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Some suggestions for education professionals,
parents, and students
The Specific Learning Difficulties (SpLD) Assessment Standards
Committee (SASC) is a limited company aiming to encourage
cooperation and embed good practice among educational
professionals in the assessment and management of specific learning
difficulties. In 2018, SASC published a guide on SpLD and visual
difficulties for assessors and SpLD practitioners.65 This report
advocated that educational assessors should ask questions about
reading difficulties and refer symptomatic students to an optometrist
before a full diagnostic assessment. The report asserts that
optometrists are the professionals best placed to assess and treat the
causes of visual symptoms. More controversially, the report states that
assessors should not conduct coloured overlay tests, or diagnose
visual stress.65 SASC guidance is that an Irlen assessment is not a valid
component of a SpLD assessment.
SASC advocates education professionals use the questionnaire in
Table 12.4. They recommended that a referral to an optometrist is
made if any symptoms occur, even rarely. Optometric treatment is
more likely if symptoms occur often or always.65 The questionnaire
does not appear to have been validated, and a priority for future
research is to investigate the validity of this approach. It will be noted
that some of the questions clearly concern behaviour which could
perhaps better be assessed by an observer than by the patient
themselves.
Chapter 12 Research priorities and practice
353
Table 12.4. SASC visual symptoms questionnaire.*
Vision, Reading Difficulties and Visual Stress
354
*Reproduced with permission from SASC Visual Difficulties and Visual
Difficulties, A Guide for Assessors and Practitioners, p20.
65 67
As noted above, reading increasingly involves digital (electronic)
devices, such as personal computers, tablets, electronic readers, and
smartphones. When pulse-width modulation (PWM) is used to vary the
brightness of the screen, the resultant flicker can cause eye strain even
when it is not noticeable as flicker.68 There is a list of screens and the
frequency of PWM they use on the web and there are videos that show
how to test a screen for PWM. Thankfully there are now screens that
do not use PWM.
When reading from digital devices, users may find it beneficial to
adjust various features including typeface, letter size, horizontal
spacing, line spacing, and the font and background colour.64 However,
such adjustments are not necessarily intuitive. As an analogy, driving
instructors recommend that before driving a car that is new to them, a
person should familiarise themselves with the instruments and adjust
the controls (e.g., seat, wheel, mirrors) to optimise their performance.
A similar attention to setting up a digital device is likely to be beneficial
for many readers. Several studies show that most dyslexic readers are
helped by increasing print size69 and the spacing between letters,
69 70
words, and lines. It seems likely that if education professionals spend
time with a child adjusting these settings on digital devices, they should
be able to help the child find the optimal settings which could assist
their reading. Unfortunately, one setting may well affect another, so an
iterative process of adjustment may be necessary. It would be useful if
the device itself could interact with readers so as to adjust settings
appropriately. The effects of parameters of type size, letter spacing
word spacing and line spacing all interact together to influence reading
fluency and comfort. Fortunately, the way in which they interact is now
the subject of study.71
Summary
A significant body of research over the last 20 years supports the
existence of optometric correlates of reading difficulty. The most
common such correlate is probably visual stress, although this topic
remains controversial. More work is needed to investigate the
treatment of visual stress with coloured filters in larger randomised
controlled trials. We need to understand better the mechanism(s) of
visual stress and to learn the most efficient approach to diagnosis.
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Appendices
Appendix 1: Guidance for eye care professionals
concerning publicity on dyslexia, visual stress, and
related conditions
Dyslexia has a multifactorial aetiology (Chapter 1). There is strong
evidence that a major causal factor in dyslexia is a deficit of
phonological awareness, which is not amenable to optometric
treatment. Indeed, the main validated treatment for dyslexia is
specialist teaching (Chapter 1). Some dyslexic individuals have co-
occurring visual problems, as detailed in this book, and in these cases
eye care practitioners (ECPs) may help by managing the visual
problem(s). It is not within the core competence of an optometrist to
make a diagnosis of a specific learning difficulty such as dyslexia. The
ECP’s role in these cases is as one member of a multi-disciplinary
team and practice publicity needs to reflect this role.
ECPs often encounter patients whose parents attribute marked
improvements in reading to optometric interventions. These cases
are gratifying, but of course are anecdotal and should not lead ECPs
to make general claims based on these anecdotes. Table A1 provides
advice on publicity for ECPs to help them navigate a path through the
interdisciplinary landscape, respecting boundaries between the
various professionals who work in this field.
© The Editor(s) (if applicable) and 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
361
discussed throughout this book, the evidence-base regarding the
visual factors that affect reading is open to different interpretations.
The last point in Table A1 highlights this point. As is the case in other
healthcare professions, there are many interventions within
optometry for which the evidence base is not strong and for which
there is a diversity of opinions on effectiveness, as noted at the
beginning of Chapter 10. Coloured filters for visual stress are one of
these interventions. It is therefore recommended that ECPs and their
teams are candid in publicity and explanations to patients and
acknowledge any controversy. Sufficient information should be
provided to ensure that patients can make an informed decision as to
whether to proceed with any recommended intervention. This
information should be balanced and presented in a way that can be
easily understood. GOC Standard 16.6 requires that advertising avoid
misleading or confusing statements.
The advice in this appendix is not meant to be prescriptive. As
Appendices
362