IDOC: Interpreting Data from the Oyler Clinic

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree of Master of Science in the Graduate School of The Ohio State University

Sarah K. Lasher

Graduate Program in Vision Science

The Ohio State University

2015

Thesis Committee:

Dr. Jeffrey J. Walline, Advisor

Dr. Michael J. Earley

Dr. Terri A. Gossard

Sarah K. Lasher

2015

Abstract

The OneSight Vision Center located within Oyler School in Cincinnati, OH is the first self-sustaining school-based vision center in the nation. The center is a Federally

Qualified Health Center Look-Alike. The center opened its doors on October 1, 2012 and during its first year, 1,255 children received eye examinations, 420 of which were enrolled in the Oyler School. The examination records from the Oyler students were collected and analyzed to document the prevalence of vision anomalies and compare ocular characteristics between students with Individualized Education Programs (IEPs) and non-IEP students. Students in preschool through 12th grade were examined, and examination records were de-identified before transmittance to The Ohio State University

College of Optometry. Data were dual entered, and mismatched entries were corrected based on source documents. Prevalence data for various ocular characteristics was compared using Chi- square analysis and were compared between IEP and non-IEP students of Oyler, as well as literature-based values for both IEP and non-IEP children in the general public.

The ages of students examined were 3 to 19 years, and the average (± standard deviation) age was 10.7 ± 4.1 years. The students at Oyler had a significantly higher prevalence of hyperopia (Chi-square, p<0.0001), myopia (Chi-square, p=0.005), and astigmatism (Chi-square, p<0.0001) than literature values for the general public. Ocular characteristics that had a significantly higher prevalence in Oyler students with an IEP ii compared to non-IEP Oyler students were: astigmatism greater than or equal to -1.25DC

(Chi-square, p=0.001), exophoria at near (Chi-square, p=0.046), exotropia at distance

(Chi-square, p=0.002) or near (Chi-square, p=0.001), and a reduced near point of convergence (Chi-square, p<0.001). No other significantly different prevalences between

IEP and non-IEP children were detected.

Not all children who attended Oyler were examined during the school year. Those examined were more likely to have an IEP or a suspected vision-related problem. This fact alone may explain why there is a higher prevalence of ocular anomalies among Oyler students than the general population, and why few differences were detected in the prevalence of ocular anomalies between children with and without IEPs.

iii

Dedication

This document is dedicated to every child working to overcome the challenges they face

on a daily basis. We’re pulling for you.

Acknowledgments

To my advisor, Dr. Walline: I don’t know if I’ll ever be able to thank you enough for everything you’ve done. You worked so tirelessly to answer my questions, answer my emails, drop whatever you were doing to help me when I’d show up unannounced in your office, and I thank you for all of that and more. I’d like to thank Dr. Earley and Dr.

Gossard for taking the time out of their insanely busy schedules to not only read this thesis, but to sit on my defense committee. You both have had such a huge impact on me, and I know that I’ll be better able to serve my community as an optometrist because I’ve had you both to look up to. I’d also like to thank Dr. Zadnik for getting me in touch with

Dr. Gossard, which spawned this thesis project.

To the OneSight Vision Center Staff, especially Cari VanPelt and Dr. Thiemann: you all are such an asset to that center, and I hope you realize how much your hard work is appreciated. I feel blessed to have been able to not only write a master’s thesis on the data, but also to have been the first intern to rotate there and work with all of you.

Nick and Caitlin Perichak, you were both such a huge help to me in the writing process. To my parents, who raised me with the sense of drive that made me crazy enough to sign up for the Opt VII program. And to Chris – I don’t know how you put up with me studying night after night, but it will all be worth it very soon.

Vita

May 2007 ...... …………………Morgan High School

May 2011 ...... B.S. Biochemistry, Niagara University

2011-present………………Doctor of Optometry, Ohio State College of Optometry

Fields of Study

Major Field: Vision Science

Table of Contents

Abstract ...... ii

Dedication ...... iv

Acknowledgments...... v

Vita ...... vi

List of Tables ...... x

List of Figures ...... xi

Chapter 1: Introduction ...... 1

1.1 What is an IEP? ...... 1

1.2 IEP’s and Eye Examinations ...... 4

1.3 Poverty, Race, and Visual Correction ...... 7

1.4 Federally Qualified Health Center ...... 10

1.5 Why Oyler? ...... 12

1.6 Purpose of this Study...... 15

Chapter 2: Methods ...... 17

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2.1 IRB Approval ...... 17

2.2 Oyler Examination ...... 17

2.3 Subjects ...... 19

2.4 Refractive Error Definitions ...... 20

2.5 Binocular Vision ...... 20

2.6 Statistical Analysis ...... 21

Chapter 3: Results ...... 22

3.1 Oyler Demographics ...... 22

3.2 Refractive Error Prevalence ...... 27

3.3 Binocular Vision ...... 31

3.3.1 Distance and Near Cover Test ...... 32

3.3.2 Near Point of Convergence ...... 34

3.3.3 Convergence Insufficiency ...... 34

3.3.4 NRA/PRA ...... 34

Chapter 4: Discussion ...... 36

4.1 Oyler Demographics ...... 36

4.2 Refractive Error Prevalence ...... 39

4.3 Binocular Vision ...... 42

Chapter 5: Conclusion...... 46

viii

Bibliography ...... 48

List of Tables

Table 1: Normative values and study values listed for various binocular vision tests and

CI diagnosis ...... 21

Table 2: Percentage of recorded values, mean, or percent prevalence for Oyler demographics ...... 23

Table 3: Distribution of favorite classes among grades ...... 26

Table 4: Average values collected from various refractions, and prevalence of performance ...... 27

Table 5: Percentages of IEP and non-IEP students among refractive errors of all Oyler students, and uncorrected Oyler students………………………………………………...41

Table 6: Averages and percent prevalence for binocular vision testing ...... 42

Table 7: Prevalence of refractive error among Oyler students examined, among Oyler IEP students, and general public literature values ...... 53

List of Figures

Figure 1: Distribution of patient ages categorized by IEP and non-IEP ...... 23

Figure 2: Distribution of grades examined categorized by IEP and non-IEP ...... 24

Figure 3: Number of IEP and non-IEP students at Oyler by gender ...... 25

Figure 4: Proportion of IEP among hyperopic, myopic, and astigmatic eyes of Oyler students ...... 28

Chapter 1: Introduction

1.1 What is an IEP?

In 1975, a new federal law, known as the Individuals with Disabilities Education

Act (IDEA), was enacted. It was re-authorized in 1990, 1997, and again in 2004. The purpose of this law is to protect the rights of students with disabilities by ensuring that each person receives free appropriate public education, regardless of their ability. IDEA consists of two parts: Part A covers individuals from birth to 3 years while Part B covers individuals from 3 to 21 years of age. Under this law, Individualized Education Programs

(IEPs) were implemented (Building the Legacy, 2004).

IEPs are legally binding documents developed for an individual child who has been identified with a disability. An IEP includes information about a child’s academic and functional performance, and lists annual, measurable goals (Building the Legacy,

2004). Along with developing periodic progress reports, each IEP is reviewed/renewed annually, and updated with a description of the student’s progress. Every three years, the

IEP is re-evaluated (earlier if otherwise requested) to determine if the student is still eligible for special education services (C. Perichak, personal communication, January 29,

2015).

The Child Find mandate of IDEA states that it is the responsibility of the school to identify, locate, and evaluate any student suspected of having a disability. This mandate covers all students at both private and public schools (Child Find - Wrightslaw,

2008). Parents also have the right to request an evaluation if they feel their child may benefit from special education services. If a parent is the party requesting the evaluation, they must present the request in writing. The written request also serves as consent for the school to perform the evaluation (C. Perichak, personal communication, January 29,

2015).

Once a request for an IEP is made, the school is required to evaluate the child within 60 days (Building the Legacy, 2004). The first step in the evaluation process is to develop an Intervention Assistance Team (Special Education, 2012). An Intervention

Assistance Team is composed of teachers, administrators, and other support staff. The responsibility of the team is to set up various interventions for the student to try to solve the student’s learning difficulties. There are numerous variables that can prevent a child from learning properly in the classroom, and the Intervention Assistance Team’s job is to determine likely causes and proper interventions. Interventions include, but are not limited to, counseling and library media/technology systems designed for student support.

Schools are required to collect data on how the interventions affect the student, and this data is used to determine eligibility for special education services, and to document what methods are most beneficial to that child (C. Perichak, personal communication, January

29, 2015).

The school will then decide if the interventions developed by the Intervention

Assistance Team are sufficient, or if the student should be further evaluated through a

Multi-Factorial Evaluation. Parents must be notified of whatever decision the school has made, and why the school came to this conclusion. If the decision was made that the child does not need the Multi-Factorial Evaluation, parents have the right to appeal this decision. During an evaluation, schools must assess all areas related to the suspected disability including, but not limited to: health, vision, hearing, social and emotional status, IQ, communication and motor abilities (Special Education, 2012). The vision standard is simply a measure of whether or not the child is legally blind. It is assessed by a school nurse to determine if the child has acuity of 20/200 or worse. No other visual assessment is conducted to determine need for a vision-related IEP.

There are 11 disability categories that one can fall under to be eligible for an IEP; cognitive disability, hearing impairment (including deafness), visual impairment

(including blindness), deaf-blindness, speech or language impairment, emotional disturbance, orthopedic impairment, autism, traumatic brain injury, specific learning disability, or other health impairments/multiple disabilities (Special Education, 2012).

Those in preschool can qualify for an IEP under the category of ‘developmental delay’; it is not necessary for preschoolers to have a specific diagnosis (C. Perichak, personal communication, January 29, 2015). If the results of the Multi-Factorial Evaluation deem the student eligible for special education services, an IEP must be written within 30 days

(Special Education, 2012). The date of the IEP meeting is the date the IEP becomes effective (C. Perichak, personal communication, January 29, 2015).

1.2 IEP’s and Eye Examinations

The American Optometric Association (AOA) estimates that 80% of learning occurs through the visual pathway (Health Reform Offers Better Children’s Vision Care in the U.S., 2014), so uncorrected vision problems may be significant contributors to early reading difficulties and learning disability classifications. If a vision problem were to remain undetected via school screening, or if a comprehensive examination never occurred, a child could easily be wrongly classified as disabled, thus leading to the development and enforcement of an unnecessary IEP (Health Reform Offers Better

Children’s Vision Care in the U.S., 2014).

Beginning January 1, 2014, the Affordable Care Act classified vision care for children as an essential benefit under every level of insurance. Under this provision of the

Affordable Care Act, each individual 18 years and under has access to vision care by optometrists and ophthalmologists including comprehensive eye examinations and glasses every year (Health Reform Offers Better Children’s Vision Care in the U.S.,

2014). This was a massive step in the right direction, as undetected/untreated eye conditions are major health problems for children in the US and may be associated with poor reading and other poor school outcomes. It is estimated that 25% of school aged children have preventable visual impairments, which can lead to developmental disabilities (Walker, 2009). Early detection decreases the risk of development of amblyopia and developmental delays, thereby increasing the maximum potential for school performance (Walker, 2009).

School vision screenings are fairly commonplace, and can be beneficial for the detection of certain refractive errors and ocular conditions such as myopia (near- sightedness), strabismus (eye-turn), and amblyopia (lazy-eye). However, the AOA claims that 73% of children who needed vision care did not receive it because of reliance on screenings that failed to identify them. The sensitivity of amblyopia detection or high refractive error via vision screenings is only 27%. This means of the children who require further eye care, only 27% were identified through the screening, leaving 73% of children unidentified (Health Reform Offers Better Children’s Vision Care in the U.S., 2014).

Of the meager 27% correctly identified from the screenings, very few actually received the proper eye care. As of 2009, only 5 states required a comprehensive vision examination for children who failed a vision screening: Arkansas, Massachusetts, North

Carolina, Oklahoma, and Rhode Island. In addition, two states legislatively mandate eye examinations for pre-school children: Kentucky and Massachusetts. Only Ohio and

Massachusetts require comprehensive eye examinations for those newly identified with an IEP. The majority of these requirements only pertain to children enrolled in public schools (Walker, 2009).

Across the US, only 7% of first graders received an eye examination (Health

Reform Offers Better Children’s Vision Care in the U.S., 2014). This number is extremely low considering the high rate of learning that occurs at this age, and that visual factors are a primary cause of beginning reading failure in kids (Quaid, 2013). As previously stated, uncorrected visual impairments can result in unnecessary IEP identification, but may also result in misdiagnosed attention disorders. There is a three

5 times higher prevalence of convergence insufficiency in the Attention Deficit

Hyperactivity Disorder (ADHD) population when compared to those without attention disorders. The diagnosis of ADHD involves answering a survey called DSMV. Many of the questions on the DSMV are also asked on the Convergence Insufficiency Symptom

Survey (CISS). While convergence insufficiency does not cause ADHD, it is possible that children requiring proper eye care are being misdiagnosed as ADHD (Quaid, 2013).

Comprehensive eye examinations can identify and potentially treat ocular conditions before they contribute to learning disabilities or misdiagnosis of attention disorders.

Students with reading-based learning disabilities are assessed by school nurses in terms of visual acuity, but there is a lack of evaluation on other visual factors that may contribute to the disability. One study, published in 2013, compared reading speed, cycloplegic refraction, and oculomotor function between 50 students identified with reading-based IEP’s to 50 non-IEP students. The mean refractive error in the IEP group was +1.37D, while the mean refractive error for the non-IEP group was -0.66D, showing that the IEP group had a significantly higher degree of hyperopia while the non-IEP group was closer to emmetropia (no visual correction needed). The researchers noted that

93% of those in the IEP group had visual acuities better than 20/25 at the vision screening, which lead to the authors’ conclusion that visual acuity is a poor predictor of refractive error. Those in the IEP group also had significantly reduced vergence facility, which was correlated with reading speed as well as the number of eye movements made when reading. Along with refractive error, distance visual acuity is also a poor predictor of reading speed (Quaid, 2013).

The conclusions of this study were that students with IEP’s typically have higher amounts of hyperopia and reduced vergence ranges, resulting in slower reading speed and increased number of eye movements while reading. Based on their results, the authors suggest that each child being considered for a reading-based IEP receive a full, comprehensive eye examination as well as a binocular vision assessment (Quaid, 2013).

1.3 Poverty, Race, and Visual Correction

Individuals whose socioeconomic status is 400% below the Federal Poverty Level

(FPL) are three times more likely to have permanent vision problems (Health Reform

Offers Better Children’s Vision Care in the U.S., 2014). It is this same population that lacks access to proper eye care. A medically underserved population is considered one of an urban or rural area designated with a shortage of personal health services. The criteria include the population’s ability to pay for services and the accessibility to services

(Federally Qualified Health Center Look-Alikes, 2014).

The rate of uninsured persons is higher among low income households than high income households. In 2011, 25.4% of households whose annual income was less than

$25,000 were uninsured; compared to only a 7.8% rate of uninsured individuals with annual incomes of $75,000 or more (DeNavas-Walt, C., Proctor, B., & Smith, J., 2012).

Uninsured individuals are more likely to lack visual correction, as well as other services.

In 1998, 22% of uninsured children were without needed medications, mental health care, or eyeglasses while only 6% of insured children were without these health care necessities (Walker, 2009). In 2006, 23% of children who lacked insurance for at least 1

7 year did not have their vision needs met; only 5% of insured children had unmet vision needs. Of the uninsured children, black or Hispanic children have the highest risk of not having the proper visual correction (Walker, 2009).

Historically, Mexican-Americans and non-Hispanic Blacks have been medically underserved, and may not have the same access to eye care as Caucasians. In fact, being

Mexican-American or a non-Hispanic Black is the strongest predictor of inadequate refractive error correction in every age group, according to a 2014 study from the

University of California, San Francisco Department of Ophthalmology (Qiu, 2014). This study found that of those with health insurance, 20% of Mexican-Americans and non-

Hispanic Blacks had inadequate visual correction compared to 8% of Caucasians. Of those without health insurance, 30% of Mexican-Americans and non-Hispanic Blacks lacked proper correction compared to 14% of Caucasians (Qiu, 2014). Based on this, the authors concluded that having health insurance is not enough for non-Caucasians to seek vision care. Two other note-worthy conclusions from the study are: “Race/ethnicity disparities seem to be more pronounced in subjects with low annual household income, low education level, and lack of health insurance coverage…The lack of appropriate refractive correction has extensive social and economic impact including limiting education and employment opportunities, which exacerbates the disparity between non-

Caucasian and Caucasian populations (Qiu, 2014).”

Barriers to proper visual correction include cost/insurance coverage, poor quality of available frames, lack of transportation, and a lack of knowledge of the benefits of correction. A 2014 study looked at various methods to providing spectacle correction as

8 well as mathematic scores on fourth and fifth grade students in China (Ma, 2014).

Subjects were randomized into three groups for the study: free spectacles dispensed at the child’s school by an optometrist, vouchers for free glasses sent home to parents along with a note explaining the child needed visual correction (parents responsibility to provide transportation for glasses), and a spectacle prescription and letter sent home to parents explaining their child required glasses. From a school’s standpoint, the easiest of these options was the vouchers for the free glasses, however, this group did not have the best results in terms of spectacle wear and mathematics scores. The results of the study claimed that providing free glasses nearly doubled the number of children wearing spectacles compared to the group with the spectacle prescription only. At baseline, 14% of control, 14% of voucher, and 16% of subjects in the free glasses group were wearing glasses. After implementation of vouchers, free spectacles, and education, study coordinators visited schools to record the number of students wearing spectacles.

Subjects were also asked if they were wearing their glasses; both observed and self-report results are listed; 26% observed and 37% self reported wearing glasses in the control group, 37% observed and 63% self reported in the voucher group, and 41% observed and

68% self reported spectacle wear in the free glasses group. The free glasses and vouchers groups also had a statistically significant impact on the students’ performance in mathematics; control group had an improvement of 0.07 while the vouchers and free glasses had an improvement of 0.15 and 0.16 respectively (Ma, 2014). Considering results such as these, it appears the best solution for uncorrected and under-corrected,

9 especially those in medically underserved communities, is school-based eye and vision care.

1.4 Federally Qualified Health Center

A health center is defined by the US Department of Health and Human Services as “…an entity that serves a population that is medically underserved…by providing, either through the staff and supporting resources of the center or through contracts or cooperative arrangements, required primary health services and additional health services necessary for the adequate support of the primary health services.” (Federally Qualified

Health Center Look-Alikes, 2014). Services that are considered ‘required primary health services’ are pediatric eye, ear, and dental screening to determine the need for vision and hearing correction and dental care (Federally Qualified Health Center Look-Alikes,

2014).

A Federally Qualified Health Center (FQHC) is an umbrella term that encompasses all organizations receiving grants under Section 330 of the Public Health

Service Act. FQHC’s are able to receive enhanced reimbursement from Medicaid and

Medicare. In order for a health center to become an FQHC, there are certain requirements that must be met: the center must serve an underserved population, must offer a sliding fee scale, must provide comprehensive services, must have an ongoing quality assurance program, and must have a governing board of. Examples of FQHC’s include community health centers, public housing centers, Indian Health Service Outpatient clinics, and programs serving migrants and the homeless. Benefits of being classified as an FQHC

10 include: grant funding under Section 330 to offset uncompensated care, malpractice coverage under the Federal Tort Claims Act, enhanced Medicaid reimbursement through the Prospective Payment System, discounted pricing on pharmaceuticals under the Public

Health Services Act Section 340B, access to employees under the National Health

Service Corps, and others such as access to Vaccines for Children Program for uninsured, and Child Health Insurance Program enrollment services (Program Benefits, 2014). The

Prospective Payment System is the method by which Medicaid reimburses for certain procedures and services. The reimbursement amount is a pre-determined, fixed amount that varies depending on the particular service or procedure that is billed for (Prospective

Payment Systems, 2013).

The OneSight Vision Center at Oyler is part of a community health center, and is classified as an FQHC Look-alike. FQHC Look-alikes meet Section 330 of the Public

Health Service Act eligibility requirements, but do not receive grant funding. Many of the benefits are the same for Look-alikes as FQHC’s, however Look-alikes are unable to gain malpractice coverage under the Federal Tort Claims Act as well as not receiving grant funding to offset uncompensated care costs (Program Benefits, 2014). Look-alikes automatically receive designation as a Health Professional Shortage Area, which allows them to apply to receive National Health Service Corp personnel employees (Federally

Qualified Health Centers). The OneSight Vision Center utilizes this benefit and has employed a full-time AmeriCorps worker each of the years it has been open.

1.5 Why Oyler?

In Ohio, House Bill 95 was passed in 2003 and requires all students identified with an IEP to receive a comprehensive eye examination if they have not received one in the past 9 months. Upon their child’s identification, parents are required to schedule an appointment with an eye care provider within 90 days. While this bill sounds very promising, it lacks enforcement: “However, no student who has not undergone the eye examination required under this section shall be prohibited from initiating, receiving, or continuing to receive services prescribed in the students IEP” (Eye Exam Requirements for Special Education Students). Children should not be with-held from school because they are un-insured, lack access to care, or have parents that lack the time and means to get their child examined. However, by not enforcing the mandate from House Bill 95, at risk children are unlikely to receive proper care due to previously discussed barriers. The

Ohio Department of Education surveyed and determined that only 13% of identified students had received the required eye examination. Herein lies the importance of the

OneSight Vision Center located within Oyler Public School.

Oyler Public School is one of 55 schools in Cincinnati Public School District

(CPSD). There are approximately 33,000 students enrolled in CPSD, and of those 5,484

(17.7%) have Individualized Education Plans (IEP’s). For the 2010-2011 academic year, the national average for enrolled students with an IEP was 13%, with a state average of approximately 15% in Ohio (Students with disabilities, 2013). In that academic year,

31.1% of students enrolled in the Oyler School had an IEP. It is clear that CPSD, especially Oyler, has a higher rate of students on an IEP when compared to both the

12 national and state averages (Cincinnati Public Schools, 2013). Not only does Oyler have an IEP rate significantly higher than national and state averages, but the rates of economically disadvantaged students enrolled is also quite high. The term economically disadvantaged is used to describe students in households with income less than or equal to 185% of federal poverty guidelines. These students are eligible for free or reduced fee meals (Economically Disadvantaged Status, 2007). The vast majority of Oyler students are economically disadvantaged. During the 2010-2011 school year, 85.4% were economically disadvantaged, and 92.9% were economically disadvantaged during the

2011-2012 school year (Cincinnati Public Schools, 2013). A school is considered a high poverty school if 76% or greater of the enrolled students are eligible for free or reduced lunch (Number and percentage of public school students, 2000); 92% of Oyler students qualify (Cincinnati Public Schools, 2013).

Multiple factors lead to placing the first school-based vision center in Cincinnati,

Ohio. Oyler Public School is located in an economically disadvantaged neighborhood, and is the school for the surrounding medically underserved population. Along with the high rate of IEP’s, the low economic standing, and the lack of access to care, another factor that played into the vision center was that Oyler already had the necessary infrastructure for the vision center. The vision center was originally planned to be a library, but during the building process, funding ran short. A huge advantage to this becoming a reality was that no building was necessary; the existing space was molded into a vision center. Furthermore, an interdisciplinary team of eye care professionals,

13 politicians, school officials, community advocates, and health department officials all contributed time and energy to the creation of the OneSight Vision Center at Oyler.

Many of those who fail a vision screening never receive follow-up care, and in many cases it is due to a lack of access to eye care providers. The lack of access is due to many factors including poverty, lack of providers in the area, lack of insurance, and lack of education on the importance of vision. The OneSight Vision Center at Oyler addresses each of the previously listed factors by providing comprehensive eye care in a school setting.

The OneSight Vision Center opened its doors on October 1, 2012. Any student enrolled in Cincinnati Public School District is eligible to receive eye care, as well as any school-aged child. Those enrolled in CPSD were transported to Oyler in groups of seven to 14, where they remained for the morning or afternoon. Each student received a comprehensive eye examination, including dilation, and if spectacle correction was warranted, they chose glasses in the dispensary located within the vision center. Allowing the children to pick out their own glasses without the presence of their parents was a unique aspect of the clinic, and may have increased the likelihood that the children wore their glasses on a regular basis. A letter was sent home to the parents of each student addressing the findings of the exam, as well as any spectacle prescription that may have been found, and a separate letter was sent to the school nurse. Once all eye examinations were complete, the children were transported back to their school. For children not enrolled in CPSD, parents were able to schedule an appointment, as appointment times were set aside every morning for those children.

Glasses were ordered on a daily basis through the lab that the child’s insurance utilized. If the student did not have insurance, they were able to choose glasses provided by OneSight, a philanthropic arm of Luxottica. All glasses were sent from the labs back to the OneSight Vision Center where they were verified by a certified optician, and then delivered by the optician to the student.

The staff at the OneSight Vision Center includes one full time optometrist, one full time licensed optician, one full time administrative assistant, one full time

AmeriCorps employee, and two part-time optometric technicians. As there is only one full-time optometrists, the majority of the exams were performed by the same individual thus maintaining consistency in the prescribing and referring rates. The center is a

Federally Qualified Health Center (FQHC) Look-Alike, and receives reimbursement for every examination in varying amounts depending on the child’s insurance. Insurances accepted by the vision center include: Medicaid, Caresource, Paramount, Molina, and those children without insurance are also examined. Only school-aged children are able to be examined at the center.

1.6 Purpose of this Study

The purpose of this study is to document the ocular characteristics of students enrolled in Oyler Public School, in Cincinnati, OH, and to compare these characteristics between students identified with an Individualized Education Plans (IEP) to non-IEP students. To date, there have been literature reviews of differences that may exist between children with and without IEPs, but there has not been a direct comparison of

IEP and non-IEP students within the same location to determine if differences in ocular characteristics exist.

There are no risks to the subjects because the students were already undergoing the eye examination at Oyler, and the exam results were de-identified before OSU received them. Benefits to the subjects are minimal, if even existent, from this specific study. However, the students benefitted from participating in the eye examination by receiving proper care, treatment, and correction. The information found in this study can be used as preliminary information for a study that would compare academic progress with proper visual correction for students with and without IEP’s. The results of this study may be used to educate the public at large on the importance of comprehensive eye examinations in school aged children, and educate the optometric community on which characteristics may be linked with the development of an IEP.

Chapter 2: Methods

2.1 IRB Approval

The study was approved through The Ohio State University Biomedical Sciences

Institutional Review Board on May 1, 2013. The study followed the guidelines of the

Declaration of Helsinki. A waiver of consent was approved because the data were collected as a part of routine eye care provided to the student, and they were de-identified prior to receipt at the College of Optometry.

2.2 Oyler Examination

Students enrolled in Cincinnati Public Schools are eligible to receive a comprehensive eye examination at the OneSight Vision Center located within Oyler

School, regardless of whether they have Medicaid, Caresource, Paramount, Molina, or no vision insurance. The first year the vision center was open, 1,255 students were examined. Of those, 420 were Oyler students and all of their examination data were used for this study.

The comprehensive eye examination includes the following elements: chief complaint/patient history review (including whether or not the child is on an IEP, whether or not English is a second language for the child, previous vision correction, the child’s

17 favorite class, age, and grade) color vision testing with Ishihara, random dot stereopsis, non-cycloplegic auto-refraction, non-contact tonometry (if the child is older than 10 years), distance and near visual acuities, amplitudes of accommodation, near point of convergence, confrontation visual fields, distance and near cover test, non-cycloplegic retinoscopy, non-cycloplegic manifest refraction, anterior slit lamp examination, dilation, cycloplegic autorefraction, cycloplegic retinoscopy, cycloplegic manifest refraction, dilated fundus examination. The most sophisticated method possible was used for each child; for example, as long as the student knew the alphabet, Snellen acuities were obtained instead of LEA. Students were dilated with Paramyd, cyclopentolate, or tropicamide at the discretion of the practicing optometrist. Every examination element was attempted on each patient, but not all data were collected for every student. Each examination element performed was recorded on the examination form, along with the spectacle prescription, assessment and plan, and whether the patient warranted a vision therapy evaluation. Pass/Fail criteria for the Ishihara plates is 70%: patients who get less than or equal to 7 out of 10 plates, or less than 6 out of 8 plates, are considered color deficient (Ishihara, S. 1917).

The exam forms from the 2012-2013 academic year were copied, and identifying pieces of information (patient name, date of birth) were blacked out on the copies. The copied, de-identified examination forms were then transmitted to The Ohio State

University College of Optometry. Data from the examination forms were dual entered into Excel spreadsheets, which were stored on a secure server. The two Excel spreadsheets were then compared. Mismatched data were compared to the source data

18 and corrected to create a corrected database. All refractive errors were converted into M,

J0, and J45 notation for analysis. The students examined within the vision center were those suspected of having vision problems, and therefore the prevalence of ocular conditions in both the IEP-identified and non-IEP students is artificially elevated.

2.3 Subjects

Children aged three to 19 years enrolled in Oyler Public School were eligible to receive a comprehensive eye examination at the OneSight Vision Center. Students were identified by their school ID, academic ID, age, grade, and it was noted whether they had an IEP. Those students with a documented IEP were identified on the examination form.

The optometrist hired to work at the OneSight Vision Center determined whether the student required a refractive prescription and whether vision therapy was warranted.

No recruitment was necessary for this project as information from all the patients receiving eye care at the OneSight Vision Center at Oyler School were collected as part of a regular examination. A signed parental consent form was required for all children undergoing eye examinations. The patients included students enrolled at Oyler School, students enrolled in other branches of Cincinnati Public School District that were transported to Oyler, and children brought to the OneSight Vision Center by their parents for an eye examination.

There was no need to recruit subjects separately for a control group because not all students examined at the OneSight Vision Center had an IEP. Each examination form

19 identified whether or not each child had an IEP, and this characteristic distinguished the experimental from the control group.

2.4 Refractive Error Definitions

For comparison, myopia, hyperopia, and astigmatism were all defined as -0.50 D or more myopic, +1.25 D or more hyperopic, and -1.00 DC or more astigmatism respectively. Subjects were categorized as myopic or hyperopic based on the spherical equivalent of the manifest refraction of the right eye. If the manifest refraction identified

-1.00DC or more astigmatism for the right eye, the patient was categorized as astigmatic.

If subjects did not fall into any of the refractive error definitions, they were categorized as emmetropic. Those categorized as ‘astigmatic’ are not exclusive to this category as hyperopes and myopes can both have an astigmatic component to the prescription.

2.5 Binocular Vision

The definition of phoria was determined based on the text “Clinical Management of Binocular Vision” listed norms. Only the values with quantified phoria were used in analysis, as it cannot be known if the phoria was within the normal range or not. Table 1 lists the expected values according to the textbook, and the values used for the purposes of this study.

Test Expected Finding from Text Study Values Distance Cover Test 1Δ exophoria ± 2Δ Ortho=0-3Δ exophoria Near Cover Test 3Δ exophoria ± 2Δ Ortho=0-6Δ exophoria Near Point of Convergence 5-7cm Reduced = >6 cm Convergence Insufficiency Dx Nphoria-Dphoria>4Δ exo Nphoria-Dphoria>4Δ exo Reduced NPC Reduced NPC (>6cm) Table 1: Normative values and study values listed for various binocular vision tests and CI diagnosis. Nphoria=Near phoria, Dphoria = Distance phoria, NPC = near point of convergence.

2.6 Statistical Analysis

Data were analyzed using IBM SPSS Statistics 21 statistical analysis program.

Categorical data were compared using Chi-Square analysis, while Student t-tests were used to compare continuous data. A p-value of less than 0.05 was considered statistically significant.

Chapter 3: Results

3.1 Oyler Demographics

During the first year the OneSight Vision Center at Oyler School was open, 1,255 students underwent eye examinations. Of those, 420 were enrolled in Oyler School, and these 420 examination forms were analyzed for this study. Ages of Oyler students examined ranged from three to 19 years old, although 48 of the examination forms did not have the age of the student listed. Preschool through 12th grade students were examined, and 171 were female, 147 were male, and 102 forms did not specify gender.

There were 107 (25.5%) students identified with an IEP. At the time of their examinations, 62 (14.7%) wore visual correction, 163 (38.8%) previously wore visual correction, and 59 (14%) either lost or broke their glasses. Of the 420 Oyler students examined, 271 (65%) were prescribed glasses during the eye examination and thirty students were referred for a vision therapy evaluation. Only one student spoke English as a second language. Table 2 shows how often specific variables were recorded, and the mean ± standard deviation or prevalence of that variable.

Variable Number (%) with measurement Mean ± SD or % Age (years) 372 (88.6) 10.7±4.1 Gender (% female) 318 (75.5) 53.8% Previous vision correction (%) 404 (96.2) 34.5% Wearing correction 406 (96.7) 14.8% Broken or lost 404 (96.2) 14.1% Current IEP (%) 420 (100) 25.5% Dilated (%) 383 (91.2) 91.2% Prescribed vision therapy (%) 420 (100) 7.1% Prescribed glasses (%) 420 (100) 64.5% <75% correct color vision (%) 420 (100) 10.6% Table 2: Proportion of time that variables were recorded during an eye examination and the mean ± standard deviation (continuous variables) or prevalence (categorical variables) for demographic information of Oyler students examined

No children were identified with an IEP before 5 years of age, and the largest number of

IEP-identified children was eight years of age (Figure 1).

Figure 1: Distribution of patient ages categorized by IEP and non-IEP

Figure 2 shows the distribution of IEP and non-IEP students by grade. Interestingly, the shapes of the distributions of children by age and by grade are dissimilar, indicating that many children may have repeated grades. The highest number of children on IEP occurs in the ninth and tenth grades. The presence of an IEP is significantly related to the child’s grade (Chi-square, p=0.008).

Figure 2: Distribution of grades examined categorized by IEP and non-IEP

A greater proportion of boys (34.0%) had IEP’s than girls (18.75%, Chi-Square p= 0.001). Not every examination form had gender recorded, so the analysis involves only those on which the recording was present. Figure 3 shows a breakdown of the number of IEP and non-IEP students by gender.

Figure 3: Number of IEP and non-IEP students at Oyler by gender

Children who were referred for vision therapy were not more likely to be on an

IEP than children who were not referred for vision therapy (Chi-square, p=0.06).

Likewise, neither children who lost or broke their glasses (Chi-square, p=0.82), nor children currently wearing visual correction (Chi-square, p=0.38), were more likely to be on an IEP than children who did not require vision correction.

A component of the examination at Oyler asked each patient his/her favorite class, and 400 (95.2%) students responded. Math was the favorite class for 146 (36.5%) children, 53 (13.5%) students preferred science, 29 (7.3%) preferred social studies, 65

(16.3%) liked language arts best, 36 (9.0%) had ‘other’ favorite classes (music, art, gym, etc.), and 71 (17.8%) students said they had no favorite class. Upon analysis, there was no statistically significant relationship between favorite class and IEP identification (Chi- square, p=0.70). There was also no relationship between gender and favorite class (Chi- square, p=0.21). There were, however, significant differences in favorite class by grade level (Chi-square, p<0.0001). The favorite class tended to be math in first through fourth

25 grades and science in fifth through eighth grades. Table 3 shows the distribution of favorite class in each grade of Oyler students examined.

Favorite Class Language Social Grade None Science Math Other Arts Studies Pre-K 79.3 0.0 0.0 6.9 0.0 12.1 1 16.1 0.0 58.1 16.1 0.0 9.7 2 4.1 4.1 57.1 20.4 0.0 16.3 3 6.3 6.3 62.5 18.8 3.1 3.1 4 3.7 7.4 51.9 33.3 0.0 3.7 5 0.0 38.5 30.8 19.2 7.7 3.8 6 9.5 42.9 23.8 4.8 14.3 4.8 7 3.3 23.3 56.7 13.3 3.3 0.0 8 5.3 42.1 26.3 15.8 5.3 5.3 9 17.5 7.5 25.0 12.5 27.5 10.0 10 5.6 13.9 19.4 25.0 25.0 11.1 11 5.6 11.1 44.4 16.7 5.6 16.7 12 7.7 23.1 46.2 7.7 0.0 15.4 Total 17.8 13.3 36.5 16.3 7.3 9.0 Table 3: Proportion of favorite classes among grades

As a score of 70% or worse is considered a failing score on Ishihara color vision testing, scores of 75% or above were considered passing scores for this study. All 420

Oyler students examined underwent color vision testing. Only 46 (11.0%) failed this test, of which 10 (21.7%) had an IEP. Children who failed the color vision screening were not more likely to have an IEP (Chi-square, p=0.58).

3.2 Refractive Error Prevalence

All 420 Oyler students examined underwent non-cycloplegic autorefraction and non-cycloplegic manifest refraction. A cycloplegic manifest refraction was performed on

107 (25.5%) children who were examined. The mean ± standard deviation refractive errors are shown in Table 4.

Variable Number (%) with Mean ± SD or measurement % Non-cycloplegic autorefraction (OD) 420 (100) M (D) +0.14±1.89 J0 (D) +0.23±0.49 J45 (D) +0.23±0.47 Non-cycloplegic manifest refraction (OD) 420 (100) M (D) +0.30±1.86 J0 (D) +0.20±0.41 J45 (D) +0.03±0.21 Cycloplegic manifest refraction (OD) 107 (25.47%) M (D) +0.39±1.07 J0 (D) +0.06±0.25 J45 (D) +0.00±0.07 Entering distance visual acuity (%) 414 (98.57) Worse than 20/40 23.2% Table 4: Average refractive errors based on various types of refraction, and the prevalence of entering visual acuity worse than 20/40

Of the 420 Oyler students examined, 66 (15.7%) had more than +1.25 D spherical equivalent hyperopia based on the manifest refraction. Fifteen (22.7%) hyperopic students had an IEP. Sixty-nine (16.4%) children had more than –0.50 D spherical equivalent myopia, and 21 (30.4%) of them had an IEP. Emmetropia was identified in

285 (68.8%) students, and 71 (24.9%) had an IEP (Figure 4). 27

Figure 4: Proportion of IEP among hyperopic, myopic, and astigmatic eyes of Oyler students

There was not a significant difference in the proportion of children with IEPs based on their refractive error category (Chi-square, p=0.55). In order to determine if IEP prevalence differed among various levels of myopia and hyperopia, myopia levels of -

1.00D (p=0.65) and -2.00D (p=0.84) were also analyzed, neither of which produced a significant relationship. Hyperopia levels of +2.00D (p=0.46), +2.50D (p=0.31), +3.50D

(p=0.46), and +5.00D (p=0.21) were all analyzed, none of which resulted in a significant relationship between IEP and refractive error. It appears that no level of hyperopia or myopia is significant with IEP-identification.

The magnitude of hyperopia and myopia were also analyzed. Hyperopic spherical equivalent levels ranged from +1.25D to +9.13D. The total number of students with a hyperopic refractive error in their right eye was halved, and the median level of

28 hyperopia was +2.38D. Thirty-three students with refractive errors less than or equal to

+2.38D were categorized as “low”, and the remaining 33 students were categorized as

“high”. There was no significant relationship between high and low hyperopia in terms of

IEP prevalence (Chi-square, p=0.14). The same procedure was repeated for myopia spherical equivalents, which ranged from -0.50D to -11.13D. Sixty-three students had at least -0.50D or more of myopia, and the median value was -2.00D. Thirty-one students with myopia less than or equal to -2.00DC were categorized as “low” and the rest as

“high”. Again, no significant relationship resulted (Chi-square, p=0.38).

Astigmatism of -1.00DC or more was identified in 78 (18.6%) patients upon manifest refraction. Twenty-six (33.3%) children with astigmatism also had IEP’s. Based on this level of astigmatism, no relationship exists between IEP identification and cylinder power of -1.00DC or more (Chi-Square p=0.08). A significant relationship does exist, however, between -1.25DC and IEP identification (Chi-square, p=0.001) showing that students with -1.25DC or greater astigmatism are more likely to have an IEP than students without. There were 59 (14.1%) individuals who required cylinder correction of

1.25DC or more for their right eye, 25 (42.4%) of which had an IEP. Of those 59 patients,

58 had with-the-rule (WTR) astigmatism.

With-The-Rule astigmatism is defined as any cylinder axis within 20 degrees of the 180 degree meridian, (ie, between 0 and 20 and between 160 and 180 degrees).

Astigmatic students with WTR astigmatism were not more likely than non-WTR students to be identified with an IEP (Chi-square, p=0.054).

The magnitude of cylinder power was also analyzed using the same process as with myopia and hyperopia magnitude. The range of cylinder powers found on manifest refraction was -1.00DC to -5.00DC. The median value of astigmatism was -1.75DC, and the 39 students that had between -1.00DC and -1.75DC were categorized as “low” while the remaining students were categorized as “high.” Higher magnitude of cylinder correction increases the likelihood of the student having an IEP (Chi-square, p=0.01).

The previously described refractive error analyses included all Oyler students examined, those with and without current correction. To determine if those currently wearing correction were affecting the rate of refractive error prevalence among the IEP- identified students, the analyses were repeated with only uncorrected students. There was still no difference in refractive error among IEP and non-IEP students and hyperopia

(Chi-square, p=0.77) or myopia (Chi-square=0.26).

Refractive IEP (%) Error Non-IEP (%) Myopia All students 30.4 69.6 Uncorrected 31.2 68.8 Hyperopia All students 22.7 77.3 Uncorrected 25.0 75.0 Astigmatism All students 41.0 59.0 Uncorrected 36.8 63.2 Table 5: Percentages of IEP and non-IEP students among refractive errors of all Oyler students, and uncorrected Oyler students.

Entering distance visual acuity was recorded on 414 students (98.6%), of which

96 (23.2%) students had acuities worse than 20/40. The median level of entering VA was

20/30, and 207 students had acuities better than or equal to this level; they were 30 categorized as “low” and the remaining students were grouped as “high”. No significance was found between IEP prevalence and entering visual acuity (Chi-square, p=0.37).

Entering acuities may be used to predict the presence or absence of needed astigmatic correction (Chi-square, p<0.0001), but are not valuable in determining the magnitude of the cylinder correction (Chi-square, p=0.26).

3.3 Binocular Vision

Binocular vision analysis performed during eye examinations included: distance and near cover test, and near point of convergence. The average values and associated standard deviations are listed in Table 5. Also listed in this table is the percentage of students who have convergence insufficiency based on the definition of a near exophoria that is 4 prism diopters more exo than the distance phoria.

Variable Number (%) with Mean ± SD measurement or % Cover test 403(96.0) Distance (prism diopter) 357 (85.2) -0.24±4.16 Near (prism diopter) 401 (95.5) -2.23±4.94 Tropia at distance (%) 4.8% Tropia at near (%) 4.7% Near Point of Convergence (NPC, cm) 394 (93.8) 1.3±2.9 CI (Near phoria – Distance phoria < –4, %) 371 (88.3) 35.0% CI (Near phoria – Distance phoria < –4 & NPC > 6, %) 371 (88.3) 6.7% Table 6: Averages and percent prevalence for binocular vision testing. Negative phoria indicate exophoria, CI = convergence insufficiency

3.3.1 Distance and Near Cover Test

Unilateral and alternating distance cover tests were performed on 357 (85.2%) of the 420 students examined. On 11 students, the test was performed, but the results were not quantified (ie, only the presence of a phoria or tropia was noted, not the magnitude).

For near unilateral and alternating cover test, 392 students had a recording, but 25 examination forms did not quantify the magnitude of the phoria or tropia.

The presence of exophoria at near, defined by a magnitude greater than 6Δ, was present in 35 (8.1%) of the 392 examination forms that had a recording, although 10 of these phorias were not quantified. Of those 35, 12 (34.3%) were students identified with an IEP. Exotropia at near was found in 6 (1.4%) students, and 3 (50%) of those had an

IEP. Esophoria was defined as anything beyond orthophoric, and was prevalent in 34

(8.1%) students at near. Seven (20.5%) of the 34 esophoric patients at near had been identified with an IEP. Esotropia at near was identified in 13 (3.1%) of the examination forms with a recording, one (7.7%) of whom had an IEP.

Only the values with quantified phorias were used in the analyses, as it cannot be known if the phoria was within the normal range or not. The prevalence of IEP is not similar for each category of near cover test results (Chi-square, p=0.02). Neither children with esophoria (Chi-square, p=0.71), nor children with esotropia (Chi-square, p=0.57) were more likely than children with orthophoria to have an IEP. However, children with exophoria at near (Chi-square, p=0.046) and exotropia at near (Chi-square, p=0.002) were more likely than orthophoric children to have an IEP. Including eso- and exo-tropia

32 together, children with strabismus are not more likely to have an IEP (Chi-square, p=0.26).

The range of exophoria present at near was from 6∆ to 12∆ and present in 63

(15%) children, and the median was 6∆ exophoria. Based on the median split, children with low exophoria were not more likely to have an IEP than children with high exophoria (Chi-square, p=0.06). The median amount of esophoria was 4∆, and children with more than 4∆ esophoria were not more likely to have an IEP than children with less than 4∆ esophoria (Chi-square, p=0.80).

As with near cover test results, only the examination forms with distance cover test magnitudes recorded were analyzed. IEP prevalence was not similar for distance cover test results (Chi-square, p=0.04). Children with distance esophoria (Chi-square, p=0.32), distance esotropia (Chi-square, p=0.78), distance exophoria (Chi-square, p=0.58) or any eso-deviation (phoria or tropia, Chi-square, p=0.20) were no more likely to have an IEP than orthophoric children. Likewise, children with strabismus were no more likely than children without strabismus to have an IEP (Chi-square, p=0.13).

However, children with distance exotropia were more likely to have an IEP than children with orthophoria (Chi-square, p=0.001). The prevalence of IEP among Oyler students with exotropia at distance was 100%, while the prevalence among orthophoric students was 25.6%.

3.3.2 Near Point of Convergence

Near point of convergence was measured on 394 (93.8%) students. As Schieman et al. suggested, any value equal to or greater than 6 cm was defined as reduced for this study. The majority of children were able to converge to the nose (76.9%), however 62

(15.7%) had a reduced NPC, 18 (29.0%) of whom had an IEP. A near point of convergence 6cm or greater increases the likelihood of having an IEP (Chi-square, p <

0.0001).

3.3.3 Convergence Insufficiency

To determine if a child had convergence insufficiency, distance and near cover test results were compared to identify those students who have an exo-deviation that is 4 prism diopters more exophoric than their distance posture. Based solely on this comparison, 130 of the 371 recorded values (35.0%) had convergence insufficiency (CI), and there was no difference in prevalence between IEP and non-IEP students (Chi- square, p=0.34). When a near point of convergence greater than 6 cm was also required for the diagnosis of CI, the number of students decreased to 25 (6.7%), and there still was not a significant relationship between CI and IEP-identification (Chi-square, p=0.07).

3.3.4 NRA/PRA

Only 189 (45.0%) examination forms had recorded values for NRA, of which 44

(23.3%) students had IEP’s. NRA values were categorized as low (+0.50 to +1.25D), normal (+1.50 to +2.50), or high (>+2.50D). Seven (3.7%) students in the low category,

29 children (15.3%) in the normal category, and 8 (4.2%) in the high category had IEPs, and there was not a significant difference in the proportion of children with IEPs between the three NRA categories (Chi-square, p=0.95). Values for PRA were recorded for 191

(45.47%) students. Thirty-nine of the students with recorded PRA values had an IEP

(23.1%). PRA was categorized as either normal (>-1.37) or low (<-1.37), as there is no set endpoint for PRA. Nineteen (9.9%) IEP-identified students had a normal PRA, while

20 (10.5%) had a low PRA. As with NRA, there was no relationship between PRA and the presence of an IEP (Chi-Square, p=0.38).

Chapter 4: Discussion

4.1 Oyler Demographics

The prevalence of IEP-identified students (25.5%) at Oyler Public School is higher than both the state of Ohio (15%) and national rates (13%). Although the race of the student was not recorded on the examination records, one may think the higher rate at

Oyler is due to a high population of African American students. According to one literature review, identification rates for special education were 5% for Asian, 11% for

Hispanic, 12% for Whites, 13% for American Indian, and 14% for African Americans

(Cartledge, 2008). The composition of students enrolled in Oyler for the 2011-2012 school year were: 64.5% White, 6% multiracial, and 24.5% Black (Cincinnati Public

Schools, 2013). It appears that race alone is not the only cause of the rate students with an

IEP is so high at Oyler.

Males at Oyler are more likely to be IEP-identified than females. This is consistent with literature findings. It has been reported that males are between 1.5-3 times more likely than females to be categorized as learning disabled or emotionally disturbed

(Cartledge, 2008). According to Cartledge, explanations for this disproportionality include:

1. males are more prone to birth defects that are likely to lead to developmental

delays,

2. males tend to externalize their behaviors more than females, and thus are typically

more active and disruptive in class, and

3. teachers may refer more males for identification because males are held to a

higher standard (Cartledge, 2008).

There is not a disproportionally larger male student population at Oyler; therefore the higher rate of IEP at Oyler is not due to a higher proportion of enrolled males. Instead, it is most likely a combination of factors, including race, gender, and poverty, but race and poverty level were not measured in this study. Schools with higher rates of poverty also have higher rates of children identified with special education needs (Cartledge, 2008).

Poverty results in many factors that can hinder a child’s performance in school, from environment to biology and access to academic institutions. Those in poverty-stricken areas are more prone to low birth weights, maternal health issues such as diabetes and hypertension, and increased incidence of lead toxicity from living environments.

Academic institutions also suffer from the effects of poverty as high poverty schools tend to have a high teacher turnover rate, outdated technology and equipment, lack of advanced courses, and a lack of specialists. It has been suggested that the inadequate academic situations that occur in areas with high rates of poverty further exacerbate any environmental or physical limitations students already have (Cartledge, 2008).

The highest rates of IEP occurred in the 9th and 10th grades. As academic material increases, learning disabilities may become more apparent. Children in any grade

(including preschool) can be identified, however, it is not unreasonable to think that students can overcome a disability when the course work is less complex. Another fact to be considered is that grade levels are not equally represented in the population of examined students. The highest proportion of eye examinations were for those in preschool and 2nd grade, which is potentially before many students become identified. It is also possible that those students with IEP’s in higher grades were given first priority for eye examinations to rule out any visual component that may be affecting their academic performance.

No link between vision therapy referral and having an IEP was found in this study.

However, only 30 (7.14%) students were referred for vision therapy, and this is a fairly small sample size. The 2012-2013 school year was shorter than a normal academic year for the OneSight Vision Center because it didn’t open until October 1. It is possible that by examining more students, more vision therapy referrals would have been warranted and a relationship may exist, as the p-value was close to significant with this small sample size (p=0.06).

While there was no relationship between the students’ favorite classes and IEPs, the favorite class was specific to grade. This makes sense as a teacher can play a large role in a student’s preference for or against a specific topic in school. If a teacher is particularly entertaining and strives to make learning enjoyable, more students are going to favor not only that teacher, but also that subject. Likewise, a student’s favorite class in one grade may become their least favorite the following academic year if they have a teacher they don’t appreciate. As far as students with IEP’s disliking the academic classes and

38 preferring special classes (gym, music, art, etc) as one may expect with individuals with learning disabilities, no such relationship was found in this study.

4.2 Refractive Error Prevalence

Hyperopia was defined by +1.25D or more hyperopia based on the spherical equivalent manifest refraction. This definition was chosen based on an article that claimed that academic performance suffered in students with +1.25D or more of uncorrected hyperopia. Based on this definition, 66 (15.7%) right eyes were hyperopic.

This value is significantly higher (Chi-Square, p < 0.0001) than what the literature reports to be the prevalence of hyperopia in the general public, which is 8.6% (Zadnik, 2003). Of the hyperopic right eyes, 15 (22.7%) belonged to individuals with IEPs. Of the 107 children with IEPs, 15 (14.7%) were hyperopic, which is similar to the prevalence of hyperopia among children with IEPs reported by Carder and Walline (Chi-square, p=0.76) (Walline, 2012). Although the prevalence of hyperopia among Oyler students is significantly higher than that of the general population, the rate of IEP identification among hyperopic refractive error matches literature expected values. Based on the results of this study, there is not a higher incidence of IEP identification among hyperopic school aged children than myopic, emmetropic, and astigmatic children. It is possible that no relationship was found between hyperopia and IEP-identification because the sample size for this study was too small. Many of the studies in the literature that report prevalence had thousands of subjects, while this study only analyzed 420 examination records.

Myopia was defined by -0.50 D or more myopic based on the spherical equivalent of the student’s manifest refraction. Of the right eyes examined, 69 (16.4%) were myopic. This prevalence, when compared to literature values of myopia prevalence in the general public, is higher. Literature values varied from as low as 1.6% (Jamali, 2009) to

11.6% (Zadnik, 2003). Analysis shows that the myopia prevalence is significantly higher than the highest reported prevalence in the literature (Chi-square, p=0.005). Of the myopic right eyes, 21 (30.43%) belonged to students with IEPs. When compared to the total number of IEP-identified students examined at Oyler, 21 (19.6%) were myopic in the right eye. These values are comparable to the literature which report prevalence of myopia among those identified with IEP’s anywhere from 18.8%-20% (Walline, 2012).

As with hyperopia, there is not a significant difference in the prevalence of myopia among IEP identified individuals when compared to the literature values (Chi-square, p=0.933) (Walline, 2012).

The prevalence of astigmatism -1.00 DC or more among Oyler students examined was 18.6%. Reported literature values for this degree of cylinder correction range from

2.3% (Donnelly, 2005) to 6.4% (Fotedar, 2007). There is a significantly higher prevalence of astigmatism among Oyler students than the highest prevalence rate in the literature (Chi-square, p < 0.0001). Among the 107 IEP-identified students at Oyler, 26

(24.3%) required astigmatism correction of -1.00 DC or more, however children with astigmatism were not more likely to be identified with an IEP (Chi-square, p=0.08).

Because the p-value was so close to being significant, other values of cylinder correction were analyzed, and a significant relationship was found between -1.25 DC and IEP-

40 identification. There were 59 (14.1%) individuals who required cylinder correction of

-1.25DC or more. Twenty-five (42.4%) of the students who were prescribed -1.25 DC or more were IEP-identified. A literature review by Dr. Jeff Walline reported the prevalence of cylinder greater than or equal to -1.25 DC to be approximately 14%, which is significantly lower than the prevalence students with IEPs at Oyler (Chi-square, p=0.007)

(Walline, 2012).

Ninety-eight percent of IEP-identified students requiring cylinder correction of

-1.25 DC or more had with-the-rule (WTR) astigmatism. This is not surprising because

WTR cylinder is the most common orientation among school aged children. It should be noted, however, that WTR astigmatism is much easier to squint through, thus resulting in the child being able to perform better than expected on distance visual acuity. This makes sense with the finding that entering visual acuity showed no relationship with the magnitude of cylinder found on manifest refraction. Therefore, high cylinder requirements cannot be predicted using distance visual acuities, which is noteworthy as higher cylinder correction increases the likelihood of the presence of an IEP. This fact further emphasizes the need for comprehensive eye examinations for every school-aged child.

Table 6 shows the prevalence of myopia, hyperopia, and astigmatism among students examined at Oyler, and among examined students identified with an IEP, compared to the values reported for the general public. It appears that, according to the data, refractive error may not play as large of a role in IEP identification as one may have thought, and instead binocular vision does. This may be due to an artificially high

41 prevalence of refractive error in the control group. Students that were sent to the vision center for examinations were prioritized as follows: those that failed school screenings and had parental consent, those suspected of vision problems/disruptive behavior in class and had parental consent, and then any student that had parental consent. Because the students that were given first priority were suspected of having a vision condition, this may have resulted in an artificially inflated prevalence in the control group, which would explain why no difference was found between IEP and non-IEP students. This is further emphasized by the fact that the prevalence of hyperopia and myopia are so similar among all Oyler students and the IEP-identified students.

Refractive General Oyler (%) Error Public (%) Total 16.4 1.6-11.6 Myopia IEP 19.6 18.8-20 Total 15.7 8.6 Hyperopia IEP 14.0 15.3 Total 14.5 2.3-12.3 Astigmatism IEP 23.4 8.0 Table 7: Prevalence of refractive error among Oyler students examined, among Oyler IEP students, and general public literature values

4.3 Binocular Vision

The prevalence of esophoria at near among Oyler students was 8.1%, which is comparable to the reported prevalence of 8.9% among the general public (Walline, 1998).

Among those students identified with an IEP at Oyler, only 7 (6.5%) had esophoria.

Literature reported prevalence of esophoria among IEP-identified students is 10.1%

(Walline, 1998), which is similar to the prevalence found in our study (Chi-square, p=0.27). The presence of an eso posture at near (phoria or tropia) does not increase the likelihood of being identified with an IEP.

Exophoria at near was identified in 8.1% of the students examined, which is significantly lower than a prevalence of 27.4% (Walline, 1998) in the general public

(Chi-square, p<0.0001). Among IEP-identified Oyler students, 12 (11.2%) had an exophoria at near, again, significantly lower than the reported literature prevalence of

27.6% (Walline, 1998) for exophoria among students with IEP (Chi-square, p<0.0001).

This may be again due to the sample size; studies that reported values for prevalence of exophoria at near had thousands of subjects, and again, only 420 Oyler students were examined. Any exo posture at near, whether it be an exophoria (Chi-square, p=0.046) or exotropia (Chi-square, p=0.027), increases the likelihood of that student having been identified with an IEP. This makes intuitive sense as an exo posture at near would result in difficulty reading and performing other near tasks, of which many are required in an academic setting. When a near exophoria is present, more work is required of the visual system (ie, accommodative convergence) to maintain clear, single, binocular vision, and this can result in visual fatigue. Symptoms associated with visual fatigue include headaches and eyestrain, and if this occurs every time a child performs a near task, it can result in the child avoiding near work. An exotropia at near can result in the same symptoms, or the child can suppress the strabismic eye, which results in a lack of binocular vision. An exotropia at distance, which also increases the likelihood of the student having an IEP, can result in diplopia, or a lack of binocular vision if the child

43 suppresses. If suppression occurs, the presence of a strabismic eye may not directly affect learning, however, may affect the child’s self esteem. If a child is self-conscious about his/her appearance, it is possible that they may not take an active role in the learning process, such as participating in class, because they would prefer not to draw attention to themselves.

Normal near point of convergence values are expected to range between 5 and 7 cm. For the purposes of this study a value of 6 cm was used to categorize normal from reduced. Ideally, clinically each patient would be able to converge and maintain fusion on an accommodative target as it moves all the way to the nose. This is not always the case, as the normative values demonstrate. Students with a reduction in their ability to converge on a near target are more likely, according to the data, to be identified with an

IEP. This makes sense as one must be able to converge and maintain single, clear, binocular vision to have the best outcome of a near task, such as school work.

Interestingly, there is not a significant relationship between a diagnosis of convergence insufficiency and IEP identification, according to this study. Two definitions of convergence insufficiency were analyzed, neither of which produced a significant finding. When both phoria posture and near point of convergence were combined, the p- value was closer to being significant than when considering only phoria, but it was still not significant. The Convergence Insufficiency Symptom Survey was only offered to 21

(5%) students, 12 of which had scores greater than 16. When symptomatic scores were compared to non-symptomatic scores, there was no difference in the prevalence of IEP

(Chi-square, p=0.56). When CISS score was combined with the aforementioned

44 definitions of CI, there was only one student who would be diagnosed with convergence insufficiency. This one student did have an IEP, but this sample size of one is too small to give an accurate representation of the relationship between IEP and convergence insufficiency.

This study identified some visual characteristics that had significant differences between students identified with an IEP and non-IEP students. As previously mentioned, many factors play in to evaluation for and identification of an IEP. While comprehensive eye examinations will not address every factor that leads to a student needing special education services, they can identify visual factors that increase the likelihood of IEP- identification. Any measure that can be taken to decrease the burdens and hurdles that must be overcome to maximize the learning experience should be considered. While school screenings may identify some students at risk of vision problems and are much better than nothing, they cannot replace a comprehensive eye examination. The OneSight

Vision Center is the first school-based self-sustaining vision center in the country, and the results of this study will hopefully be used to educate the public on the importance of comprehensive eye examinations, not just for factors that increase the likelihood of the presence of an IEP, but to ensure that the visual system is functioning at is maximum capacity so that there is one less factor hindering the learning process.

Chapter 5: Conclusion

Vision is arguably the most important sense utilized in the learning process, as

80% material is learned via the visual system. An improperly functioning visual system can hinder the learning process, resulting in unnecessary learning difficulties. The

OneSight Vision Center located within Oyler Public School in Cincinnati, OH is the first self-sustaining school-based FQHC-Look-Alike vision center in the country, and aims to provide complete vision care to the students of Cincinnati Public School District. Not only do the students examined from Oyler Public School have a much higher rate of IEP- identification, there is also a significantly higher prevalence of hyperopia, myopia, and astigmatism than compared to literature values for the general public, at least among those who were examined. However, it must be stressed that this was a clinical sample of patients, so they are likely to have higher rates of vision-related problems than the general population. Among those examined at Oyler, ocular characteristics that had a significantly higher prevalence within the IEP population compared to the non-IEP population are as follows: astigmatism of greater than or equal to -1.25 DC, exophoria at near, exotropia at distance and near, and a reduced near point of convergence. Many differences in prevalence between children with and without IEPs may not have been detected because only a sample of Oyler students more likely to have vision problems

46 was examined, likely decreasing the likelihood of detecting statistically or clinically meaningful differences in ocular anomalies between children with and without IEPs.

There are so many obstacles that can hinder the learning process: poverty, malnutrition, home life, personal loss or tragedy, lack of access to technology or learning resources, health, learning disabilities. An improperly functioning visual system does not have to be one of these obstacles. A comprehensive eye examination can identify and potentially correct visual problems before they lead to a learning disability, and then there is one less obstacle that child must overcome to reach his/her full potential.

Bibliography

Building the Legacy: IDEA 2004. (n.d.). Retrieved January 25, 2015, from http://idea.ed.gov

Cartledge G, Dukes C. Disproportionality of African American Children in Special Education. 2008. Chapter 24. Sage Publications. Retrieved February 15, 2015 from http://www.sagepub.com/upm-data/23169_Chapter_24.pdf

Child Find - Wrightslaw. (2008, December 10). Retrieved February 3, 2015, from http://www.wrightslaw.com/info/child.find.index.htm

Cincinnati Public Schools Dashboard: Oyler. (2013, January 1). Retrieved February 3, 2015, from https://dashboard.cps- k12.org/dashboard/public/school_summary.aspx?school=Oyler

DeNavas-Walt, C., Proctor, B., & Smith, J. (2012, September 1). Income, Poverty, and Health Insurance Coverage in the United States:2011. Retrieved February 7, 2015, from http://www.census.gov/prod/2012pubs/p60-243.pdf

Donnelly UM, Stewart NM, Hollinger M. Prevalience and outcomes of childgood visual disorders. Ophthalmic Epidemiology 2005;12:243-250.

Economically Disadvantaged Status Data Collection and Reporting. (2007, January 1). Retrieved February 9, 2015, from http://lbstat.dpi.wi.gov/lbstat_dataecon

Eye Exam Requirements for Special Education Students. (n.d.). Retrieved February 7, 2015, from http://iepeyeexam.org/

Federally Qualified Health Center Look-Alikes. (2014, January 1). Retrieved February 7, 2015, from http://bphc.hrsa.gov/policiesregulations/policies/fqhclookalikes.html

Federally Qualified Health Centers (FQHC). (2013, September 17). Retrieved February 7, 2015, from http://www.raconline.org/topics/federally-qualified-health-centers

Fotedar R, Rochtchina E, Morgan I, Wang JJ, et al. Necessity of cycloplegia for assessing refractive error in 12-year-old children: A population-based study. American Journal of Ophthalmology 2007;144:307-309.

Giordano L, Friedman DS, Repka MX, Katz J, et al. Prevalence of refractive error among preschool children in an urban populations: The Baltimore pediatric eye disease study. Opthalmology 2009;116:739-746.

Health Reform Offers Better Children's Vision Care in the U.S. (2014, January 1). Retrieved February 3, 2015, from http://www.aoa.org/newsroom/health-reform-offers- better-childrens-vision-care-in-the-us?sso=y

Ishihara S. Ishihara Instructions: Concise Edition. Univeristy of Tokyo 1917

Jamali P, Fotouhi A, Hashemi H, Younesian M, et al. Refractive errors and amblyopia in children entering school; Shahrood, Iran. Optom Vis Sci 2009;86;364-369.

Ma X, Zhou Z, Yi H, Pang X, Shi Y, Chen Q, Meltzer M, Cessie S, He M, Rozelle S, Liu Y, Congdon N. Effect of providing free glasses on children’s educational outcomes in China: cluster randomized controlled trial. BMJ 2014;349:1-12. Number and percentage of public school students participating in selected programs by state. (2000, January 1). Retrieved February 9, 2015, from http://nces.ed.gov/search/?output=xml_no_dtd&client=nces&site=nces&q=IEP

Program Benefits. (2014, January 1). Retrieved February 7, 2015, from http://bphc.hrsa.gov/about/benefits/

Prospective Payment Systems - General Information. (2013, November 29). Retrieved February 7, 2015, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/ProspMedicareFeeSvcPmtGen/index.html?redirect=/ProspMedicareFeeSvcPmt Gen/

Quaid P, Simpson T. Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls. Graefes Archh Clin Exp Pphthalmol 2013;251:169-187.

Qui M, Wang S, Singh K, Lin S. Racial Disparities in Uncorrected and Undercorrected Refractive Error in the United States. Investigative Ophthalmology & Visual Science 2014;55:6996-7004.

Scheiman M, Wick B. “Clinical Management of Binocular Vision: Heterophoria, Accommodative, and Eye Movement Disorders”. 2nd Ed. Lippincott Williams & Wilkins. 2002. Philadelphia, PA.

Special Education. (2012, January 1). Retrieved February 3, 2015, from http://www.disabilityrightsohio.org/topic-special-education

Students with disabilities. (2013, January 1). Retrieved February 7, 2015, from https://nces.ed.gov/fastfacts/display.asp?id=64

Walker, D. Building a Comprehensive Child Vision Care System: A Report of the National Commission on Vision and Health. Abt Associates, Inc. June, 2009.

Walline JJ, Mutti DO, Zadnik K, Jones LA. Development of phoria in children. Optometric Vision Science 1998;75:605-610.

Walline JJ, Carder E. Vision Problems of Children with Individualized Education Programs. Journal of Behavioral Optometry 2012;23:4:87-93.

What are Federally qualified health centers (FQHCs)? (n.d.). Retrieved February 3, 2015, from http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html

Zadnik K, Manny RE, Yu JA, Mitchell GL, et al. Ocular component date in schoolchildren as a function of age and gender. Optom Vis Sci 2003;80:226-36.