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reddish nor greenish.49 It is likely that adaptation also occurs in the
case of colour variation from electric lighting, and this may have
consequences for colour preference, see Chapter 8.
Cortical Hyperexcitability
Most of the neurological disorders discussed in this chapter are co-
morbid with epilepsy, meaning that the two conditions often co-occur
in the same person. In some of the disorders in this chapter, the
hyperexcitability of the cortex has been demonstrated directly in
neuroimaging studies. In migraine, for example, the response to
patterns gives an abnormally large fMRI BOLD response.50 The
response is reduced with coloured filters selected as comfortable for
reading, but not with those that differ in chromaticity by 0.06.51
Hyperexcitability is the basis of one of the leading biological theories
of autism,52 and has been proposed as a mechanism in visual snow.31
In contrast to conditions associated with hyperexcitability, low
vision is a condition where the input to the visual cortex is lacking.
Therefore, the finding that, in low vision, precision tinted lenses
prescribed with the Intuitive Colorimeter11 were found to be unhelpful
is entirely consistent with the cortical hyperexcitability hypothesis.
A synthesis
The possible explanations listed above are not mutually exclusive.
The differences in the chromaticities in an image have been shown to
be closely related to the magnitude of the cortical response, both
haemodynamic53 and electrical.54 So it might be expected that coloured
lenses would reduce the cortical response to visual stimulation. Long-
term exposure to 100Hz flicker from fluorescent lighting is known to
cause headaches and eye-strain20 and the visual system is known to
show long-term adaptation to colour.49 All of these factors might
Vision, Reading Difficulties and Visual Stress
332
exacerbate a susceptibility resulting from a cortical hyperexcitability.
There is no reason to think that when hyperexcitability of the visual
cortex occurs, it is uniform across the visual cortex. Indeed, any
evidence of subtle but multiple brain lesions in dyslexia55 would be
consistent with the “additive risk factor model” introduced in Chapter
5. It is possible that in susceptible individuals there are patches of
cortical hyperexcitability in the visual cortex. Since cells have been
found in several areas of the visual cortex that respond to specific
colours,56 such a hyperexcitability could explain the benefit from
individually prescribed colours, and that they sometimes need to be
prescribed with precision.
Finally, a caveat is in order. The methods outlined in this and earlier
chapters describe coloured filters in terms of their chromaticity. As has
been pointed out, there is a one-to-one correspondence between
chromaticity and the relative energy captured by the three classes of
cone. There are, however, other photoreceptors in the eye: the rods,
intrinsically photosensitive retinal ganglion cells (ipRGCs), and possibly
melanopsin containing sensory cells in the iris and cornea.57 All
photoreceptors, ipRGCs,24 rods,58 and cones,16 have been variously
linked to photophobia. It seems likely that all photoreceptors have
their part to play,
59 60
and this might mean that a more nuanced
description than chromaticity will ultimately be needed. In a recent
report of a lady with longstanding photophobia, blue light was shown
to activate pulvinar nuclei.61 She found the FL41 filter useful. It
attenuates short wavelengths to which the ipRGCs are sensitive.
Although it is possible to design filters that are better matched to the
spectral sensitivity of the ipRGCs using thin film optics, as described
above, these filters are not likely to help the majority of migraine
patients. This is because the choice of comfortable light chromaticity
Chapter 11 Other potential clinical uses of precision tinted lenses
333
Figure 11.13 Summary of light chromaticity chosen by volunteers with
migraine in two studies. Data from Wilkins et al.60
by patients with migraine differs considerably from one patient to
another, as shown in Figure 11.13. The distribution indicates that short-
wavelength attenuation is unlikely to help the majority. Indeed, most
patients choose light with blue, turquoise and green colours rather
than the red and orange tints that would reduce stimulation of the
ipRGCs.
It has recently been shown that the majority of cells in the primary
visual cortex code both for colour and space,62 this may help explain
why coloured filters sometimes improve visual distortions and visual
performance.
Vision, Reading Difficulties and Visual Stress
334
2. Brinciotti M, Matricardi M, Pelliccia A, Trasatti G. Pattern sensitivity and
photosensitivity in epileptic children with visually induced seizures.
Epilepsia. 1994;35(4):842–9.
3. Wilkins AJ, Baker A, Amin D, Smith S, Bradford J, Zaiwalla Z, et al.
Treatment of photosensitive epilepsy using coloured glasses. Seizure.
1999;8:444–9.
4. Ludlow AK, Wilkins AJ, Heaton P. The effect of coloured overlays on
reading ability in children with autism. J Autism Dev Disord.
2006;36:507–16.
5. Fong KNK, Ma WY, Pang HK, Tang PPK, Law LLF. Immediate effects of
coloured overlays on the reading performance of preschool children
with an autism spectrum disorder using eye tracking. Res Dev Disabil.
2019;89:141–8.
6. Ludlow AK, Wilkins AJ, Heaton P. Colored overlays enhance visual
perceptual performance in children with autism spectrum disorders. Res
Autism Spectr Disord. 2008;2(3); 498-515..
7. Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The “Reading the
Mind in the Eyes” Test revised version: A study with normal adults, and
adults with Asperger syndrome or high-functioning autism. J Child
Psychol Psychiatry Allied Discip. 2001;42:241–51.
8. Ludlow AK, Taylor-Whiffen E, Wilkins AJ. Coloured filters enhance the
visual perception of social cues in children with autism spectrum
disorders. ISRN Neurol. 2012:2012:298098. doi: 10.5402/2012/298098.
9. Whitaker L, Jones CRG, Wilkins AJ, Roberson D. Judging the Intensity of
Emotional Expression in Faces: The Effects of Colored Tints on
Individuals With Autism Spectrum Disorder. Autism Res. 2016;9(4):450-9.
doi: 10.1002/aur.1506.
10. Ludlow AK, Giannadou A, Franklin A, Allen PM, Simmons DR, Wilkins AJ.
The possible use of precision tinted lenses to improve social cognition in
children with autism spectrum disorders. Vision Res [Internet].
2020;170:53–9. doi:10.1016/j.visres.2020.03.007
11. Wilkins AJ, Sihra N. A colorizer for use in determining an optimal
ophthalmic tint. Color Res Appl. 2001;26:246–53.
12. Aldrich A, Lovell-Patel R, Allen P, Wilkins A. The repeatability of
colorimetry is precise(ly) as expected. Neuro-Ophthalmology Vis
Neurosci. 2018;3:1–6.
13. Ludlow AK, Wilkins AJ. Case report: Color as a therapeutic intervention. J
Autism Dev Disord. 2009;39(5):815-8. doi: 10.1007/s10803-008-0672-5.
14. Viscidi EW, Triche EW, Pescosolido MF, McLean RL, Joseph RM, Spence SJ,
et al. Clinical Characteristics of Children with Autism Spectrum Disorder
and Co-Occurring Epilepsy. PLoS One. 2013;8:1–11.
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Chapter 12
Research priorities and practice
Chapter abstract
This chapter starts with reflections on visual stress and the
multifactorial nature of reading difficulties. Priorities for research are
outlined, both concerning vision and reading difficulties. The various
research designs that have been used are described together with
some of their pitfalls. Suggestions for eye care practice are offered,
noting the importance of research evidence, patient (and parent)
preferences, and clinical state and circumstances. The chapter
concludes with comments for educational professionals, parents, and
students.
Priorities for research
Reading difficulties
In general, the variables that are found to be associated with a
condition may be causes of that condition, may be caused by the
condition, or may be non-causal correlates of the condition. A causal
role does not mean that these factors are the only cause of reading
difficulties or dyslexia. At the end of Chapter 5, it was noted that these
conditions are likely to have a multifactorial aetiology. A range of
different deficits may underly dyslexia, and only some of these deficits
may be present in any given individual.
model” of dyslexia3 means that visual interventions4 can be helpful in
some cases even where there is strong evidence that phonics training
is also effective.5
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. J. Wilkins and B. J. W. Evans, Vision, Reading Difficulties and Visual Stress,
https://doi.org/10.1007/978-3-031-65568-5_12
1-3
This “additive risk factor
341
In Chapter 3, binocular instability was shown sometimes to co-occur
with dyslexia and it was noted that children with binocular instability
are predisposed to make reading6 and spelling7 errors that are of a
visual nature. Additional support for a causal role for binocular
instability comes from the observation that covering one eye reduces
the number of these errors.8 Recent research on vision therapy (eye
exercises) for one type of binocular vision anomaly (convergence
weakness exophoria) shows a beneficial effect on optometric variables
but not on symptoms
9 10
or reading.11 This research excluded
individuals with poor reading and it would be useful for future research
to investigate the effect of treatments for binocular instability on
symptoms and reading in children who have both binocular instability
and reading difficulties.
It was also noted in earlier chapters that attention
deficit/hyperactivity disorder (ADHD) often co-occurs with dyslexia. It
would be interesting to investigate the relationship between ADHD and
the optometric correlates of dyslexia.12
Visual stress
Hyperexcitability of the visual cortex (Chapter 8) seems likely to be
involved causally in visual stress, but we do not fully understand the
mechanisms. It is possible that visual stress is exacerbated by rapid
flicker from school and office lighting. LED lighting can flicker more or
less than fluorescent lighting, depending on the design of the control
circuitry. It is important to know the relationship between visual stress
and the degree of flicker at various frequencies.
Some studies have identified subtle accommodative factors as
correlates of visual stress,
13-19
although not consistently.20 This
highlights the need, when investigating visual stress, to control for
Vision, Reading Difficulties and Visual Stress
342