Ophthalmological support of a vision/learning link.


A clinician has a singular task before him as the patient (or client) presents him or herself: the clinician must solve or enable the solving of the presenting complaint. How effectively or how rapidly that solution occurs are important concerns that are secondary to the primary task. Whether the solution works for others is of scientific interest, for replication’s sake, but of almost moot concern to the patient. Scientific proofs and data are only partially reassuring to the person whose problem has been solved.

Besides, disease and behavioral sciences follow different rules of reasoning than the “hard” sciences. First of all, correlations merely support hypotheses and second, behavioral correlations are meant to demonstrate relatedness vs. lack of relatedness. So therefore, behavioral correlations are not proofs (scientific arguments are never proven by data, anyway – DIS-proven, yes – but never proven).


Reason alone suggests that learning is a visually-predominant process. Vision extends our grasp, opening horizons of experiences for which our arms are too short, and to which our bodies cannot move.

Vision provides feedback of what we’ve just done – and more importantly, “feed-forward” of what we wish to do. We visualize, plan, have insights, and reason over events we have not yet experienced. (Electronic media have robbed our children of much of visualization, but that’s a different subject of great importance.) We plan solutions to problems and act upon them. We then measure the accuracy of our predictions by the results of our visually-directed response. In short, vision and learning are virtually synonymous. That is why it is no big surprise to hear people say “I see” when they mean “I understand”.

But reason alone is not enough to commit children to clinical therapies that are baseless in dealing with learning disabilities.

Are vision, perception and learning related? What do we mean by vision? Will all learning problems respond to visual and perceptual therapy? These questions are not insignificant, for we must solve the clinical question of learning problems for each child presented to us, not as a question of science, but to bring to bear the wisdom of the sciences to aid the individual. If the method used to gain the results will solve others’ problems as well, then both the clinician and science have gained a new tool.

Visual and perceptual therapy have emerged as effective tools.


Dr. Janet Lerner in her textbook (1990) cites a study that reviewed 161 papers on perception through the process called meta-analysis, which concluded that there is a strong component relationship between visual perception and reading. Dr. Lerner’s book addresses the more effective techniques of remediating deficits in perceptual skills. A significant portion of her text reviews strategies for improving motor, visual, and auditory perceptual skills, perhaps because she notes that in fifteen studies – all that she could find – of “teaching to the strengths”, a common school strategy with perceptually handicapped, there was not one positive outcome.

Vision is the mental process by which radiant energy is converted into a single, identified image that can be acted upon. Learning is the acquisition of new data that can then be related to what we’ve already learned. Jean Piaget, the great learning pioneer, called these processes assimilation and accommodation. The most rapid acquisition of data is through the eyes and the process of vision

Not all therapy programs are equal. Over thirty years of clinical experience at The Learning Clinic have shown that while there are spurious programs that are advocated, there are also highly effective – and validated – methods available. Circling answers on a page is not equivalent to reproducing a geometric form on a piece of paper, and yet both are “perceptual tasks”. Telling whether a pig’s grunt is the same or different as a cow’s moo, while also a perceptual task, is not the same as telling what sound was omitted from “learn” when we heard “earn”. Yet, both are admittedly perceptual tasks.

What are the differences? The first tasks, while perceptual, are not performance related (criteria-referenced) to academics, while the second ones have been validated to transfer into academic skills. That is, matrixing geometric patterns and similar tasks, training motor skills, and phonologically sorting sounds have been proven to transfer into academic skills in seven years of basic research by Dr. Jerome Rosner (1972) at the Learning Research and Development Center, University of Pittsburgh. These principles have been quantified and expanded into a program (now in the public domain) and was republished in two different forms by Walker Books, New York, New York (1987). Their rapidity of remediation is amazing, a clinical observation also made about results in Dutch studies (Bakker and Vinke) cited by Dr. Jane Healy (1990).

Sight is often mistaken for vision, even by highly reputable authorities. They point out that sight and eye problems do not relate well to poor academic performance. And in fact, the literature supports a fairly close (but inverse) relationship between unaided sight and academic success. (Nearsighted students, who have poor unaided vision, often are superior students – this is supported by major studies in Japan, Israel, and Denmark. Also see the Linksz notation below.) However, eye coordination problems can provide a mental barrier to learning, purely by drawing the student’s attention away from perception and learning into the act of attempting to see. Eye complaints frequently attend this greater effort, because of frowning to see, head thrusting to converge the eyes, or squinting to focus the eyes because of poor ability to use the focusing mechanism of the eyes.

As Dr. Arthur Linksz, assistant professor of ophthalmology at the New York Medical College, says in his book, “The children…whom I as an eye specialist have really been able to help generally had trouble with binocular coordination.” And, “Myopes are notoriously good readers. One does not have to use both eyes in order to be a good reader. But one must be free of eyestrain, a clear-cut entity, however nebulous the term.” (1968)

Sometimes eye problems do not cause symptomatic strains or stress, yet will affect performance. At a conference on Dyslexia, Dr. Curtis D. Benton, a pediatric ophthalmologist, reported on a study of 1500 Florida students with specific reading problems (1968), and wound up contradicting Dr. Linksz’ comment that we do not have to use both eyes to read well (which can be true in very specific cases). He reported that 80% of the students – four out of five – had a suppression of the central vision of one eye; that is, they did not use both eyes at the same time. (By comparison, only 8% of 300 – about one out of fifty – good readers had trouble with the same exact test.) Dr. Benton also was able to help 88% of those children with that problem through a prescribed program of therapies. It is readily apparent that lack of two-eyed vision does affect reading, and he also demonstrated that therapy is highly effective.

At the same conference, one of Dr. Benton’s colleagues, Dr. John V.V. Nichols, McGill University of Montreal, reported that in properly selected cases, extraocular muscle exercises will enhance functional visual reserves and thus “help ocular fatigue and enhance the attention span in any child.” (Emphasis added.)

Hammerberg and Norn (1972) found that when they performed therapy on children having reading problems along with the noted visual function problems, that more than two thirds of the group that elected to do therapy were positively affected.

Dr. Eugene Helveston, one of the editorial reviewers of the American Journal Ophthalmology, found that the best primary grade readers also did best on a test of his own creation, the “Draw-a-Bicycle Test”, which requires a child to visualize and reproduce a two-wheeled bicycle. The poorest readers did poorest at this visual-motor skill. In the same paper, he encouraged ophthalmologists to begin doing the Draw-a-Bicycle test as part of their screening on children with reported school problems (1985a).

Puzzlingly, this positive correlation appears in his paper that concludes that there is no relationship between components of visual function and academic performance relationship, even though he never tests that question in his data. (That is, he never statistically showed whether a relationship did or did not exist as he set out to do. Dr. Helveston later published a paper on this specific test (1985b) which showed a very statistically strong relationship of the Draw-a-Bicycle test to reading level in early school grades (p<.0001).


However, controversy rules when agencies get involved. In two position papers: The Eye and Learning Disability (1972), and Learning Disabilities, Dyslexia and Vision (1981), the American Academy of Pediatrics, American Academy of Ophthalmology and three other medical agencies, made the claim that there was “…NO KNOWN EVIDENCE…” (emphasis added) supporting the contention that visual or perceptual therapy was of value for academic abilities of dyslexic or learning disabled children.

These assertions are made in spite of the availability of their colleagues’ reports as noted above and Rosner’s research many years prior to that. The scholarship of the papers and their conclusions appear to lack thoroughness and objectivity.

The first two papers of controversy were critically examined for accuracy of citation and accuracy of reporting, but found to contain “gross distortions and inaccuracies” (1972) and “gross distortions again prevailing” (1984). That is to say, that few, if any of the citations were relevant to the arguments, or they were used in highly inappropriate ways. Additional dismissal of the vision connection was perpetuated in another position paper, Learning Disabilities, Dyslexia, and Vision: A Subject Review (1998). That paper has been severely rebutted and the literature reviewed appropriately. (Bowan, 2002) There has been no response to any of the critiques as of this writing.

Unfortunately for many children, all of these papers were disseminated with little, if any, acknowledgment of their great flaws and no proper response to the questions raised about their scholarship. (Many of their references indicted a technique of cross-crawling and patterning, promoted by Drs. Doman and Delecato of The Institutes for Achievement of Human Potential, which is not a technique that optometrists generally use; or the papers were not papers about Optometric therapy; or the arguments were drawn out of context from papers that supported a positive outcome for visual therapy.)


As a last point, when positive results are attained with visual or perceptual therapy, critics of these techniques raise the objection that there is a “halo effect” or the “Hawthorne Effect” operating. This effect is supposed to mean that mere attention and social approval is enough to change the behavior.

A reasonable assumption…however, it’s never been scientifically demonstrated to be a real phenomenon.

The original Hawthorne study done in 1927-32 does not stand up under any standard of scientific research design:

  1. There were only five subjects in the study.
  2. Two of the subjects were replaced part way through because the research model created unsuitable behavior.
  3. The subjects were rewarded with time off for meeting quotas.
  4. There was no control group.
  5. The experimental results were the opposite of the conclusion.

Most children with learning problems have had significant individual help before perceptual and visual therapy is sought. Rarely are perceptual therapeutics the first course of action. Therefore, if there really were some sort of “halo effect”, the child should have improved prior to the therapies. As pointed out above, research has proven that real changes do occur in grades when the Rosner program is used. There is no scientific basis for dismissing any behavioral changes from visual or perceptual therapy because of some supposed “halo effect”. The “Hawthorne Effect” has yet to be established as a scientific fact.


The conclusions are persuasive:

  1. Research supports the transfer of sensorimotor skills into academic abilities;
  2. Controversy is based on reports that are of highly questionable scientific integrity;
  3. Educators recognize and address perceptual skill development as intrinsic to learning.

Learning problems demand a multidisciplinary approach, for just like the common cold, there are different causes of what seem to be a common problem, so no one approach will be a panacea. The clinician must search for the roots of each individual’s problem and this almost invariably is a multidisciplinary quest. There are visual and perceptual bases to many of the problems, for certain, but also birth or pre-natal influences, environmental and nutritional reasons, pathologies and emotional causes from inside the child’s family constellation and outside factors, as well. And, although it’s a whipping boy topic, the quality of education must be accounted for, along with the teacher/student interactions. The care provider must take all of these potential barriers into account: for all the barriers providing figurative “static” to the smooth function of learning must be cleared away.

Ultimately, the goal is to clinically solve the individual’s problem, by whatever means. Thus a multidisciplinary diagnostic process promises to give the most valid evaluation to making the appropriate interventions to eliminate that person’s barriers to their classroom problems. The clinical solutions can then contribute to validation of a scientific model.

There is an “earn” in “learning” and vision plays a major role in leading us through the steps by which we organize our brains to receive it. Therapeutic intervention in appropriately identified students will improve performance, even ophthalmological literature shows.

It has been said that if a person is insecure in his visual state, he will be insecure in his ego state. The late Dr. Ward Halstead, of the Department of Psychology, University of Chicago School of Medicine, commented this way on Vision:

Vision – one of the major contacts with reality in the early experience of the child. The outcome of the future development of the personality is to a great degree a function of the extent and quality of that visual contact.

— is there baby in the bathwater? We need to be careful of dismissing ideas that are just different than our presuppositions


Benton, C; Reported in Keeney and Keeney, Dyslexia: Diagnosis and Treatment of Reading Disorders, C.V. Mosby, 1968.
Bowan, MD; Learning Disabilities, Dyslexia and Vision: a subject review. A rebuttal, literature review and commentary, Optometry.73( 9):(553-75), 2002.
Flax, N; The Eye and Learning Disabilities, J. Am. Optom. Assn., Vol. 43, No. 6, 1972.
Flax, N; et al; Learning Disabilities, Dyslexia, and Vision, J. Am. Optom. Assn., 1984.
Hammerberg, R; and Norn, L; Defective Dissociation of Accommodation and Convergence in Dyslectic Children, Acta Ophthal. 50:(651-654), 1972.
Healy, J; Endangered Minds: Why Our Children Don’t Think, Touchstone Books, New York, 1990.
Helveston, E; Visual Functioning and Academic Performance, Am. J. Ophthal. 99:(346-355), 1985.
Helveston, E; The Draw-a-Bicycle Test, J. Ped. Ophthal. & Strab. 22(1):(917-919), 1985.
Lerner, J; Learning Disabilities, 5th Ed., 1990. Linksz, A; On Writing, Reading and Dyslexia
Nichols, J; Reported in Keeney and Keeney, Dyslexia: Diagnosis and Treatment of Reading Disorders, C.V. Mosby, 1968.
Rosner, J; The Green and Blue Readiness Books, Walker Books, New York, NY, 1987.
Rosner, J; Perceptual Skills Curriculum, Walker Books, New York, NY, 1973.
Jonathan Edwards said:
“It has been very observable that persons of greatest understanding and who had studied most about things of this nature have been more confounded than others. Some such persons declare that all their former wisdom is brought to naught and that they appear to have been babes who knew nothing.”

© 2011 - 2018 Merrill D. Bowan, O.D. All rights reserved


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