Allied Health - Vision Therapy for the Treatment of Learning Disabilities

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

Description
It has been proposed that some learning disabilities are associated with deficits in eye movements and/or visual tracking. Most interest in the possible relationship between vision abnormalities and learning disabilities has focused on reading disorders. It is theorized that defects in binocular vision (i.e., the integration of both eyes to produce a single image), including problems of coordinated eye movement, can cause reading difficulties; however, the proposition that binocular vision pathology has a role in learning disabilities is controversial.

A variety of visual training programs have been proposed to address learning disabilities, such as attention deficit disorders, dyslexia, and reading disorders. Eye exercises, known as orthoptics, involve a wide range of techniques used to expand fusional vergence amplitudes and permit improved single binocular vision (2). Other proposed treatments include optometric vision therapy and the use of training glasses, prism glasses, or tinted or colored lenses.

Policy/Criteria
The following interventions are considered investigational in the treatment of learning disabilities and mild traumatic brain injury:

1. Orthoptics training
2. Vision therapy
3. Training glasses
4. Prism glasses
5. Tinted or colored lenses

Scientific Background
This policy is based on a 1996 BlueCross BlueShield Association Technology Evaluation Center (TEC) Assessment (3), which offered the following observations and conclusions:

• Three scientific issues must be addressed in the evaluation of orthoptic training or vision therapy: 1) whether available evidence supports the proposition that visual defects have a role in the development or maintenance of reading disorders; 2) whether or not training alters the identified visual defects; and 3) whether treating the visual defects results in improved reading comprehension. This latter was judged to be the most important issue for the TEC Assessment.
• The available evidence did not demonstrate that visual anomalies cause learning disabilities or were even more common among persons who had learning disabilities. If, as a few studies suggested, atypical eye movements are associated with learning disabilities, they may be secondary or compensatory to an information-processing deficit. This suggests the possibility that vision therapy could be detrimental by disrupting a compensatory mechanism.
• The available evidence did not support the conclusion that orthoptic training improves reading comprehension. (4-7) Specifically, the study population in the available published literature was not well defined; while the subjects were reported to be “poor readers,” it could not be determined whether they actually had a verifiable diagnosis of a reading disorder. In addition, objective outcomes of reading comprehension were lacking in the published studies. Finally, several studies reported no improvement in the treatment groups compared to the control groups.

In 1997, the American Academy of Optometry and the American Optometric Association jointly issued a policy statement on vision, learning and dyslexia; this statement was reaffirmed in 2008. (8) This policy states, “Optometric intervention for people with learning-related vision problems consists of lenses, prisms and vision therapy. Vision therapy does not directly treat learning disabilities or dyslexia. Vision therapy is a treatment to improve visual efficiency and visual process, thereby allowing the person to be more responsive to educational instruction. It does not preclude any other form of treatment and should be a part of a multidisciplinary approach to learning disabilities … Vision therapy, the art and science of developing and enhancing visual abilities and remediating vision dysfunctions, has a firm foundation in vision science, and both its application and efficacy have been established in the scientific literature. Some sources have erroneously associated optometric vision therapy with controversial and unfounded therapies, and equate eye defects with visual dysfunctions.” This document does not provide a detailed review of the literature and the most recent reference listed in the policy statement is from 1996.

In November 1998, the American Academy of Pediatrics (AAP), American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus issued a joint policy statement concerning pediatric learning disabilities, dyslexia, and vision. (9) The policy offered the following statement: “Eye defects, subtle or severe, do not cause the patient to experience reversal of letters, words, or numbers. No scientific evidence supports claims that the academic abilities of children with learning disabilities can be improved with treatments that are based on 1) visual training, including muscle exercises, ocular pursuit, tracking exercise, or “training” glasses (with or without bifocals or prisms); 2) neurological organizational training (laterality training, crawling, balance board, perceptual training); or 3) colored lenses. These more controversial methods of treatment may give parents and teachers a false sense of security that a child’s reading difficulties are being addressed, which may delay proper instruction or remediation. The expense of these methods is unwarranted, and they cannot be substituted for appropriate educational measures. Claims of improved reading and learning after visual training, neurologic organization training, or use of colored lenses are almost always based on poorly controlled studies that typically rely on anecdotal information. These methods are without scientific validation. Their reported benefits can be explained by the traditional educational remedial techniques with which they are usually combined.”

An updated search of the MEDLINE database did not identify any published literature that addresses the limitations noted in the AAP statement above. Two studies focused on the use of tinted lenses and eye patching as a technique to steady binocular vision as a therapy for dyslexia; these studies reported conflicting results. Stein and colleagues reported results of a randomized trial in which 143 dyslexic children were instructed to wear yellow tinted glasses with or without the left lens occluded. (10) The children were instructed to wear the glasses whenever they were reading or writing. Significantly more of the children who were given occlusion gained stable binocular vision in the first 3 months (59%) compared with children given the unoccluded glasses (36%). Christenson and colleagues, however, found no difference in reading ability in children with dyslexia and abnormal binocular vision who were tested both with and without occluded, blue-tinted lenses. (11)

In summary, the published scientific evidence does not support the contention that vision therapy, orthoptics training, or the use of training glasses, prism glasses, or tinted or colored lenses improves reading comprehension for people with learning disabilities or mild traumatic brain injury.

References

1. BlueCross and BlueShield Association Medical Policy Reference Manual, Policy No. 9.03.03
2. Yanoff M, Duker J et al, eds. Ophthalmology, Second Edition. St. Louis: Mosby, 2004
3. 1996 TEC Assessment: Orthoptic Training for the Treatment of Learning Disabilities
4. Cooper J, Selenow A, Ciuffreda KJ et al. Reduction of asthenopia in patients with convergency insufficiency after fusional vergence training. Am J Optom Physiol Opt 1983;60(12):982-9
5. Heath EJ, Cook P, O’Dell N. Eye exercises and reading efficiency. Acad Ther 1976;11:435-55
6. Rounds BB, Manley CW, Norris RH. The effect of oculomotor training on reading efficiency. J Am Optom Assoc 1991;62(2):92-7
7. Weisz CL. Clinical therapy for accommodative responses: transfer effects upon performance. J Am Optom Assoc 1979;50(2):209-16
8. Vision, learning and dyslexia. A joint organizational policy statement of the American Academy of Optometry and the American Optometric Association. www.children-special-needs.org/parenting/dyslexia_dyslexic_pf.html (Verified 09/23/08)
9. American Academy of Pediatrics. Learning disabilities, dyslexia and vision: a subject review (RE9825). Pediatrics 1998;102(5):1217-9. Also available on the Web at:  http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/5/1217 (Verified 09/23/08)
10. Stein JF, Richardson AJ, Fowler MS. Monocular occlusion can improve binocular control and reading in dyslexics. Brain 2000;123:164-170
11. Christenson GN, Griffin JR, Taylor M. Failure of blue-tinted lenses to change reading scores of dyslexic individuals. Optometry 2001;72(10):627-33

Cross References

Regence ConsumerTx: Vision Therapy for the Treatment of Learning Disabilities

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