A new cut off score of 8.5 was found with an improved
sensitivity to screen for NSBVA. Also it was found that with an additional clinical test of
AC/A for new cut off score, the sensitivity of questionnaire to screen for NSBVA was
good.

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 Limitation and Future Scope

Since our study is a cross-sectional study, we are not able to comment that the
occurrence of NSBVA (event) was because of more near work (exposure) or children
scoring poorly at academics were avoiding near work resulting in less symptoms.

In future a cohort study can be conducted by examining children at baseline without any
non-strabismic binocular vision anomalies and following them up for years until they
develop NSBVA which will enable us to undertsand the real impact of NSBVA on
academic performance.

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