It has been proposed that some learning disabilities, particularly those in which reading is impaired, are associated with deficits in eye movements and/or visual tracking. For example, many dyslexic persons may have unstable binocular vision and report that letters may appear to move around, causing visual confusion. Orthoptics is a technique of eye exercises intended to improve eye movements and/or visual tracking and has been investigated in the treatment of attention deficient disorders, dyslexia, dysphasia, or other reading disorders. Also known as vision therapy or ocular pursuit, the treatment may include the use of training glasses, prism glasses, or tinted or colored lenses.

This policy only discusses orthoptic training as a treatment of learning disabilities.

Orthoptic eye exercises for the treatment of learning disabilities are considered investigational.

Orthoptic eye exercises may be offered by orthoptists, optometrists, or ophthalmologists.

This policy is originally based on a 1996 TEC Assessment (1), which offered the following observations and conclusions:

• If visual problems have a causal relationship to reading disorders, then it would follow that successful treatment of such visual anomalies might result in an improvement in reading. However, if visual anomalies are the result of a central processing deficit, orthoptic training would not be effective and might possibly be harmful. For example, atypical eye movements might be a compensatory response among persons with reading disorders to obtain sensory information in a manner that they can process. Finally, if eye movement anomalies are uncorrelated to reading disorders, then the presence of a reading disorder would not be an indication for orthoptic intervention.
• Three scientific issues must be addressed in the evaluation of orthoptic training: 1) whether available evidence supports the proposition that visual defects have a role in the development or maintenance of reading disorders; 2) whether or not orthoptics alters the identified visual defects; and 3) whether treating the visual defects results in improved reading comprehension. This latter was judged to be the most important issue for the assessment.
• The TEC Assessment concluded that the available evidence did not support the conclusion that orthoptic training improves reading comprehension. (2-5) Specifically, the study population in the available published reported is not well defined; while the subjects may be reported to be “poor readers,” it cannot be determined whether they actually have a verifiable diagnosis of a reading disorder. In addition, objective outcomes of reading comprehension are lacking in the published studies.

Updates
A search of the literature from 1998 to December 2005 did not identify any published literature that would address the limitations noted in the AAP statement; therefore, the policy statement is unchanged. Two studies focused on the use of tinted lenses and eye patching as a technique to steady binocular vision as a therapy for dyslexia. Stein and colleagues reported results of a randomized trial in which 143 dyslexic children were instructed to wear yellow tinted glasses with or without the left lens occluded. The children were instructed to wear the glasses whenever they were reading or writing. Significantly more of the children who were given occluded glasses gained stable binocular vision in the first 3 months (59%) compared with children given the unoccluded glasses (36%). (8) Christenson and colleagues, however, found no difference in reading ability in children with dyslexia and abnormal binocular vision who were tested both with and without occluded, blue-tinted lenses. (9)
2007-2008 Update
A search of the MEDLINE database for the period of January 2006 to December 2007 did not identify any evidence that would alter the conclusions reached above. A clinical practice update indicates a consensus that visual therapies are not effective for reading or learning disorders. (10) The policy statement remains unchanged.
2009 Update
A search of the MEDLINE database for the period of January 2008 to January 2009 did not identify any evidence that would alter the conclusions reached above. Consensus remains that visual therapies are not effective for reading or learning disorders.
Summary
No evidence was identified that would alter the conclusions reached above. The policy statement remains unchanged; this therapy is investigational given the insufficient evidence available to evaluate the impact on net health outcomes.

Guidelines and Position Statements

In November 1998, the American Academy of Pediatrics, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus issued a joint policy statement concerning pediatric learning disabilities, dyslexia, and vision. (6) This policy offered the following statement: “Eye defects, subtle or severe, do not cause the patient to experience reversal of letters, words, or numbers. No scientific evidence supports claims that the academic abilities of children with learning disabilities can be improved with treatments that are based on 1) visual training, including muscle exercises, ocular pursuit, tracking exercise, or “training” glasses (with or without bifocals or prisms), 2) neurological organizational training (laterality training, crawling, balance board, perceptual training), or 3) colored lenses. These more controversial methods of treatment may give parents and teachers a false sense of security that a child’s reading difficulties are being addressed, which may delay proper instruction or remediation. The expense of these methods is unwarranted, and they cannot be substituted for appropriate educational measure. Claims of improved reading and learning after visual training, neurologic organization training, or use of colored lenses, are almost always based on poorly controlled studies that typically rely on anecdotal information. These methods are without scientific validation. Their reported benefits can be explained by the traditional educational remedial techniques with which they are usually combined.”

The American Academy of Optometry and the American Optometric Association have jointly issued a policy statement on vision learning and dyslexia. (7) This policy states, “Optometric intervention for people with learning-related vision problems consists of lenses, prisms and vision therapy. Vision therapy does not directly treat learning disabilities or dyslexia. Vision therapy is a treatment to improve visual efficiency and visual process, thereby allowing the person to be more responsive to educational instruction. It does not preclude any other form of treatment and should be a part of a multidisciplinary approach to learning disabilities … Vision therapy, the art and science of developing and enhancing visual abilities and remediating vision dysfunctions, has a firm foundation in vision science, and both its application and efficacy have been established in the scientific literature. Some sources have erroneously associated optometric vision therapy with controversial and unfounded therapies, and equate eye defects with visual dysfunctions.” This document does not provide a detailed review of the literature, and the most recent reference listed in this undated policy statement is from 1996.

References:

1. 1996 TEC Assessment, Tab 2.
2. Cooper J, Selenow A, Ciuffreda KJ et al. Reduction of asthenopia in patients with convergency insufficiency after fusional vergence training. Am J Optom Physiol Opt 1983; 60(12):982-9.
3. Heath EJ, Cook P, O’Dell N. Eye exercises and reading efficiency. Acad Ther 1976; 11:435-55.
4. Rounds BB, Manley CW, Norris RH. The effect of oculomotor training on reading efficiency. J Am Optom Assoc 1991; 62(2):92-7.
5. Weisz CL. Clinical therapy for accommodative responses: transfer effects upon performance. J Am Optom Assoc 1979; 50(2):209-16.
6. American Academy of Pediatrics. Learning disabilities, dyslexia and vision: a subject review (RE9825). Pediatrics 1998; 102(5):1217-9. ( www.aap.org/policy/re9825.html )
7. Vision, learning and dyslexia. A joint organizational policy statement of the American Academy of Optometry and the American Optometric Association. www.children-special-needs.org/parenting/dyslexia_dyslexic_pf.html
8. Stein JF, Richardson AJ, Fowler MS. Monocular occlusion can improve binocular control and reading in dyslexics. Brain 2000; 123(Pt 1):164-70.
9. Christenson GN, Griffin JR, Taylor M. Failure of blue-tinted lenses to change reading scores of dyslexic individuals. Optometry 2001; 72(10):627-33.
10. Wright C. Learning disorders, dyslexia, and vision. Aust Fam Physician 2007; 36(10):843-5.

Orthoptics
Training, Eye
Visual Training