was going to have to repeat first grade! Over the school year, I had not progressed in my reading or spelling skills! It was the early 1980s, and not advancing in school was seen as a significant failure and a sign of intellectual deficiency. Fortunately, with guidance from my teacher, my parents had me evaluated by a neuropsychologist who diagnosed me with dyslexia. He recommended I enroll in a class that used the Slingerland approach (a whole classroom adaptation of the Orton-Gillingham method), “a comprehensive, multi-sensory, structured learning program inclusive of all five pillars promoted by the science of reading: phonological awareness; phonics; word recognition; reading fluency; vocabulary; and comprehension, with the added benefit of handwritten instruction.” After many difficult years, I managed to catch up to my classmates academically and attend medical school, graduating near the top of my class.

Early elementary school children with dyslexia may have trouble learning letters and the sounds they make. Photo: Getty Images.

 

Fast forward to today: I now work as a pediatric ophthalmologist at the Dean McGee Eye Institute in Oklahoma City. In my clinical practice, I see hundreds of children every year, many of whom struggle with the same reading issues I have. I often wondered about my role as an ophthalmologist and how I could help these kids. Four years ago, I started volunteering as a member on the American Association of Pediatric Ophthalmology and Strabismus Learning Disabilities committee. My only knowledge about dyslexia at the time consisted of memories from my schooling experiences. As a committee member, I have had the privilege to participate on several workshop panels about dyslexia and interact with many of the foremost experts in the field. 

I have learned so much from their expertise and would like to share six practical things you can do to help these kids:

1. Educate yourself (and your trainees) on the basics of dyslexia. Consider attending a workshop at the American Academy of Ophthalmology or AAPOS annual meeting to update your knowledge base about dyslexia. Review the joint policy statement from AAPOS, AAP and AAO on dyslexia and learning disabilities. Look for new educational materials on the AAPOS website in the upcoming months, including updated links and terms. The AAO Basic Science and Clinical Course now includes a section on learning disabilities for trainees, which means it may be tested on the OKAPs and American Board of Ophthalmology written and oral board examinations. 

2. Know the warning signs of dyslexia (Figure 1). Many people think dyslexia can’t be diagnosed until children are in the third grade; however, screening tools exist for children as young as two. One of the earliest warning signs of dyslexia is a speech delay. Pre-school-age children may have trouble learning letters in their names and may not appreciate rhymes. Early elementary school children with dyslexia experience trouble learning letters and the sounds they make.

 

Figure 1. Signs of Dyslexia

The Preschool Years

  • Trouble learning common nursery rhymes, such as “Jack and Jill”
  • Difficulty learning (and remembering) the names of letters in the alphabet
  • Seems unable to recognize letters in his/her name
  • Mispronounces familiar words; persistent “baby talk”
  • Doesn’t recognize rhyming patterns like cat, bat, rat
  • A family history of reading and/or spelling difficulties (dyslexia often runs in families)

Kindergarten and First Grade

  • Reading errors that show no connection to the sounds of the letters on the page—will say “puppy” instead of the written word “dog” on an illustrated page with a picture of a dog
  • Does not understand that words come apart
  • Complains about how hard reading is; “disappears” when it is time to read
  • A history of reading problems in parents or siblings
  • Cannot sound out even simple words like cat, map, nap
  • Does not associate letters with sounds, such as the letter b with the “b” sound

Second Grade through High School

Reading

  • Very slow in acquiring reading skills. Reading is slow and awkward
  • Trouble reading unfamiliar words, often making wild guesses because he cannot sound out the word
  • Doesn’t seem to have a strategy for reading new words
  • Avoids reading out loud

Speaking

  • Searches for a specific word and ends up using vague language, such as “stuff” or “thing,” without naming the object
  • Pauses, hesitates, and/or uses lots of “um’s” when speaking
  • Confuses words that sound alike, such as saying “tornado” for “volcano,” substituting “lotion” for “ocean”
  • Mispronunciation of long, unfamiliar or complicated words
  • Seems to need extra time to respond to questions

School and Life

  • Trouble remembering dates, names, telephone numbers, random lists
  • Struggles to finish tests on time
  • Extreme difficulty learning a foreign language
  • Poor spelling
  • Messy handwriting
  • Low self-esteem that may not be immediately visible

Adapted from: Shaywitz S. Overcoming Dyslexia: Second Edition Completely Revised and Updated. New York: Penguin Random House LLC, 2020.

 

3. Ask all of your patients and their caregivers about reading issues. Many parents don’t think to bring up school troubles at an eye exam appointment, especially if they are presenting with another concern. At our clinic, we include a question about education and reading issues on the intake form, and technicians confirm this information by asking again during their work-up. Dyslexia is one of the most common learning disabilities, affecting 1:5 American children (if you see 35 to 40 patients per clinic day, seven or eight of these children will have dyslexia).

4. Perform ophthalmological testing to rule out ocular conditions that may worsen or accompany a learning disability (Figure 2). Significant refractive errors, strabismus and accommodative and convergence insufficiency don’t cause dyslexia but may co-exist. Pediatric ophthalmologists perform cycloplegic retinoscopy and motility exams on our patients, but we may miss testing for convergence and accommodative insufficiency. Testing convergence and accommodation is not difficult to perform but must be done before dilation, so it’s essential to remind technicians to flag charts of children with reading issues.

 

Figure 2. Ophthalmologic Exam Techniques in Children with Reading Difficulties

— Visual acuity at Near

— Accommodation

  • Near point of accommodation
  • Accommodative amplitudes
  • Accommodative facility
  • Dynamic retinoscopy

— Convergence

  • Near point of convergence
  • Convergence amplitude

— Cycloplegic retinoscopy

 

5. Supply parents with resources about appropriate testing and interventions. Misinformation about dyslexia abounds. Just google “dyslexia,” and you’ll find hundreds of websites advocating various treatment options and cures. Many ophthalmologists mistakenly believe that because dyslexia is “not an eye issue” it belongs solely to pediatricians and education specialists. However, we play a crucial role in ruling out vision problems and, simultaneously, have a unique opportunity to educate caregivers and prevent them from pursuing non-evidence-based treatments. Such treatments can cost families hundreds to thousands of dollars and delay the child from receiving the most effective interventions. You can help families by providing information on requesting free testing through the public school system available online at the Learning Disabilities Association of American website (https://ldaamerica.org/advocacy/lda-position-papers/right-to-an-evaluation-of-a-child-for-special-education-services). You can also advise on evidence-based treatment approaches and steer them away from ineffective options. Ninety percent of children with dyslexia who are diagnosed and have treatment in kindergarten and first grade will achieve grade-level reading skills, compared to 25 percent with late intervention. 

6. Participate in the upcoming survey from the AAPOS LD committee on dyslexia. The AAPOS LD committee wants to hear from you about what you need to better care for these patients so we can create an online learning disabilities toolbox for ophthalmologists. This survey will be available on the AAPOS and AAO websites in the next few months.

 

Figure 3. Noteworthy Physicians and Academics with Dyslexia

  • Beryl Benacerraf, MD, a pioneer in obstetrical and gynecological ultrasound.
  • Fred Jacob Epstein, MD, made notable breakthroughs in pediatric neurosurgery.
  • Helen Brooke Taussiq, MD, a pediatrician, described by the National Institutes of Health as the “founder of pediatric cardiology.”
  • Peter Lovatt, PhD, (psychologist), uses a unique combination of clinical psychology and dance to help patients.

 

 So that’s it, the Ophthalmologist’s 6-Step Dyslexia Challenge. If you identify a child that might have dyslexia, rule out and treat any eye problems and communicate with their caregiver and pediatrician so they can pursue formal testing. Truthfully, from an ophthalmologist’s perspective, dyslexia may seem like a rather dull topic, but it’s vitally important. Experiencing early struggles in school negatively affects a child’s psychological and emotional well-being. They start disliking school, and the problem compounds. They face long-term social, emotional and economic consequences. By helping these children obtain proper diagnosis and intervention, you can help them reach their full potential. As I write this concluding paragraph, all I can think is something clich√© but true: I, and many others (Figure 3), are living proof.

 

Dr. Collinge is an assistant professor in the Department of Pediatrics of the University of Connecticut School of Medicine. She has no financial interest in any of the products discussed in the article.

Dr. Yanovitch is a clinical professor of pediatric ophthalmology and strabismus and director of Medical Student Education at the Dean McGee Eye Institute/University of Oklahoma College of Medicine-Department of Ophthalmology.

 

Recommended Resources

1. Shaywitz S. Overcoming Dyslexia: Second Edition Completely Revised and Updated. New York: Penguin Random House LLC, 2020.

2. Shaywitz S, Shaywitz J, Shaywitz B. Dyslexia in the 21st century. Current Opinion in Psychiatry 2021;34:2:80-86. 

3. Collins ME, Mudie LI, Inns AJ, Repka MX. Pediatric Ophthalmology and childhood reading difficulties: Overview of reading development and assessments for the pediatric ophthalmologist. Journal of AAPOS 2017;21:6:433-36.

4. Stevens EA, Austin C, Moore C, Scammacca N, Boucher AN, Vaughn S. Current state of the evidence: Examining the effects of Orton-Gillingham Reading Interventions for students with or at risk for word-level reading disabilities. Except Child 2021;87:4:397-417.

5. Slingerland. https://www.slingerland.org/.

6. Orton-Gillingham/Orton-Gillingham and So Much More. https://www.orton-gillingham.com/.

7. Learning Disabilities Toolkit - American Association for Pediatric Ophthalmology and Strabismus. Feb. 2, 2018.https://aapos.org/viewdocument/learning-disabil

8. Learning Disabilities - AAPOS. https://aapos.org/glossary/learning-disabilities.

9. Policy Statements - AAPOS Home. 07 Feb. 2018, https://aapos.org/viewdocument/learning-disabilities-dyslexia-and.

10. 9 Famous Doctors With Dyslexia: If They Can Do It, You Can Too. 10 Mar. 2022, https://numberdyslexia.com/famous-doctors-with-dyslexia/.

11. Right to an Evaluation of a Child for Special Education Services – Learning Disabilities Association of America (ldaamerica.org)