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The Use of Orthoptics
in
Dyslexia 
Haskel
M.
Haddad, MO, Nancy S. Isaacs, MS, Karin Onghena,and Ayala
Mazor'
In
73
children with reading difficulty, ophthalmological evaluation
show-ed
that
18
had
~rt
refractive errors.
18
had dyslexia and no ocular anomalies, and
37
had
impaind
Jusional amplitudes.
24
oj
whom
wen
dyslexic. In all patients with poorfusional amplitudes the reading mechanism could
~
impf'Otled
with orthoptic exer-cises designed to augment the Jusional amplitudes. The treatment did not affect theperceptual deject associated with dyslexia.
D
yslexia
is a
perceptual disorder
which
literally
means
reading diffi
. culty
(Money 1966,
Public
Law
91230Title
VI).
There
are
cases,
however.
whose
reading difficulty may not be associated with a perceptual defect. Dyslex.ia
was
first described by
ophthalmolo
gislS,
yet
the role
of
ophthalmology
andorthoptics
in
the
management
of
readingdifficulties
is
not well
defined (Eames
1948, Benton. 1961). In the past
decade.
the author
in
his capacity as a pediatricophthalmologist
examined
many
children
referred
because
of
reading difficulty (asa
symptom
or
complaint).
The
study
of
these
children and their follow up
by
learning disability specialists
shOW'ed
thatthey fall into three basic categories:(
1)
Refractive
error contributing to
reading difficulty.(2) Poor fusional amplitudes
either
inthe fonn
of
convergence insufficiency
or
convergence excess
causing confusion
atnear
and
thus
contributing
to readingdifficulties.(3)
An
actual perceptual
problem
(dyslexia) with reading difficulty
with
or
without fusional
amplitude defect.
Material
and
Methods
The cases
included in this
study
werechildren referred from private
or
public
schools, children
referred
by
special
edu
cational
teachers. and children
referred
by
learning disability specialists
or
speech
modified
Monroe
method
CMonroe 1932)
which
consists of:
1)
the evaluation
of
the
time span
of
unintelTUpted reading
by
the
child
before the learning disabilityspecialist, 2) delineating the degree
of
attentiveness
during
a
period
of
reading,
and
3)
detennining
the degree
of
under
standing
or
recall
of
what was read bythe
child.
Every
child
had a
complete
ophthalmological
examination
which includeddistant and
near
vision. refraction andcycloplegic retinoscopy (for objective refraction). funduscopic and slit lamp ex
aminations, orthoptic
analysis with phoriatesting (ability
of
sustaining binocularity)including the
measurement
of
fusional
amplitudes
at distance
and at
near, andtroposcopic evaluation (using an instrument for
phoria
testing subjectively).
Orthoptic exercises
were aimed at:1.
Correction
of
the
near
point
of
convergence CNPC)
when
present.
2. Correction
of
the fusional amplitudes
Cat
near
in particular) using framing
exercises.
3.
Anti-suppression exercises
(whenmonocular suppression
existed) using redfilter
tracing
or
cat
stereograms.
4.
Relaxation
exercises
and
physiological
diplopia training
to
imprc:M:
on
any
degree
of
accommodative
spasm
or
eso
phoria which might
aggravate the fusional
amplitudes.
S.
Fusional exercises
using the tropo
scope
when
indicated and
when
home
supervision
of
a parent. a relati ve.
or
ateacher. Follow up was on monthly orbimonthly intervals.Tropia. including esotropia, exotropiaand hypertropia. alternatesuppression,and all
monocular
cases were not in
cluded
in
the study.
RESULTS
During the school years
of
1976-1978.73 children ranging
in
age from six to
13
years,
with a male to female ratio
of
seven
to one,
were referred with readingdifficulties (Table 1). Eighteen children
had
overt
refractive
errors
(Primarily
astigmatism, high myopia and high
hy-
peropia--refractive
errors
causing
nearvision blurr
and/or
confusion) with no
other
ophthalmological
or
orthoptic
disor~
ders.
With the prescription
of
glasses thereading difficulty was
soon
ameliorated .Eighteen
other
children had dyslexia withno
abnonnal
ocular
manifestations eitherin the
fonn
of
refractive
error
or
in
thefonn
of
orthoptic defect. Thirty-sevenchildren (Table 2) had
impainnent
of
thefusional amplitUdes with occasional smalldegree
of
myopia
or
hyperopia rangingbetween
maximums
of
1.75 and
+
. 1.50.
Of
thes~,
24 were
d~xic
and
13
showed no perceptual defect.
21
hadexophoria with convergence insufficiency,
12
had esophoria with convergence
excess,
and four were orthophoric.
Tab'e
1.
1078-1078
Age
MaJ.:F.male
Refractive Error Alone
Dysl.xla (Perceptual Defect)
AlonePoor
Fusional Amplitudes
With
Dyslexia
Without
Perceptual Defect
73ChildrenwithReading
Difficulty61013
years
64:9
1818
37
24
13
~pists.-AIL
-eases..JNefe-.l'ef.ene(L..be."..
exercises
..
were.JlOl-.sufficientlyJle.1pfuL
..
_._._~uslonal
..
amplitudes.
were..~o~.idc:rc:d.
cause
of
reading difficulty.Except for
the
latter, all orthoptic ex-
nonnal
at the range
of
four to six
A
The
reading evaluation was done
by
aercises were
done
at home under
th~
,,_
(ptism
diopters) base-in
(81)
at
distance
Journal
of
L,ornin~
DlSobililifJ
142
 
Table
2.
37
C~lIdren
with Poor Fusional Amplitudes:
21
X
12
S
4 0
20
Both Convergence and Divergence Poor
13
4
Table 3.
Rate
of
Reading ImprovementModified Monroe Method
Length
of
Uninterrupted ReadingAttentiveness
l
Recall--Understanding \ Subjective
Amplitudes 
16
o
to 2 Months 152 to 4 Months 4
4
to 6 Months 2Over 6 Months 
and eight
Ll
to
12
Ll
(prism diopters)base-in (81) at near for divergence, and
18
Ll
(prism diopters) base-out
(80)
fordistance and
30
Ll
(prism diopters) baseout
(80)
at near for convergence.
In
the37 children studied and found to havepoor fusional amplitudes, even those withdyslexia. orthoptic exercises resulted
in
improvement
in
the attention span (Table3). The rate
of
improvement was faster inthe group without perceptual defect, and
in
the group with divergence instead
of
convergence insufficiency.
The
learningdisability specialist usually. reported improvement in the reading ability as aresult
of
improved focusing. Prior toorthoptic treatment, the child was noted
to
stop his
gCize
at each word read, andoften lost
it,
eventually losing interest incontinuing to read. Often the child appeared as if daydreaming, especially thosewith convergence insufficiency.
Discussion
It
should be emphasized: I. That eventhough dyslexia
is
not an ophthalmological disease, the process
of
reading may
be
affected
by
the fusional amplitudes
of
the child especially if there is intermittent diplopia as a result
of
convergence
Volume
/7
.
.
"umber
3.
March 1984
(Convergence Insufficiency)(Convergence Excess)(Orthophoric)Only Convergence PoorOnly Divergence Poor
Reading Improvement 
o
to 2 Months 292 to 6 Months 4Very Slow 4
insufficiency
or
convergence excess. 2.
That
reading difficulties may not only berelated to perceptual defects and
dyslex~
ia, because there are children whose reading difficulty is not accompanied
by
perceptual defect. 3.
That
children with dyslexia and reading difficulty with normalophthalmological examination and fusional amplitudes
do
not benefit fromorthoptic exercises
or
any other ophthalmological attention.
4.
That parents,orthoptists, learning disability specialistsand ophthalmologists should accept theproposition that Qrthoptic exercises givento the child with dyslexia
do
not affectthe perceptual problem
of
the child, andthat the ophthallllologist
or
orthoptist arenot treating dyslexia
or
the perceptualproblem
of
dyslexia, and that orthopticexercises affc:ct
only
the fusional amplitudes and thus help the reading process,and not the perceptual process.In a child,
if
there
is
a frank fusiondisturbance, he will either qevelop suppression, amblyopia
or
alternation.
How-
ever,
if
fusion is relatively well established, but the
f~sional
amplitudes are
disturbed, especially
at near, then a
'struggle'
will ef!sue when the child attempts to maintain fusion, especially during the reading process. The difficlilty
y
will be much further aggravated when ,hechild has an added perceptual problem as
in
dyslexia. When the neuro-muscularand innervational factors involved
in
thefusional process, especially
in
convergence and accommodation, are faulty tosome extent, but not severe enough toproduce exotropia
or
esotropia,
i.e.,
notsevere enough to cause monocularity,then the child will attempt to fuse at
all
costs. This impulse to fuse will fatiguethe child, especially when he has
to
maintain and sustain fusion for a longperiod
of
time as
is
the case duringreading. When such a difficulty developsduring reading, the first manifestationwill be that
of
focusing difficulty, sincethe child cannot sustain binocularity for along period
of
time and thus will keeptrying to focus each word separately. Alternately, he will have to go back from
one
word to the other
in
order to maintain fusion.
The
second step results fromimage confusion during reading, which
particularly develops
as a
result
of
crossed diplopia, as in convergence insufficiency. Thus the child will begin tosee the words shifting backwards, andthus he will shift his gaze from right toleft as he tries to continue to read. Thechild will complain that
tnt
letters appearto move . from right to left.
The
learningdisability specialist often mentions thatwhile reading, the child appears to
be
unable to follow the reading material onthe line
in
a continuous fashion and willmake stops at each letter, a process whichbecomes very tiring. This was recently
corroborated
by
electro-oculographic
studies
of
the eye movements (KrausMackiw.
Muller-Kuppers,
&
Rabetgc1978)..Even though this study is directed tothe orthoptist, there is no reason why the
ophthalmologistwhoexamines
preschool and school age children may notbe able to institute such orthoptic exercises for the child without having to havethe help
of
an orthoptist in his office. Anorthoptist might be better equipped forfollow up and for training, but the ophthalmic student should be trained to dothe same when he does not have accessto an orthoptist.
REFERENCES
Benton.
J.
D.
Jr. Ophthalmological approach
to
the problem
of
retarded readers among elemen-
/43
of 00

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