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OPTOMETRY'S ROLE IN AUTISM SPECTRUM DISORDERS

Sight_and_visionManaging Editor's Note: Dr. Schulman treats my daughter Bella. Bella's eyes were not tracking, and you could see each eye "wander" as she lost focus. After a long exam by a top pediatric opthalmologist, her ocular health was pronounced, "intact." Mind you, this doc spent over two hours with Bella. He was really interested in her health and we chatted amiably. I'd go back to him in a second for opthalmological care. (Heck, he even drives a Prius!) He said that Bella's vision problem was neurological, not muscular. So while he sent us off, we still had a real eye problem. We went to Dr. Schulman, who created a pair of glasses that have helped Bella noticeably. The moral of the story is that even the best docs in the medical field are often unable to help a child on the spectrum. We require specialists within specialties. Isn't that special?  She was kind enough to prepare this post for our readers. Enjoy. Kim

By Randy Schulman, MS, OD, FCOVD

Many of the behavioral characteristics of those falling within the autism spectrum involve the visual system. Poor eye contact, staring at lights or spinning objects, looking askance, side viewing and general difficulties attending are often symptoms of visual dysfunction. Thus, any individual with a diagnosis of autism, PDD, learning disability, speech-language delay, sensory integration dysfunction, Asperger syndrome, non-verbal learning disability or with psychological problems should most certainly undergo a thorough examination by a developmental optometrist. 

The earlier families of children with autism undergo a visual examination and begin visual intervention, the faster the improvement and the longer lasting the gains and overall chances for success. The American Optometric Association (AOA) recommends that all children undergo visual exams by six months of age. If parents complied with this guideline, optometrists would certainly note many visual problems in these young, yet undiagnosed children. For those with autism spectrum diagnoses, an immediate developmental exam is essential. After age four, a child may make adaptations which further embed the visual problems.  For example, an eye turn out becomes an eye turn in or a suppression becomes firmly established by a large angle head turn or tilt.

Children with autism spectrum disorders (ASD) have motor, sensory, language and social-emotional delays that affect visual processing.  Likewise visual problems affect cognitive, speech-language, social-emotional and perceptual development.  Specifically, delays in oculomotor function, focusing, and binocular abilities can affect gross and fine motor abilities and language acquisition. Sensory problems result when vision does not coordinate with the vestibular and proprioceptive systems properly, or if there is poor synchronization between the central and peripheral visual systems. Poor visual awareness and poor eye contact negatively affects socialization and poor visualization can hinder the development of skills for imaginative play.

What is important is that the time period from age 18 months to four years of age, when autism is usually diagnosed, is an extremely important window of development for vision, as well as language, socialization and other crucial areas.

During this very critical time frame, vision should begin to dominate the movement system, to coordinate the proprioceptive, vestibular and tactile systems. As vision combines with the other senses, central or focal vision should emerge. If there is faulty information processing in any of the primitive sensory systems, visual dysfunction is inevitable. These patients then still need to touch and move to experience their environment because their visual systems are so inefficient. Some of their stimulatory behaviors such as flapping and side looking, may actually serve the purpose of allowing them to interact with their world, and tell the brain where the body is in space.

Most individuals on the less severe end of the spectrum, generally show more subtle, but very significant visual processing problems. Patients with attention deficits and learning disabilities are often very attracted to external, highly charged visual stimulation. They love to play video games and are generally highly skilled with computers. These traits lead to the misunderstanding by well-meaning adults that vision is an area of strength. Often it is these kids who are then labeled “visual learners” because they learn best when they can touch and see the materials.  The real crime is that this misunderstanding about vision often prevents them from seeing any eye doctor, let alone one who can make a profound difference in their functioning.  Optometrists must enlighten educators and parents about vision as a developmental process that must work with other systems in a coordinated manner.  Just because the visual system is “strong” does not necessarily mean that it is operating in an efficient manner.

The literature supports that a very high percentage of children with autism spectrum disorders demonstrate eye movement disorders and a high incidence of strabismus.  Many children with autism also have many competing stressors on their bodies during the critical second year of life. Inadequate or inappropriate sensory stimulation and health problems, ranging from food allergies to ear infections and asthma can all wreck havoc with vision development. Whether the health or the vision issues come first, visual concerns are real, and parents and professionals must pay attention to them.  Even when health issues subside, and behavior, attention, and even eye contact improve, underlying visual delays often remain, and optometric intervention is necessary. Those with autism spectrum disorders simply have gaps in sensory, motor and visual areas so enormous that they cannot be closed without therapy.   

Presentation of Vision Problems

Children on the autism spectrum typically bring a number of unusual visual behaviors or concerns to the eye doctor. 

Squints or closes an eye
Stares at certain objects or patterns
Looks through hands
Flaps hands, flicks objects in front of eyes
Looks at objects sideways or with quick glances
Shows sensitivity to light (photophobia)
Becomes confused at changes in flooring or on stairways
Pushes or rubs eyes
Has difficulty making eye contact
Widens eyes or squints when asked to look
Bumps into objects
Is fascinated by lights and shadows
Touches walls or tables while moving through space

Parents, teachers, and other professionals assume that most behaviors seen in autism spectrum disorders are simply a result of the disorder, not a by-product of vision problems. They are astonished to learn that poor eye contact, repetitive stimulatory behaviors, and practically every other behavioral symptom, could be caused by poor fixation, accommodation, or eye teaming abilities.

Vision Examination

A vision examination with a behavioral optometrist, such as can be found on www.oep.org or www.covd.org, will determine not only the eye health and refraction or whether they require a compensatory prescription, but also the visual skills of an individual with autism and how they are functionally performing.  The examination will assess acuity, or ability to see clearly, accommodation, or the ability to focus clearly, pursuits, fixations and saccades, the ability to move the eyes appropriately, and binocular or eye teaming ability.  She will also determine whether there is an eye turn or lazy eye and assess higher-level visual functions such as visual motor integration, or how the eyes direct the hands and the body, visual auditory integration, or how the visual system interacts with auditory commands, and most importantly, visual perception or processing or how the brain understands what is being seen.  For example, she will determine if the individual can picture in his head what he is seeing, recall what is being seen or differentiate the figure from the ground.

Consultation

The optometrist will explain each aspect of the exam, discussing the child’s skills in focusing, eye teaming, visual motor and visual perceptual abilities.  She will also discuss treatment options in terms of lenses and prisms, how they create changes in the light energy coming into the eye, and how they allow the brain to organize visual information in a different, hopefully easier, fashion.  In the majority of the cases, in addition to lenses and prisms, vision therapy is appropriate.  Vision therapy, like occupational or speech therapy, is a tool to teach the visual system how to work.  Most children with autism spectrum disorders require one-on-one, in-office therapy plus a home program to reinforce the work done in the office. The frequency and duration of therapy must be determined on a case-by-case basis.  The optometrist may also make a referral to adjunct professionals whose interventions are also indicated.

References:

1 Streff, JW. Optometric care for a child manifesting qualities of autism.  J Am Optom Assoc 1979; 46-592-7.

2 Scharre JE, Creedon MP. Assessment of visual function in autistic children. Optom vision Sci. 1992;69:433-439.

3 Kaplan

4 Kaplan, Edelson

5 Ratner Eye Center (www.add-adhd.org)

6 Another study (COVD white paper on ADHD)

7 Harvard (COVD vision and dyslexia)

8 Beth Israel (COVD vision and dyslexia)

9 “Vision, Learning and Dyslexia” (To order a copy call COVD’s Fax on Demand at 800-365-2219 and ask for document #0040 or go to www.aoanet.org)

10 Bowan

11 Cheatem

12 Out-of Sync Child

13 Szpulski

14 Gesell

15 Shankman, A. Behavioral Optometry’s Birthright-Skeffingon’s Four Circles. J Optom Vision Dev. 1993;24:29-30.

16 Schulman, R. Optometry’s Role in the Treatment of Autism. JOVD. 1994; 25: 259-268.

17 Kavner R. Your Child’s Vision: A Parents Guide to Seeing, Growing, and Developing. New York: Simon and Schuster, Inc.; 1985.

18 Williams D. Somebody Somewhere. New York: Times Books; 1994.

Dr. Schulman graduated cum laude from the University of Pennsylvania where she received her degree in psychology. She graduated with both her Doctor degree and a Masters degree in Vision Science from the State University of New York, State College of Optometry. She received her Fellowship in the College of Optometry for Vision Development and is an Associate member of the Optometric Extension Program. She has lectured extensively on such topics as vision in the classroom, vision and aging, and visual difficulties in the developmentally delayed, and has published on vision and autism. She is fully licensed to diagnose and treat eye disease and specializes in vision therapy, pediatrics, learning disabilities and preventative vision care for all ages. You can reach Dr. Schulman at her practices in Fairfield County, CT:

VisionWorks
139 Main Street
Norwalk, CT 06851
203-840-1991
www.optometrists.org/schulman

Total Learning and Therapy Center
5893 Main Street
Trumbull, CT 06611
203-268-8852
www.tltc.org

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Wow, Kim! Thanks for this amazingly timely piece. My daughter has her follow up eye exam this Wednesday. I brought her to a pediatric eye doctor as I noticed her right eye was suddenly beginning to make weird tracking movements that were out of synch with her other eye. She has special glasses now, and when I looked through them to see how strong they were (as I have myopia and was curious), I was surprised that anyone could see better, much less at all, by looking though them. They are definitely helping her (much less eye turning since she got them two months ago), she is much happier with them (and she even remembers to put them on herself!) My son is about to have his eyes checked on Wednesday, too, although I have not seen a pronounced problem with his eyes. I am printing out your article for my husband to read. Thanks, again.

Total agreement- This is a terrific article as well as posts. It had surprised me that there was little mention earlier of eye problems. I have had two interesting experiences regarding eyes and mercury:
1. A 4 year old boy in my school had severe photophobia and slight nystagmus. Various glasses were made for him to deal with the photophobia and the mother stopped vaccines and fish. Over the next year this boy showed marked improvement in the photophobia. Meanwhile I noticed that a disorder known as Leber's congenital amaurosis , which supposedly degenerates into blindness, has the same symptoms. After a year I casually asked the mom, "I wonder if the doctors thought that he was going to get worse" and she replied emphatically, "Yes, I think they did!" I wonder now if Leber's is actually a mercury related disorder rather than a genetic one.
My second experience is my own. I have had a number of symptoms that I attribute to the mercury which I received in gamma globulin injections at age 2 or 3. Over the years these symptoms waned and vanished, which I believe could be due to mercury leaving my body. Recently it ocurred to me that my eye that rolls outward and gives me double vision if I dont wear glasses could also have been a result of mercury. Then I thought, "Well, if its due to mercury, it could also have improved", so I removed my glasses and found that I am now easily able to focus without my glasses.
By the way, we got very much increased use of mercury in Indian vaccines from the year 2000. I was able to ask one opthamologist in Jaipur , India if he had seen an increase in cases of photophobia. His reply was" Yes, about 10 to 15% increase"
I am happy to hear of this focus on sight problems in autistic kids and lets not leave out the cause because that is going to affect treatment success.

I agree that during the very critical time frame, vision should begin to dominate the movement system, to coordinate the proprioceptive, vestibular and tactile systems.In spite of that our eyes find it more difficult to adjust from light to darkness. Thank you so much for the wealth of information.

jayn

I am the Editor of the book to which Dr. Schulman is referring. To learn more about vision and autism, the book, EnVISIONing a Bright Future, and to link to the publisher to purchase it, go to www.devdelay.org

Thank you Randy for this enlightening article!

Patricia Lemer

My vision was perfect, and I mean perfect- until I got a flu shot, and ended up with chronic fatigue immunodeficiency. It was after that fateful day that people began to remark- "look, your pupils are different sizes!". My vision and my health has been in jeopardy ever since.

GREAT ARTICLE!! I am going to link it on my blog and also share this information with parents that I know here in the state.

Thank you all for your feedback on the article I posted. Just as there are practitioners out there that say everything is fine yet have no clue, there are eye doctors that do not know what they are looking for. It is the difference between a functional, holistic view of vision and a limited structural view of the eye only. Though there are fewer of us (see www.oep.org and www.covd.org), we can often make a difference for individuals of all ages. Obviously, the sooner the better but we have success with adults as well. I have 43 year old who is making gains in a number of areas from prism glasses and a home program of vision activities implemented at his group home. As far as the question of toxicity on the visual system, there is some evidence of optic nerve damage and cataracts as well. As with everything else, the biochemical issues need to be addressed concurrent with any other treatment modality. The hard part is fitting it all in in terms of time and money. Most of us in this field are willing to work with parents to design a program that is manageable to the family and can work with other professionals as well. Any further questions, do not hesitate to contact me directly.
Randy Schulman

This has my interest regarding the mercury issue. I had found these awhile back and just wanted to pass them along-

1: Science. 1979 Oct 5;206(4414):78-80. Links
Heavy metals affect rod, but not cone, photoreceptors.
Fox DA, Sillman AJ.
Low concentrations of lead, mercury, or cadmium depress the amplitude of the rod receptor potential in the perfused bullfrog retina. Responses from the cones were not affected. The data implicate the rods as a lesion site in animals exhibiting scotopic vision deficits as a result of heavy metal poisoning.
PMID: 314667 [PubMed - indexed for MEDLINE

http://hyperphysics.phy-astr.gsu.edu/hbase/vision/rodcone.html#c4
The rod sensitivity is shifted toward shorter wavelengths compared to daylight vision, accounting for the growing apparent brightness of green leaves in twilight.

While the visual acuity or visual resolution is much better with the cones, the rods are better motion sensors. Since the rods predominate in the peripheral vision, that peripheral vision is more light sensitive, enabling you to see dimmer objects in your peripheral vision. If you see a dim star in your peripheral vision, it may disappear when you look at it directly since you are then moving the image onto the cone-rich fovea region which is less light sensitive. You can detect motion better with your peripheral vision, since it is primarily rod vision.

then this one too-

Multifocal and full-field electroretinogram changes associated with color-vision loss in mercury vapor exposure

We evaluated the color vision of mercury-contaminated patients and investigated possible retinal origins of losses using electroretinography. Participants were retired workers from a fluorescent lamp industry diagnosed with mercury contamination (n = 43) and age-matched controls (n = 21). Color discrimination was assessed with the Cambridge Colour Test (CCT). Retinal function was evaluated by using the ISCEV protocol for full-field electroretinography (full-field ERG), as well as by means of multifocal electroretinography (mfERG). Color-vision losses assessed by the CCT consisted of higher color-discrimination thresholds along the protan, deutan, and tritan axes and significantly larger discrimination ellipses in mercury-exposed patients compared to controls. Full-field ERG amplitudes from patients were smaller than those of the controls for the scotopic response b-wave, maximum response, sum of oscillatory potentials (OPs), 30-Hz flicker response, and light-adapted cone response. OP amplitudes measured in patients were smaller than those of controls for O2 and O3. Multifocal ERGs recorded from ten randomly selected patients showed smaller N1–P1 amplitudes and longer latencies throughout the 25-deg central field. Full-field ERGs showed that scotopic, photopic, peripheral, and midperipheral retinal functions were affected, and the mfERGs indicated that central retinal function was also significantly depressed. To our knowledge, this is the first demonstration of retinal involvement in visual losses caused by mercury toxicity.

http://journals.cambridge.org/action/displayAbstract;jsessionid=8EED037166989BF29BDC30D941F691B0.tomcat1?fromPage=online&aid=293345
(Received September 7 2003

and one more --

http://www.ip.usp.br/laboratorios/visual/producao/2006BJMBR_HgeletrofisiologiaTanan6011.pdf

The present findings constitute the first
intracellular demonstration of the retinal effects
of MeHg. They demonstrate that the
cone system is profoundly affected by the
intoxication, thus confirming previous suggestions
from the literature regarding fish
(19,25) and humans (9,12). The effects
ranged, in a dose-dependent manner, from
complete elimination of the response to response
reduction in the acute intoxication
procedure, while in the chronic procedure,
they ranged from reduction of the response
to a hypersensitive response at low doses.
These effects are compatible with the findings
that cone-mediated functions such as
color vision and contrast sensitivity are affected
by mercury intoxication in humans
(9,12).

Thank you for this article. My son has been doing a lot of the squinting (one eye only) lately and I wonder what's the reason for that. He's got perfect vision otherwise (on regular optometrist tests).

Kim,
Has anyone told you lately that you rock? A thousand thanks for this post! You just explained my daughter's morning: the inability to see a frog swimming in her grandmother's swimming pool, despite the frog's presence just inches from her face; the constant fascination with staring at her reflection in a silver ice cream scoop (how's that for a stim?!); and the sudden tantrum when we had to go from bright sunlight into a dark church to pick up her sister from vacation Bible school. We live in the middle of nowhere but I am looking up a developmental optometrist, ASAP (no pun intended!).

USE SIDE-SHIELDS and TRANSITION LENSES. After noticing my son's distress from bright light transition, we got him glasses even though he passed the eye exam. (Walmart vision center) You ask for frames that come with (special order) dark "side-shields" that clip on and block peripheral vision (and distractions). The darkening lenses ease light sensitivity. We got colored glasses at Rainbow Blossom and played with the world through these lenses. Creative measures were of great assistance to him K-3rd grade - don't wait for a doctor to give the go-ahead!

From "across the pond":- Some of you might also care to check out Irlen lenses. In the UK there have been reports of children with individually prescribed coloured (pink/green/blue/whatever) lenses suddenly being able to see the printed word clearly. N.B. I know that when I'm very tired, black print on white paper "flares" - my cure for this is to use polarised sunglasses until I can have a short nap. Please excuse the unscientific nature of this posting.

Now now, you wretched haters. If your autistic child can't see that's part of their gift. How dare you change it? So your son or daughter has the vision of housefly? What joy! Can't tell where his feet hit the ground? Fantastic! Can't safely walk up or down stairs? Praise St. Autism and pass the holy water! Can't talk, can't see! Hey, it worked out fine for Tommy. Quit yer belly aching and just accept your child.

Yeah, it's me. :) K

Thanks for putting more ASD puzzle pieces together. Is there any information on the incidence of cataracts in ASD patients? My son has a unilateral cataract that was diagnosed at 11 months, well before he was diagnosed with autism at 27 months. We know that he has mercury poisoning (from urinary porphryrin profile). I've wondered whether mercury or other heavy metals deposited in his eye may be responsible for the cataract.

Thank you everyone at AoA for disseminating the truth and bringing light and hope to all affected families.

I'm so happy to see the news on behavioral optometry getting out there. My six year old daughter engaged in chronic peering out of the corners of her eyes, which top behaviorists continually told us was a stim. We saw Dr. Joel Warshowsky (highly recommended in NY area) who prescribed bifocal prism glasses. The first night after picking up the glasses, Ava put the glasses on, kept them on all night, and the peering (or "stim") disappeared. I sat at dinner that night saying over and over to my husband, "she's not doing it". It was an instant success for us, which is extemely hard to come by in treating the many facets of ASD.

Fascinating article. Our local eye doctor helped us understand and work with the exotropia Ronan has. That began about 2 years ago and seemed to come and go every 3-4 weeks. Due to Ronan's other problems (neuro, GI, immuno, etc.), we'll be heading to the big city this summer for more testing. Included is also a more intense eye exam with an assiciate of the specialists we already see. I'm definitely going to make a copy of this article to bring with us.

Kim, Thanks for finding such helpful people to contribute to AOA.

Dr. Shulman, Thanks for writing such an *eye-opening* article that helps me further understand Ronan's needs.

Cathy

My son was having problems with his eyes 2-3 years ago. He was seeing different colors and then went blind right before a seizure for about half a minute, or maybe a minute. Talk about stress!

Took him into the eye doc and he claimed his eyes were fine. Can you imagine that? Here is my son claiming he is seeing different colors at different times - sometimes pink, sometimes yellow, even went blind and the standard medical tests can find no problem? Is it any wonder we are so disgruntled with these people? What are they learning that they cannot even identify and measure problems when they occur? Look at the gap between the extent of the problem and the measurement of it. This is not only in optometry but across the board. They are walking, living disasters. Here is an entire population that is having serious issues with their health, their state of being, and these jokers can't see it? Talk about disconnect. Then they show up here and wonder why the heck we don't worship the hallowed ground they walk on.

Anyway, my diatribe aside, I took him into the developmental optometrist and they said he had problems with tracking and convergence. They gave us eye exercises which my son did for about 3 months. There was substantial improvement. We stopped of our own accord, other health problems claiming our attention, but we need to go get a reevaluation at some point and finish it up as soon as we get the neopterin levels under control.

As per the dev. optometrist, there is no way around this - you have to do the exercises. I think every ASD family needs to see one when they are able, its *very* important.

PS: BTW insurance did not pay for this therapy either.

great post! i would think this would be helpful to thousands of parents and something that i've never seen spelled out so well.

i have increasingly come to believe that visual problems can explain a LOT of what autism really is. my hunch is if we could straighten out these kids' sensory issues we'd have a big piece of the puzzle. i know that's not an original thought but it is sinking in deeper and deeper for me.

and visual problems are a hallmark of mercury poisoning that is often diagnosed as a psychological issue.

Amazing piece Kim and Dr. Schulman. Thank you so much. I am understanding Michelle's eye problems in an entirely different light now. What's amazing to me is that the list of problems or eye type behaviors Dr. Schulman lists began after Michelle received the MMR in December 1995. I think they must have started by Jan or Feb of 1996. In fact, those eye/hand behaviors were very prominent and I remember my mom and I talking about them. Although Michelle has diagnosed optic nerve atrophy, I want to look into what Dr. Schulman talks about as well - even though we are well past the 4 year age he talks about for optimum treatment. Thanks again!

Wow, Kim! Thanks for this amazingly timely piece. My daughter has her follow up eye exam this Wednesday. I brought her to a pediatric eye doctor as I noticed her right eye was suddenly beginning to make weird tracking movements that were out of synch with her other eye. She has special glasses now, and when I looked through them to see how strong they were (as I have myopia and was curious), I was surprised that anyone could see better, much less at all, by looking though them. They are definitely helping her (much less eye turning since she got them two months ago), she is much happier with them (and she even remembers to put them on herself!) My son is about to have his eyes checked on Wednesday, too, although I have not seen a pronounced problem with his eyes. I am printing out your article for my husband to read. Thanks, again.

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