Visual Motor Disorders in a Pediatric Patient with Dyslexia and Dysgraphia: A Case Report
Nguyen Tran, OD Pasadena, CA
Abstract: A 7 year old Caucasian male with dyslexia and dysgraphia, is referred for a vision evaluation. Binocular, oculomotor and visual perceptual disorders are diagnosed. Vision therapy is initiated to remediate deficient visual skills.
Background: Dyslexia is a learning disability in reading, interpreting words, letters, and symbols (3). Dysgraphia is a learning disability affecting writing, that also manifest in difficulties of spelling, poor handwriting, orthographic coding, and fine motor skills (4). Although visual dysfunction has not been found to cause these learning disorders, inefficient visual skills can contribute to the reading dysfunction of these individuals. Integrating vision, motor and perceptual systems are pre-requisite skills for academic achievement, especially in young school aged children learning to read and write.
Case History: A 7 year old caucasian male, was referred by an educational psychologist for a vision evaluation, after being diagnosed with dyslexia and dysgraphia. Although there were no complaints of blurry vision during the eye exam, asthenopia, difficulty with reading skills and speed, and poor handwriting was reported. Mild ocular and seasonal allergies were also reported, which were treated orally with Claritin Jr.
Pertinent Findings: During the exam, his vision was 20/20 in both eyes, with a refractive error of +0.50 OU. Entrance tests were unremarkable. No ocular health disorders were apparent on anterior segment and dilated fundus exams. On binocular examination, base out vergence ranges at distance were x/10/2 and x/35/1 at near. Base in vergence ranges at distance were x/35/1 and x/24/4 at near. Oculomotor testing with NSUCO saccades were 5/4/3/5 and pursuits were 3/4/4/5. Accommodative facility was reduced, measuring OD 4 cycles per minute (cpm), OS 7cpm, 2.5 cpm OU. Vergence facility was also reduced, measuring 10.5 cpm. Although saccades were judged to be normal, pursuits ability were below expected value. Vertical Developmental Eye Movement (DEM) tested very low, in the 2nd percentile, and normal horizontally in the 44th percentile, which indicated that both an automaticity and oculomotor dysfunction problem were present. Upon further visual spatial evaluation, poor judgement of Jordan Left – Right Reversal Tests, Van Orden (VO) Star, and problems with eye tracking on Gazepoint reading analysis. Visual motor integration and motor coordination were also weak when tested on Beery Developmental Test of Visual Motor Integration (6th ed.), measuring in the 19th and 14th percentile respectively. Visual spatial disorders should also be considered according to the deficits in laterality and directionality, and motor skills.
Differential Diagnosis: The differential diagnoses could include: - Sensory Processing Disorder - Attention Deficit Hyperactivity Disorder (ADHD or ADD) - Autism Spectrum Disorder - Primary language disorder - Non-specific learning disabilities.
Diagnosis and Discussion: - Oculomotor dysfunction - Visual spatial disorder - Accommodative Dysfunction - Binocular dysfunction - Visual tracking disorder - Visual motor disorder Binocular, accommodative and visual motor development is important for academic achievement during early school years, when a child is learning to read and write. Building the pre-requisite skills is an important step for developing literacy needed for learning (2). Dyslexic readers tend to have eye movement with longer fixation duration, shorter saccadic length, and greater number of regressions than normal readers. The faulty eye movement control has an adverse effect on reading efficiency (1). Dysgraphia is found within the processing system involved with sequencing, especially the motor movements that should be sequential and very automatic. Because writing is a developmental process, children need to learn the motor skills needed to write (4). Visual inefficiencies create a challenge during the learning process of reading and writing, compounded by the diagnosis of dyslexia and dysgraphia.
Treatment and Management: The recommended treatment is 30 to 40 sessions of weekly office vision therapy, with assigned home vision therapy of approximately 20 minutes a day. Areas of deficiency are contributing factors to his problem with reading and writing disorders. Remediation of visual deficiencies will include improving binocular and accommodative vision, oculomotor skills, as well as laterality and directionality. Additionally, we referred the patient to a multi-sensory reading program with a reading specialist, emphasizing phonemic awareness, symbol and concept imagery that will likely improve his word decoding/encoding skills.
Citations: 1. Griffin, JR, Christenson, GN, Wesson MD, Erickson GB. Optometric Management of Learning–Related Vision Problems, 1997. 2. Scheiman, S, Rouse M. Optometric Management of Learning Related Vision Problems, 1995. 3. www.mayoclinic.org. Dyslexia. 1998-2017. 4. www.ldonline.org. What is Dysgraphia? 2017.