Photo by Kari Mauser The Bulletin Special Projects

One-hundred-and-fifty years ago, Dutch ophthalmologist Hermann Snellen developed a chart to test visual acuity, or clearness, in kids and adults.

The chart of seemingly random letters gradually getting smaller still sits in doctors’ offices and is the go-to procedure testing for “standard” 20/20 vision.

But the Snellen ratio only tests distance, and ophthalmologists and other champions of vision worldwide are beginning to educate the public on the many other types of vision problems.

“Vision is the main way we, as humans, take in information,” said Dr. Gabby Marshall, optometrist and clinical director of the pediatric vision clinic Elemental Eyecare in Bend.

While 85 percent of a child’s learning comes from their vision, last year the Children’s Vision Foundation found that close to 25 percent of students in Bend-LaPine Schools had vision problems. With this strong link between vision and learning, as well as education and juvenile delinquency, its easy to see why proponents are pushing for early testing.

To that end, Gov. John Kitzhaber proclaimed August 2014 as Children’s Vision and Learning Month. The proclamation, along with a new law and the work of nonprofits such as CVF, is working to educate the public on the community benefits of comprehensive vision screenings.

While the 20/20 vision test serves as a way for pediatricians and general practitioners to check for obvious eye problems, such as tumors and cataracts, a comprehensive exam extends the testing to include how well the eyes work together.

A comprehensive eye exam, such as the one offered at Elemental Eyecare, includes the testing of depth perception, color vision, distance acuity, near acuity, near-to-far focus, near alignment, pupil check, eye movement, pursuit eye movement, convergence, Saccadic eye movement, refractive status, visual stress and peripheral vision. (Learn more about these tests in the “Eye Care Glossary,” Page 7.)

While yearly comprehensive eye exams are preferred for all children, there are symptoms for parents to watch out for. Warning signs may include poor coordination, fear of heights, not riding a bike, poor school performance, and non-age appropriate meltdowns caused by a child’s frustration.

The Importance of Eye Exams

Five-year-old Tessa Pedersen was 3½ when her parents began noticing she was walking on her toes. Although Tessa had an eye exam when she was 6 months old, her mother decided to have her checked again.

“I knew that walking on her toes could be a sign of poor depth perception,” explained Erin Pedersen, Tessa’s mom and lead vision therapist at Elemental Eyecare.

Usually, parents won’t be able to suspect poor vision until their child begins to read, but because Erin had studied eye care and works for an optometrist, she knew other important signs to watch for.

As it turned out, Tessa has anisometropia, or a difference in the clarity of her two eyes. Because they caught it early, it won’t be a problem for Tessa in the future. However, it can turn into lazy eye, or dominance in one eye, or the brain could just shut the bad eye down completely.

After confirming with a second exam, Pedersen and her husband, who both wear contacts, started Tessa on visual therapy, which trains the eyes to be more efficient and accurate, and had her begin wearing therapeutic eyeglasses.

“Because I knew about it, it wasn’t heartbreaking,” said Pedersen.

The eyeglasses equalize the vision and reduce the competition between the eyes. The prescription changes every three months, as she grows and her eyes begin to correct themselves. Tessa also undergoes red lens therapy, or the use of colored lenses to train the brain to use both eyes equally.

While the glasses bothered Tessa in the beginning, she has grown accustomed to them. It also helps that some of Tessa’s preschool classmates wear glasses, and her parents were sensitive to the change.

“My husband and I wore our glasses for the first week, and we prepared our friends and family for the new glasses,” explained Pedersen. “They were ready to tell her how cute she looks in them.”

As is recommended, Tessa gets re-tested every year.

Vision Care for Kids

When Marshall was 17, her ophthalmologist serendipitously recommended ophthalmology as a career. She trained at Pacific University in Forest Grove before beginning her career working with all aspects of eye care. After nine years, she decided to specialize in children.

“I found I was most passionate about working with kids,” explained Marshall.

Besides the comprehensive exams they offer, Elemental Eyecare also offers a complete line of vision therapy. The therapy, with a focus on full sensory-motor integration, involves one-hour weekly office sessions along with assigned home therapy. A typical program lasts five to eight months as they address the symptoms and deficiencies noted in the examination and developmental evaluation.

Alongside Kitzhaber’s proclamation, programs and laws to assist with early detection and eye treatments have begun to emerge. InfantSee, an American Optometric Association public health program, connects children ages 6 to 12 months with participating optometrists, including Marshall, for free vision exams. They check kids, such as Tessa, for visual acuity, refractive status, ocular motility, alignment, binocular potential and overall eye health.

In addition, the Children’s Vision Foundation gives comprehensive eye exams to all second- and fourth-graders in Bend-La Pine Schools, as well as in other communities.

The Affordable Care Act included children’s vision in their 10 essential health benefits. Because pediatric eye exams are included, insurance has to cover it. For additional costs beyond the exams, there are many foundations, including the Bend-based CVF, that counsel families on the many programs available to help cover the fees.

Taking effect this year is the Oregon Legislature’s HB 3000. Lobbied for its inception by the Oregon Optometric Physicians Association and supporters such as Julie Bibler, executive director of CVF, the bill recognizes the connection between a child’s vision and success in school. It requires all children have a vision screening or comprehensive eye exam before entering public school.

“In a perfect world, children are getting comprehensive eye exams and screenings on a regular basis because vision can change very quickly,” said Marshall.

Marshall recommends annual vision checkups while stressing the importance of prevention. She said it is also vital to remember reading and computer work are akin to holding a muscle. As a rule of thumb, for every 20 minutes of near-vision work, it’s important to look away for 20 seconds.

“The challenge with young kids is they may not tell you about vision problems because they may not know what normal should be,” reiterated Dr. Robert Mathews of Bend Memorial Clinic’s ophthalmology department. “For adults, the problem is if it’s gradual, they may get used to it.”

Vision Care for Adults

Elemental Eyecare, which opened in 2008, now offers eye exams to adults as well as children.

But adults face different challenges with vision as they age. Usually beginning in the mid-40s, they may be less able to move the focal point from far to near. Near vision becomes worse as the lens becomes less flexible. The only remedy is compensation through eyeglasses.

Symptoms for worsening eyesight in adults include redness, pain and loss of vision. Ophthalmologists recommend adults over the age of 45 get comprehensive exams every two years, providing there is no history or symptoms of problems.

Eye problems are usually placed into one of two categories. The first, with no eye problems, refer to near-sighted, far-sighted or astigmatism. The second, which requires medical attention, include cataracts, glaucoma, diabetic eye disease and macular degeneration. Most vision characteristics are hereditary.

Many of the problems that arise are treatable through therapy or surgery. Cataract surgery uses high frequency sound waves to remove or replace the cataract lens. Lasik, also called PRK, changes the curvature of the cornea to improve near-sightedness, far-sightedness and astigmatism. Amazingly, both procedures are outpatient and only take 15 minutes.

The improved technology, alongside increased vision coverage in insurance and programs aimed at catching eye problems before they get worse, are reason enough to have annual eye exams. Yearly comprehensive exams as a child, and biyearly exams as an adult allow doctors to correct any potential problems that may arise.

From an early age, when eyes are beginning to develop, to adulthood, when the eye muscles begin to weaken, taking care of vision will ensure visibility in the long run.

“Vision is so very important,” Pedersen said. “It’s about helping people and children be a part of the world instead of watching it go by.”