Impact of Vision Therapy on Eye-hand Coordination Skills in Students with Visual Impairment

Abstract

Purpose
To evaluate the enhancing effects of vision therapy on eye–hand coordination skills in students with visual impairments.

Methods
Thirty-five visually impaired patients who underwent vision therapy comprised the treatment group, and 35 patients with impaired vision who received no treatment comprised the control group. Full ophthalmic examinations were performed, including biomicroscopy, retinoscopy, and assessments of subjective refraction and visual acuity. Eye–hand coordination was evaluated using the Frostig test. Vision therapy in the treatment group was performed using the Bernell–Marsden ball, perceptual-motor pen, random blink test, and random shape assessment.

Results
Data were analyzed for the 35 visually impaired patients and 35 control participants. The mean age was 11.51 ± 3.5 and 11.09 ± 3.1 years in the treatment and control groups, respectively. Female participants comprised 80% of the treatment group and 57% of the control group. Before treatment, the mean scores on the Frostig test were 22.74 ± 4.32 and 21.60 ± 4.10 in the treatment and control groups, respectively, and after treatment, the mean Frostig test scores were 24.69 ± 3.99 and 21.89 ± 3.92, respectively. Statistically significant intergroup differences were found in eye–hand coordination (P < 0.05). No significant intergroup differences were noted in the distance and near visual acuity values.

Conclusion
The results demonstrated that vision therapy could significantly improve eye–hand coordination, but no enhancement was found in near or distance visual acuity.

Full text

© 2018 Journal of ophthalmic and Vision research | published by Wolters KluWer - medKnoW 301
Impact of Vision Therapy on Eye‑hand Coordination
Skills in Students with Visual Impairment
Javad Heravian Shandiz1,2, PhD; Abbas Riazi3, PhD; Abbas Azimi Khorasani1,2, PhD; Negareh Yazdani1,2, MS
Maryam Torab Mostaedi2, BS; Behrooz Zohourian2, MS
1Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
3Department of Ophthalmology, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
Abstract
Purpose: To evaluate the enhancing effects of vision therapy on eye–hand coordination skills in students
with visual impairments.
Methods: Thirty‑ve visually impaired patients who underwent vision therapy comprised the treatment
group, and 35 patients with impaired vision who received no treatment comprised the control group.
Full ophthalmic examinations were performed, including biomicroscopy, retinoscopy, and assessments
of subjective refraction and visual acuity. Eye–hand coordination was evaluated using the Frostig test.
Vision therapy in the treatment group was performed using the Bernell–Marsden ball, perceptual‑motor
pen, random blink test, and random shape assessment.
Results: Data were analyzed for the 35 visually impaired patients and 35 control participants. The mean age
was 11.51 ± 3.5 and 11.09 ± 3.1 years in the treatment and control groups, respectively. Female participants
comprised 80% of the treatment group and 57% of the control group. Before treatment, the mean scores on
the Frostig test were 22.74 ± 4.32 and 21.60 ± 4.10 in the treatment and control groups, respectively, and
after treatment, the mean Frostig test scores were 24.69 ± 3.99 and 21.89 ± 3.92, respectively. Statistically
signicant intergroup differences were found in eye–hand coordination (P < 0.05). No signicant intergroup
differences were noted in the distance and near visual acuity values.
Conclusion: The results demonstrated that vision therapy could significantly improve eye–hand
coordination, but no enhancement was found in near or distance visual acuity.
Keywords: Eye–hand Coordination; Eye Movement; Low Vision; Visual Impairment; Vision Therapy
Original Article
Correspondence to:
Behrooz Zohourian, MS. Department of Optometry,
School of Paramedical Sciences, Mashhad University of
Medical Sciences, Mashhad 91779, Iran.
E‑mail: bzohourian@gmail.com
Received: 21‑05‑2017 Accepted: 13‑11‑2017
INTRODUCTION
Vision plays a leading role in different aspects of
education, employment, adaptation, and communication,
and is the mode by which 80%–90% of all information
from the environment is perceived.[1] Therefore, any
visual impairment can dramatically affect the quality
J Ophthalmic Vis Res 2018; 13 (3): 301‑306
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How to cite this article: Shandiz JH, Riazi A, Khorasani AA, Yazdani N,
Torab Mostaedi M, Zohourian B. Impact of vision therapy on eye-hand
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Res 2018;13:301-6.
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Vision Therapy and Eye- hand Coordination in Visually Impaired Students; Shandiz et al
302 Journal of ophthalmic and Vision research Volume 13, Issue 3, July-september 2018
of life and increase the risk of injury.[2‑9] The challenges
associated with severe visual impairment in children
are different from those encountered in adult blindness.
Since all failures in normal visual development cannot
be corrected in adulthood, it is essential to treat any
ocular and visual disorders during childhood.[10] The
World Health Organization (WHO) has categorized
visual impairments with respect to the best‑corrected
visual acuity as follows: blindness (Snellen visual
acuity of 3/30), severe visual impairment (Snellen
visual acuity between 6/60 and 3/30), moderate
visual impairment (Snellen visual acuity between
6/18 and 6/60), and mild or no visual impairment
(Snellen visual acuity of 6/18). In this classication,
low vision constitutes both moderate and severe visual
impairments.[11] The prevalence of visual impairment was
estimated to be 3% in an adult population[12] and 4.4%
in school children.[13] Based on the WHO classication,
visual impairment in children is categorized according
to the anatomical region affected by the impairment,
the etiology of the disease, and whether the causes
are avoidable or unavoidable. As estimated by WHO,
approximately half of the causes of visual deciency
in children are preventable or treatable.[14] According
to this organization, the principal causes of visual
impairment include refractive errors, cataract, and
glaucoma, in which refractive errors are recognized
as the main contributing factors for visual impairment
internationally. Eye–hand coordination, which is dened
as the use of vision to guide hand movements such as
reaching and grasping, is essential for upper extremity
dexterity.[15] It requires the integrated use of eyes, arms,
hands, and ngers to produce controlled, accurate, and
rapid movements.[15] Normal eye–hand coordination
occurs in an ordered sequence as follows: 1) visual
detection of the target, 2) focused attention, 3) perceptual
identication of the target location, 4) cognitive planning
and programming of the reaching movement, and 5)
activation of arm muscles to initiate the action.[16] In fact,
eye movements are associated with hand movements,
even though the eyes begin and complete their
movements more rapidly than the hands.[17] Coordination
disorder is defined as any problem or limitation in
motor coordination, resulting in a lower than expected
performance, depending on the patient’s chronological
age.[18] Improvement of eye–hand coordination as a
perceptual‑motor skill depends on the visual system as
well as efcient eye muscle control.[19] Vision therapy
is recognized as an individualized intervention to
improve the binocular system, ocular motor control,
visual processing, visual motor skills, and perceptual or
cognitive deciencies.[18] According to several studies,
vision therapy could improve binocular skills, ocular
motor control, visual attention, visual perception, and
visual processing skills.[20‑24] Since the first essential
stage of normal eye–hand coordination is the visual
detection of the target, reduced visual acuity could affect
stereo‑acuity and eye–hand coordination. Therefore,
improvements in both eye–hand coordination and visual
acuity can remarkably improve the quality of life in
individuals with low vision. However, to the best of the
authors’ knowledge, very few publications are available
in the literature that discuss the efcacy of vision therapy
in eye–hand coordination, so the present study aimed to
assess the efciency of a vision therapy protocol using the
Marsden ball technique, perceptual‑motor pen, random
blink test, and random shape assessment in improving
eye–hand coordination in patients with low vision.
METHODS
Study Population
The study population included 35 visually impaired
individuals who underwent vision therapy and 35
age‑ and sex‑matched visually impaired individuals
who received no treatment. The participants were
recruited from a low vision school of rehabilitation
according to the following inclusion criteria: 1) students
with low vision at schools for the blind and visually
impaired; 2) willingness to participate in the study; 3)
healthy sensorimotor system; 4) corrected monocular
distance visual acuity less than or equal to 20/70; and
5) ability to perform the Frostig Developmental Test
of Visual Perception. The WHO criteria were used to
dene low vision in the participants. Each participant
underwent comprehensive ophthalmologic and
eye–hand coordination examinations. Follow‑up tests
were conducted for each patient in an identical order.
Clinical Examinations
Objective refraction was determined using a Heine
Beta 200 Retinoscope (Heine Optotechnik, Herrsching,
Germany) as an effective method for prescribing
corrective lenses in cases where subjective refraction
assessment was not possible. The fogging method was
also applied if there was any sign of accommodative
spasm or pseudo‑myopia. Radical retinoscopy, a
useful technique to distinguish the dim astigmatism
reex easily, was also performed by moving closer
to the patient and neutralizing the reflex. Radical
retinoscopy is widely used in cases of opacity, miosis,
or pupil invisibility.[25] In the next step, monocular and
binocular subjective refractions were assessed. Visual
acuity was assessed using a LogMAR (minimum
angle of resolution) chart (Bailey‑Lovie chart) both
at far and near distances. The subjects were asked to
wear their best visual aid throughout the test. The
biomicroscopic examination was also performed using
a Topcon slit lamp (Topcon Corporation, Tokyo, Japan;
Neitz Instruments Company, LTD, Tokyo, Japan).
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Vision Therapy and Eye- hand Coordination in Visually Impaired Students; Shandiz et al
Journal of ophthalmic and Vision research Volume 13, Issue 3, July-september 2018 303
In this stage, both anterior and posterior segments
were evaluated for any existing abnormalities.
Evaluation of eye–hand coordination was performed
after complete ophthalmic examinations using the
eye–hand coordination subtest of the Frostig test
(Welty Leteuer and John R.B. Whittleseey, United
State of America) [Figure 1]. This subtest consisted of
16 sequential sections, each containing an image with
straight, curved, or angled lines drawn between two
points at various distances without any guiding lines.
The Frostig booklet and two pens were used to initiate
the test. Pens with wide tips were preferred, as these
were easy to distinguish for students with low vision.
The subjects were asked not to pick up the pen from
the page until the test was completed. Picking up the
pen from the page or even departing from the straight
line showed a weakness in eye–hand coordination skill,
which necessitated proper treatment. The test had a
maximum score of 30 marks. For each patient, scoring
was done as follows: two points were recorded if the
patient could match the two distance objects correctly
and also if there was no interruption, deviation, or
angulation in the line. One point was recorded if the
pencil crossed the line more than once or if the drawn
line exited from the two objects (less than 0.5 inches).
Zero points were recorded if the drawn line crossed the
guidelines, or there was any interruption, deviation,
or angulation in the line and if the line exited from the
objects by more than 0.5 inches. After careful evaluation
of ophthalmic status and eye–hand coordination, vision
therapy was performed for each subject in the treatment
group. The vision therapy protocol included the
Bernell–Marsden ball technique (Bernell, A Division of
Vision Training Products Incorporation, United State of
America) [Figure 2], use of a perceptual‑motor pen (Wayne
Engineering, United State of America) [Figure 3], random
blink test (Farakavosh Communication Technology,
Islamic Republic of Iran) [Figure 4], and random shape
assessment (Farakavosh Communication Technology,
Islamic Republic of Iran) [Figure 5].
Marsden Ball Technique
In this technique, the ball was hung from the ceiling,
and each participant was asked to bunt the ball with
a dowel. A similar and distinctive pattern needed to
be followed for every 20 hits. The test was performed
both monocularly and binocularly. The entire test took
6 minutes for each participant.
The Perceptual‑motor Pen
In this task, each subject was asked to move a specic
pen on the lines of the page. No sound was produced if
the pen was moved correctly, while errors in tracing the
lines resulted in an auditory feedback. This biofeedback
encouraged the subjects to increase their accuracy and
improve their eye–hand coordination. The test took
6 minutes for each subject.
Figure 1. The Frostig test, which consists of an image with
straight, curved, or angled lines drawn between two points
at various distances without any guiding lines. The Frostig
booklet and two pens were used to initiate the test. The subjects
were asked not to pick up the pen from the page until the test
was completed.
Figure 2. Bernell–Marsden Ball. The ball was hung from the
ceiling, and each participant was asked to bunt the ball with
a dowel.
Figure 3. Perceptual‑motor pen. Each subject was asked to
move a specic pen on the lines of the page. No sound was
produced if the pen was moved correctly, while errors in
tracing the lines resulted in auditory feedback.
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Vision Therapy and Eye- hand Coordination in Visually Impaired Students; Shandiz et al
304 Journal of ophthalmic and Vision research Volume 13, Issue 3, July-september 2018
Random Blink Test
In this test, a circle was presented on a computer
screen in a random order. The color, size, and time of
presentation were adjustable and could be changed. The
subjects were asked to mark the circle on the screen. It
was preferable to choose a size that was initially difcult
for the subject to distinguish. The test took 6 minutes for
each subject to complete.
Random Shape Assessment
In this test, the subjects were asked to nd and draw
pictures that were presented on the computer screen.
The size, line thickness, and contrast of the pictures were
adjustable. Both size and contrast were selected on the
basis of the participant’s detection threshold. The duration
of the monocular test, binocular task, and the entire test
was 3 min, 6 min, and 12 min, respectively. Vision therapy
was performed for 30 min three times a week. Follow‑up
examinations were performed for three months for
each participant. Vision therapy was implemented in
a simple‑to‑hard order. After completing 36 sessions of
vision therapy, all subjects were re‑examined using both
ophthalmic and eye–hand coordination tests.
Statistical Analysis
All data are expressed as mean ± SD values. Statistical
analyses were performed with SPSS version 11.5
(SPSS Institute, Chicago, IL, USA). The Student t‑test was
used to assess the statistical signicance of continuous
variables. A P value of <0.05 was used as the criterion
for statistical signicance.
Ethics
All participants were informed about the objectives of
the investigation, and informed consent forms were
obtained before inclusion in the study population. The
study protocol was approved by the Ethics Committee of
Mashhad University of Medical Sciences and the protocol
adhered to the tenets of the Declaration of Helsinki.
RESULTS
The study was conducted on 35 patients in the control
group (mean age = 11.09 ± 3.1 years) and 35 participants
in the treatment group (mean age = 11.51 ± 3.5 years)
from 50 visually impaired individuals who were initially
invited. Fifteen individuals were excluded because
of missed follow‑up examinations. Table 1 shows the
demographic data of the participants. The mean spherical
equivalent of the treatment and control groups was
2.06 ± 7.61 D and 2.50 ± 7.36 D, respectively. Before
treatment, the mean distance and near best‑corrected
visual acuities were respectively 1.11 ± 0.27 LogMAR
and 0.78 ± 0.27 LogMAR in the treatment group and
1.07 ± 0.26 LogMAR and 0.81 ± 0.25 LogMAR in the
control group. The results showed no statistically
significant intergroup differences in improvements
in both distance (P = 0.27) and near (P = 0.30) visual
acuities following vision therapy. Frostig test scores
showed a statistically significant improvement in
eye–hand coordination in the treatment group. The
mean Frostig test score was 22.74 ± 4.32 and 21.60 ± 4.10
before treatment in the treatment and control groups,
respectively. After treatment, the mean Frostig test scores
improved to 24.69 ± 3.99 and 21.89 ± 3.92 in the treatment
and control groups, respectively. The test results showed
Figure 4. Random blink test. A circle was presented on a
computer screen in a random order. The color, size, and time
of presentation were adjustable and could be changed. The
subjects were asked to mark the circle on the screen.
Figure 5. Random shape assessment. The subjects were asked
to nd and draw pictures that were presented on the computer
screen.
Table 1. Demographic characteristics of the participants
Age (years) Male Female Total
Treatment 11.51±3.5 7 28 35
Control 11.09±3.1 15 20 35
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Vision Therapy and Eye- hand Coordination in Visually Impaired Students; Shandiz et al
Journal of ophthalmic and Vision research Volume 13, Issue 3, July-september 2018 305
that vision therapy could signicantly enhance eye–hand
coordination skills (P < 0.05). The overall measurement
results are summarized in Table 2.
DISCUSSION
The main purpose of the paper was to evaluate the
effect of vision therapy on eye–hand coordination in
patients with low vision. We have also assessed the
consequences of vision therapy on vision and visual
acuity. Based on the ndings, a statistically signicant
difference was noted in eye–hand coordination between
the treatment and control groups (P < 0.05). Following
vision therapy, the mean eye–hand coordination score
improved by 1.94 ± 2.01 in patients with low vision.
Consistent with our ndings, Aki et al also found a
signicant difference in motor skills before and after
vision training in children with low vision.[26] Abrams
stated that eye–hand coordination is essential for daily
activities such as eating, working, and competing.[27]
Moreover, the results of a study by Jeon showed that
training and activity played an important role in the
development of independence in patients with low
vision.[28] Considering the higher vulnerability and
sensitivity of visually impaired children, this population
requires more attention and needs to be trained on
the use of residual vision. Therefore, vision therapy
could be a useful method for improving the quality
of life in these individuals. This experiment revealed
that vision therapy did not improve distance and near
visual acuity. Regan[29] showed that vision guides
hand movements, while Ren[30] believed that the hands
guide saccadic eye movements via stereoscopic vision.
In this regard, Suttle employed a three‑dimensional
motion capture system to evaluate the reach‑to‑grasp
performance of the preferred hand under binocular and
monocular conditions in two groups of amblyopic (aged
4‑8 years) and normal (aged 5‑11 years) children.
They reported that binocularity training in amblyopic
children could improve eye–hand coordination.[31]
Moreover, visual perceptual learning could improve
visual acuity by increasing visual sensitivity. Kasten
evaluated the efcacy of vision restoration therapy in
subjects with homonymous visual eld defects (mean
age: 40.8 ± 3.3 years) by using high‑resolution and
conventional perimetry to plot the visual field.
A two‑dimensional eye tracker (Chronos Vision GmbH,
Berlin, Germany) was used to record the eye movements.
The device could measure horizontal and vertical eye
movements at a sampling rate of 200/s (2 ms latency).
The results suggested that continuous peripheral visual
stimulation could diminish scotoma.[32] Moreover, Maples
showed that eye–hand coordination plays an important
role in students’ achievements, and vision therapy could
improve eye–hand coordination.[33] These ndings were
in congruence with the present results, indicating the
effectiveness of vision therapy in improving eye–hand
coordination in school children with low vision.
In conclusion, the outcomes of this study showed
that vision therapy is effective in improving eye–hand
coordination in visually impaired individuals. However,
the results showed no improvement for both distance
and near visual acuities with treatment. Although
the research fullled its objectives, there were some
unavoidable limitations. First, because of the small
number of intended participants, patient identication
was done using a non‑random sampling method. Second,
the examiner was not blinded to the applied treatment
methods.
Acknowledgment
We thank the research vice chancellor of Mashhad
University of Medical Sciences for supporting this
study. The results described in this paper were of an MS
optometry thesis.
Financial Support and Sponsorship
Nil.
Conicts of Interest
There are no conicts of interest.
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VA, visual acuity
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