Case Report: Visual Information Processing in a patient with Asperger’s Syndrome Keri Nebelsick, O.D.

Abstract: Asperger’s syndrome is a developmental disorder on the autism spectrum. Binocular vision and visual information processing deficiencies in these patients can be treated by using goal-orientated, individualized therapy plans.

I. Case History a. 17 year old Caucasian male b. Patient reports difficulty with reading including near blurry vision, eyestrain, and skipping lines c. Ocular history is unremarkable. Last eye exam was 8 years ago. Medical history includes diagnosis of Asperger’s Syndrome and ADHD. d. Medications: None. Discontinued use of Aderol and Lexipro for past 8 months e. Asperger’s syndrome (AS) is a developmental disorder on the autism spectrum characterized by problems with social interaction and communication. Many patients with this disorder have normal intelligence and verbal skills. A unique and distinguishing characteristic of AS is the individual’s obsessive interest in a single topic. II. Pertinent findings a. Comprehensive Eye Exam in Primary Care Clinic (2/23/11) i. Cover test: Ortho at distance, 8∆ Exophoria at near ii. Vergence ranges: Near BI: x/8/6, Near BO: x/8/6 iii. Near point of convergence: Break at 10cm iv. Accommodative Amplitudes: 12.5D OD, OS v. Referral to Peds/BV for visual efficiency exam b. Visual Efficiency Examination in Pediatrics (03/23/11) i. Cover test: Ortho at distance, 8∆ Exophoria at near, No vertical deviation ii. NPC: Break at 17cm, recovery at 20cm iii. Convergence Insufficiency Symptom Survey (CISS): 56 iv. Developed a vision therapy plan following the Convergence Insufficiency Treatment Trials (CITT) guidelines c. Visual Information Processing Testing in Pediatrics (7/12/11) i. Developmental Test of Visual Perception (Adolescent & Adult): Figure Ground subtest of Motor Reduced Visual Perception was in the low range with a standard score of 3. ii. Woodcock Johnson III (selected subtests): Average scores in Visual Matching, Letter-Word Identification and Word Attack. Low score in Reading Fluency. iii. Visagraph: Grade level efficiencies of 4.4 at the 7th grade reading level were achieved with increased fixation, increased regressions, decreased span of recognition, and increased duration of fixation. Overall decreased reading rate was demonstrated with 154 words per minute compared to the grade average norm of 250. III. Differential diagnosis a. Convergence Insufficiency i. Pseudoconvergence insufficiency, basic exophoria, divergence excess ii. Convergence paralysis secondary to: ischemic infarction, demyelination, flu or infection, Parkinson disease, Parinaud syndrome iii. Medial rectus weakness due to: Multiple Sclerosis, Myasthenia Gravis, previous strabismus surgery5 b. Visual Information Processing Disorder i. Saccadic Dysfunction ii. Pervasive Developmental Delay (Asperger’s Syndrome) IV. Diagnosis and Discussion a. Convergence Insufficiency (CI) is a binocular vision disorder associated with ocular discomfort with near tasks including: eyestrain, headaches, blurred vision, diplopia, sleepiness, concentration difficulties, movement of print, and loss of comprehension. i. The Convergence Insufficiency Symptom Survey (CISS) is a 15 question survey developed by the Convergence Insufficiency and Reading Study (CIRS) group to analyze the symptoms of CI in children ages 9 to 18. With a CISS score above 16, the patient is considered to have abnormal levels of symptoms. A change of more than 10 points after treatment is considered clinically significant. b. Unique to this case is the diagnosis of Asperger’s syndrome and the visual processing problems that can occur with Autism spectrum disorders. After improvement of the CI symptoms with vision therapy, visual information processing deficiencies were discovered. V. Treatment and Management a. Weekly in-office vision therapy, along with home activities, was done for fourteen weeks according to the Convergence Insufficiency Treatment Trial guidelines. Progress checks were done every six weeks. b. Vision Therapy progress check (5/17/11) – after 6 weeks of VT i. Patient reports improved comfort with reading ii. NPC: 7/10cm, after 5 attempts 8/11cm iii. Vergence ranges: Near BI: x/6/4, Near BO: x/16/14 iv. CISS: 53 v. Continue in-office and home VT according to CITT guidelines c. VT progress check (6/28/11) – after 12 weeks of VT i. Patient reports able to read half a book with no eye strain and good ocular comfort with near work. Patient now reports he feels that his reading speed is reduced compared to classmates. ii. NPC: 5/8cm, after 5 attempts 6/8cm iii. Vergence ranges: Near BI: x/4/2, Near BO: 10/14/10 iv. CISS: 26 v. Patient was scheduled for Visual Information Processing Testing in Pediatrics d. VIP testing revealed deficits in figure ground processing, reading fluency, and overall reading rate. In office visual processing training was started to improve these skills. Activities include Computer Perceptual Therapy (CPT) visual scanning and visual search and Ace reader programs working on functional reading with comprehension and increase in eye span with comprehension. After two weeks of therapy, the patient has increased his reading rate from 120 to 145wpm while maintaining 100% comprehension. VI. Conclusion a. Vision therapy has been a proven treatment for improving the symptoms associated with convergence insufficiency6. It is important, however, to continue to assess the patient’s specific complaints and concerns once the CI improves. Children with disorders on the Autism spectrum can suffer from a number of vision and visual processing anomalies. Using VIP assessment methods, the specific deficiencies can be identified and improved upon using VIP therapy. Individualized, goal-specific therapy is the key to success for the patient. VII. Bibliography 1. Coulter RA. Understanding the visual symptoms of individuals with autism spectrum disorder (ASD). Optometry and Vision Development 2009;40(3): 164-175. 2. Borsting E, Rouse M, Mitchell GL, Scheiman M, Cotter S, Cooper J, Taylor Kulp M, London R. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years. Optometry and Vision Science 2003;80:832-838. 3. Kaplan M. Seeing through new eyes: changing the lives of children with autism, Asperger syndrome and other developmental disabilities through vision therapy. London: Jessica Kingsley Publishers, 2006. 4. Scheiman M, Rouse M. Optometric management of learning-related vision problems, 2nd ed. St. Louis: Mosby Elsevier, 2006. 5. Scheiman M, Wick B. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders.3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2008. 6. Scheiman M, Cotter S, Mitchell GL, Kulp M, Rouse M, Hertle R, Redford M. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126(10):1336-1349. 7. Hurlbutt KS, Handler BR. High school students with Asperger syndrome: a career path binder project. Intervention in School and Clinic 2010;46(1):46-50.