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Learning Is Visual: Why Teachers Need to Know about Vision



This chapter adopts an integrative literature review to describe and analyze theories and empirical research on visual development, impairment, screening, and intervention. The purpose is to inform teachers on how to influence students’ education and social growth through understanding vision. Vision is especially essential for reading, accessing classroom materials, and learning. Yet, in many countries, vision problems in children are not assessed and thus not treated. The negative consequences for individuals and society are often significant. Though there is an abundance of eye health specialists in developed countries, not all visual problems that influence learning and reading are screened or treated effectively. This is worse in developing countries where eye health infrastructure often is lacking. Even screening and treatment given through the eye healthcare system is not always sustainable, since regular follow-up is lacking. The literature review shows that vision is a developing sense important for learning and that teachers can screen children’s vision and support visual development. It can be concluded that every child in the twenty-first century school should have teachers with knowledge in vision. An example of a higher education initiative is presented to illustrate possible further education for teachers in the area of vision.
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Learning Is Visual: Why Teachers
Need to Know about Vision
Gunvor BirkelandWilhelmsen and MarionFelder
This chapter adopts an integrative literature review to describe and analyze
theories and empirical research on visual development, impairment, screening,
and intervention. The purpose is to inform teachers on how to influence students
education and social growth through understanding vision. Vision is especially
essential for reading, accessing classroom materials, and learning. Yet, in many
countries, vision problems in children are not assessed and thus not treated. The
negative consequences for individuals and society are often significant. Though
there is an abundance of eye health specialists in developed countries, not all visual
problems that influence learning and reading are screened or treated effectively.
This is worse in developing countries where eye health infrastructure often is lack-
ing. Even screening and treatment given through the eye healthcare system is not
always sustainable, since regular follow-up is lacking. The literature review shows
that vision is a developing sense important for learning and that teachers can screen
childrens vision and support visual development. It can be concluded that every
child in the twenty-first century school should have teachers with knowledge in
vision. An example of a higher education initiative is presented to illustrate possible
further education for teachers in the area of vision.
Keywords: visual development, stimulation, learning through vision, vision
screening, teacher education
1. Introduction
The world is changing rapidly, and the necessity for good functional vision is
greater than ever. Education is essential for the individuals’ overall life quality and
for personal, social, and occupational development. Societies depend on it for eco-
nomic growth and democracy. Recent research revealed how important good vision
is in all learning- and for all academic-related tasks. In classrooms around the world,
visual inputs are involved up to 70% of the time [1], so even tiny disturbances can
result in a lack of important information.
Unfortunately, not much has changed since Rogers, in 1924, claimed that the
importance of vision in reading and writing is often overlooked [2, 3]. Even today
few teachers have any special knowledge about the visual functions and vision
disturbances [4] or how they affect learning, the development of motor skills and
cognitive capacities. Reading is a particularly significant vision task depending on
good visual acuity (VA) for detecting all the tiny details in a text. In addition, it
Education at the Intersection of Globalization and Technology
relies upon an intact functional visual attention span in the visual field (VF) for
getting an overview of the next letters, the words to come, the end of line, and from
where to continue reading the next text line. Vision is not a passive sensory system
that is only receiving inputs; it is also an active and complex motor system that is
continuously moving. The eyes must coordinate to fixate on the same spot, move
around to different areas for searching, while the lenses adjust to the ever-changing
locations. The goal is to give the brain clear inputs, no matter the distance. During
reading, the gaze must jump precisely and should be coordinated from one fixa-
tion point to the next and adjust to the light level of the actual surrounding. This
complexity indicates why vision must be considered in teaching [5–7]. There is no
doubt that literacy is the foundation of almost all education and probably the most
important skill to have in the twenty-first century, and this skill starts as a visual
process. Thus, when children have problems with their vision, they may not be able
to succeed in school [8].
Visual impairment is classified extensively by the International Classification
of Diseases, ICD-11 [9]. Although the criteria are health classifications, many
countries use them very strictly as eligibility criteria for educational services by
the teacher for the visually impaired or blind. In most cases, only a significantly
reduced VA and/or a VF loss after correction of refractive error will lead to
services [10]. What is often not understood is that vision plays such an enormous
role in learning, that even milder problems, which are frequent among children
and youth must be considered in school. These problems will be the focus of this
chapter. Several vision disturbances, not just decreased VA and VF, have a nega-
tive influence on the academic work, sports and leisure activities, and general
learning. Such “milder” visual problems are often not addressed even in countries
with a highly developed eye health-care system, although many children exhibit
them [11]. If these problems are not identified, the children are left without
treatment and sometimes even the wrong explanations are given for their learn-
ing problems. This may result in frustration, low school results, and a reduced
self-esteem. Thus, regular vision screenings may be necessary in finding out
whether children have the visual capacity to learn. Screenings are done by eye
health professionals, but school-based vision screenings by trained teachers have
shown to be effective [1214].
In this chapter, we will describe and analyze the relationship between vision
and learning, the implication of visual problems on reading, and how teachers can
screen their students’ vision more comprehensively and make interventions as
necessary. It begins with (1) an introduction and the description of the methodol-
ogy we adopted. This is followed up with (2) our inquiry about the relationship
between vision and learning, (3) the impact of visual disturbances on reading,
and (4) screening and intervention of visual functions through teachers. The
chapter concludes with the description of a Continuing Professional Development
(CPD) course based on the theoretical framework and results of this litera-
ture review.
2. The integrative literature review methodology
The theoretical framework of the literature review is based on teachers’ under-
standing, identification, and intervention of childrens vision and vision screening.
Literature sources from various disciplines such as neuroophthalmology, oph-
thalmology, optometry, education, visual impairment, vision sciences, and vision
rehabilitation were used. A thorough integrative literature review approach [15] was
conducted to explore the relationship between vision and learning, the impact of
Learning Is Visual: Why Teachers Need to Know about Vision
impaired visual functions on learning, and the reasoning for visual screening and
interventions conducted by teachers. In general, a literature review is well suited to
review the theories and evidence that exist in a very specific area, such as the role of
vision in learning. In addition, a literature review is helpful to provide an overview
of the topic. This also seems important since there appears to be a knowledge gap
about the relevance of intact visual functions in learning. A literature basis can also
be a foundation for the development of a model for new theories and practices. It
will be investigated in this chapter whether a new model of teachers’ screening and
intervention can be derived from the literature review. However, in order to be more
specific, it was necessary to narrow down the very broad method of a “literature
review.” An integrative literature is described as.
Most integrative literature reviews are intended to address mature topics or new,
emerging topics. In the case of mature topics, the purpose of using an integrative
review method is to overview the knowledge base, to critically review and poten-
tially re-conceptualize, and to expand on the theoretical foundation of the specific
topic as it develops ([], p. ).
The new emerging topic that we would like to address is the greater emphasis
that schools and teachers may possibly have in the area of prevention, screening,
and intervention of vision problems. We altogether viewed 65 sources, from the
years 1901–2020 using various databases and search engines, using keywords such
as vision, visual development, visual stimulation, vision screening, and vision
screening in schools. The sources were analyzed by the themes established in the
introduction, namely, the relationship between vision and learning, the impact of
vision problems on learning, and screening and intervention.
3. Inquiry into the relationship between vision and learning
Teachers and other caretakers of children may largely impact on the develop-
ment and remediation of visual capacity. An analysis of the process of visual
functioning, description on the relationship between visual development, and
stimulation and how structured teaching improves some visual problems are of
importance for conducting visual screening and for the possibilities of teachers to
intervene when children do exhibit visual problems.
3.1 Complexity of visual functioning
Increased knowledge in neurology, anatomy, and psychology has provided new
insight into the complexity of the visual sense (e.g., [1621]). It is evident that visual
functions such as a clear VA at near and far for seeing details and object together
with the ability of noticing people, objects, and movements in the VF are essential
for being able to function in our surroundings. A single image on different distances
is reached with a functional vergence-convergence where the eyes stay parallel when
looking at a point far away and turns more and more inward, converge, when fixat-
ing an object that comes closer. At the same time, the eye lenses must change their
form, accommodate, for bending the light waves to fall on the central part of the
retina. Only then the image is seen clearly respective to the distance. This accommo-
dation function can be compared with a lens in a camera which also has to change its
form due to the distance for the focused object. Convergence and accommodation
are closely connected and must function coordinated and easily when the eyes are
tracking and scanning on different items and objects of interest at far or near. These
Education at the Intersection of Globalization and Technology
functions are developing throughout childhood in response to stimulation and
activation. This development is going on until children are in their teens [22].
Researchers have shown how cognition can influence vision by selectively
directing the gaze to special elements of interest [23], but first of all, vision provides
us with information about the world around us. Intact visual inputs are, among
other things, a prerequisite for motor activities, higher level visual abilities, and the
cognitive development. Clear visual inputs are necessary for fundamental visual
perceptual skills, that is, identification of objects and people and for concepts of
same—different, comparing, sorting, matching, catching, reading, and writing.
3.2 Visual development and stimulation
In order to support the development of vision, children need an environment
and activities which stimulate their senses, including their visual sense, from an
early age on. Visual capacity is often taken for granted, although as we pointed out,
it develops through childhood and also during the years in primary school. Children
should be engaged in visual activities together with their caretakers and teachers
from a very early age on. Words should accompany objects and pictures. When
pointing to pictures shifting from close or far, the child is training accommodation
and convergence, steady fixation, and saccades (the gaze jump from one position
to the next) together with eye-hand coordination. This can be strengthened by
entering a dialog of sounds and words, pointing to interesting features of pictures,
comparing and naming objects of different sizes and perspectives, and imitating
sounds of animals or cars. Making reading with children as part of a routine is a
reciprocal and bonding experience between children and their caretakers [24]. Such
activities can be the inspiration for children to draw or do other eye-hand activities.
Children should be encouraged to “look” at elements in their environment and
become aware of their surroundings, of the natural and man-made environments,
of differences between things they encounter such as flowers, plants, animals,
colors, objects, shapes, etc. Teachers should have conversations with children
about what they see and stimulate their visual perception, visual discrimination,
and visual memory in different ways through games and structured exercises with
a variety of age-appropriate materials. Especially, preschool teachers can include
a number of activities that are stimulating and supportive of the visual system
based on the abilities of the child. Puzzles, memory games, and building with
blocks with and without models can give a good foundation for visual develop-
ment. Children should do activities that stimulate their near and distance vision:
They should be involved in coloring with crayons at near but should also play ball
with friends from a distance. During the past years, more emphasis worldwide has
been put on “digital learning” and the use of computers and tablets in preschools
and schools. Although digital media can be used successfully in many different
areas of life, there are reasons for caution of their increased use, particularly in
preschools. Interestingly, many executives of technology development in Silicon
Valley, one of the main centers of global digital development in the United States,
seem to want to educate their children in adevice-free” school program, such as
the Waldorf Schools [25]. As experts in technology development, they also seem
to know the limits and even dangers of their products on child development. In
addition, more and more children and students turn myopic because of all the
near work done on screens [26].
Children need direct interaction with the material world to develop concepts.
They need to touch, see, smell, grasp, and reach for real objects and have real
experiences in the world surrounding them. Only then can they develop crucial
vision, visual attention, and visual motor skills. If they have a firm grasp on
Learning Is Visual: Why Teachers Need to Know about Vision
those more concrete experiences, they can move on to more abstract visual
concepts such as letters and numbers.
3.3 Vision problems and teaching
Research that was originally conducted with visually impaired students and with
people who suffered vision loss after brain injuries show that “vision” is a learned
process thus can be improved through structured teaching. Such knowledge is valu-
able for all educators and should have consequences for our education systems.
Natalie Barraga [27] was the first vision teacher who carried out research in rela-
tion to structured visual education in order to teach children with a visual impair-
ment to use their remaining vision better. She developed exercises focusing on visual
discrimination and recognition using objects with different sensory qualities: size,
figure, contrast, and color. In her lessons, she taught children to discriminate and
reflect on forms and objects and connect the forms to their surrounding objects. Her
findings revealed that structured vision education increased the childrens’ func-
tional vision and resulted in more visual effectiveness.
Later research confirmed that visual qualities like VA, the attention in VF, and
different ocular motor functions including accommodation and convergence can
develop through structured learning [28]. Gislén et al. [29] were impressed of the
VA capacity that the pearl divers showed under water, but afterward they trained
some Swedish children who rather quickly reached the same underwater VA level.
Behavioral optometrists have focused on children with eye motor disorders and
have shown how better eye movements trough structured procedures also improve
the VA at near and distance [6, 30–33].
Walter Poppelreuter [34], a psychologist and medical doctor, developed vision
rehabilitation strategies for soldiers suffering from vision problems after gunshot
wounds to their heads during World War I. Soldiers with reduced VF, the area of
vision outside the fixation, learned eye movement techniques as compensation strate-
gies [10]. These experiences laid the foundation for rehabilitation of vision problems
following neurological disorders like stroke or traumatic brain injuries [7, 35, 36].
Cyvin and Wilhelmsen [37] demonstrated how a girl with brain damage got better
balance and motor functions parallel to improved binocular vision.
All visual sensory and ocular motor functions are connected in a visual circle
where the eye motor capacities influence sensory and perceptual functions and
vice versa [38]. Tiny eye motor disturbances may affect concentration, attention,
endurance, social communication, reading and writing, and motoric activities
and have a negative influence on the ability to manage assigned tasks [33, 39].
Even communication with others is to a large degree visually mediated. Not only
is the written communication visual, but we also use nonverbal communication
when facial expressions and body language interpret the message we want to send.
Therefore, increased vision will even positively influence social behavior and
motor activities which rely on visual inputs [10, 37].
The conclusion that many visual functions such as VA, VF, accommodation, con-
vergence, and ocular motor control are important for receiving clear visual inputs
in learning and communication can be drawn from the discussion above. Thus, this
importance for learning needs visual screenings to be comprehensive and inclusive
of all visual functions involved in learning. In addition, vision is a developing
sense; for it to thrive, it needs a stimulating environment provided by teachers and
other caretakers. However, evidence from the literature show that visual function
problems can be improved through intervention. Yet, most school vision programs
however do not screen for all those visual functions mentioned, although their
impact on academics, particularly reading, is significant [40].
Education at the Intersection of Globalization and Technology
4. Impact of visual problems on the reading process
When learning to read, the first important activity is to learn the sounds con-
nected to the visual forms of each letter and how to combine sounds and form them
into words. Visually, there is a need of being able to see the difference between a
t and a f or depart an o from an e. This requires good VA for distance, so they can
see the blackboard clearly and a good accommodation capacity and convergence
for clear near inputs. For being able to read the letters in the correct order, the eyes
need to focus together on the same spot. If not, it is difficult to decide if the word
is follow or flow, spot or ptos. Letters will be turned around, or if the fixation is
unsteady, they will even be seen jumping around. For children with ocular motor
disturbances, the same word may appear differently during each time it is seen.
This phase is followed by a period where reading develops and turns into an
automatic process where the child can read for learning [41] and understand the
meaning of the texts. The child must develop a strategy where perceiving the text
turns automatic, without great effort [42]. This level may be difficult to reach if
vision is a challenge. Some can manage for a short time, but then the vision system
is worn out and the text turns blurry or double.
Seeing the text clearly is of fundamental importance and requires a good VA.
VA tests are presenting letters, numbers, or symbols with smaller and smaller sizes
on each line down the chart. The most common tests are normally the distance VA
tests carried out on 6m or 20ft, although some used for children are standardized
for 3m. If the line marked 6/6, 3/3 or 20/20 is seen from the actual test distance, the
VA is normal. Full VA means that the symbols expected to be seen at 6m, 3m, or
20ft are seen on this distance and noted as 6/6, 3/3 or 20/20 or as decimal number
1.0. If the 6/12 line is the last line seen, the vision is in decimals 0.5, which is the
border line for the category of visual impairment in ICD-11 [9]. Then symbols that
were expected and seen at 12m (40ft) are seen at 6m (20ft). For reading from the
blackboard or seeing objects clearly from a longer distance, it is important to have
good distance VA. Students with problems seeing objects far away are often near-
sighted, having myopia [42].
It is important to remember that a normal distance VA is no guarantee for a
clear VA at a reading distance. Therefore, it is also necessary to screen the near VA
separately with a VA chart developed for 40cm or 3ft. It is a harder ocular motor
activity to see clearly at near because the lenses need to adjust, or accommodate,
and more and more the closer they must focus. Children with accommodation
problems will perceive the text as foggy or blurry at near. Because the regulation
of the lens is muscle work through the ciliary muscle in the eye, some children may
lose the power to keep the accommodation over time. After some minutes, it will
be demanding and tiring to continue reading [42]. A near VA test can show if the
child has accommodation problems, a hypermetropia. The new ICD-11 [9] also
categorizes a near VA as a visual impairment, if it is less than 0.5. This criterion is
new compared to previous classifications. Together with testing the accommodation
ability, the near VA test is an important predictor of visual discomfort for reading
and other near activities [43].
The VA tests are done monocularly, with each eye alone, and binocularly, with
both eyes together, to see if each eye has a good VA and if they function well together.
When looking at something in the distance, the eyes normally stay in a parallel posi-
tion and the eye lens has a relaxed shape. When looking at something closer, both
eyes must not only accommodate, but also converge inward to fixate on the same
spot. If the eyes are not fixated on the exact same spot during reading, double images
will occur. Disturbed convergence is a binocular problem [6]. Students who struggle
with double vision, will sometimes unconsciously supress the visual inputs from one
Learning Is Visual: Why Teachers Need to Know about Vision
eye and only depend on the information from the better eye. The supressed eye will
turn into a so-called “lazy eye,” with reduced VA [42].
The classic treatment of an amblyopic eye is to patch the good eye for hours each
day, so the weak eye is used and stimulated [44]. The result may be two eyes with a
good VA, but they will not always function well together—an ability that is essential
for reading. Students may manage near-work in school if the letters are large and
the reading time is limited. But they can have problems with reading, when the
letters are smaller, the text gets longer, the line space is reduced, and the period of
reading increases. The text may turn unclear and double and the eyes may even
hurt. Some are then even rubbing their eyes or turning very sleepy.
The measured VA gives only information about the very central area of the
vision where the gaze is fixated. The VF around the fixation point informs about the
surroundings and what is happening there. This visual information tells the brain
where to look next, what to be aware of through colors, forms, and movements.
These signals are catching our interest and attention, and we move the gaze to new
places for seeing the details clearly. Even in reading, VF is important. It contributes
to the reading speed and reading flow. Only the awareness of the entire picture
of the text can give information about what is coming and where the gaze must
continue. With this information, the brain prepares where to place the next fixa-
tion. The gaze jump, or saccade, normally places the next fixation in the first part
of the next word. Reading consists of continuous new saccades and fixations, and
during this eye motor activity, the eyes must work well together to prevent double
images [6, 42]. This shows how essential well-functioning binocular activities are
for effective saccades and fixations during reading [45].
There are more accommodation challenges among school children than previ-
ously known [33]. In a group of nearly 400 schoolchildren, between 8 and 15years,
only 54% were found to have normal accommodation and convergence [46]. These
are serious findings due to the connection between ocular motor disturbances and
reading difficulties [41, 47]. Often, children with such problems receive refrac-
tion with plus lenses to relax the lens and to make text appear larger. However,
this treatment may help children to overcome their accommodation problem but
not necessarily their binocular disturbances [42]. So, prescribing glasses is not
always enough or the best help for their visual reading challenges [48]. To train and
strengthen the accommodation capacity on the other side has shown a good and
long-lasting effect on reading [6, 10, 49]. Strengthening the ocular motor control
and capacity will give better visual sensor qualities, especially the VA increases
through better accommodation and steady fixation [10, 33].
The evidence theme that is emerging from this paragraph is that reading is a
highly complex visual activity which relies upon intact visual functions. Some
visual functions can be improved with eyeglasses, but not all. In terms of learning, it
appears that many different visual functions have to be checked and also that there
has to be some awareness of teachers that these functions are important. Otherwise,
they may miss important signs of their students to indicate a visual problem. In
addition, there is also the question what other types of intervention are identified
by the literature if glasses are not the sole solution for visual problems that children
may exhibit during learning [3, 22].
5. Screening and intervention of vision problems in school
The functional consequences of a vision problem are often misunderstood
and may be interpreted as signs of dyslexia or attentional disturbances [6, 22, 50].
Because vision inputs are so fundamental for the learning and reading process,
Education at the Intersection of Globalization and Technology
vision should be checked regularly. There is even an increase in vision disturbances
through the years in school [51]. Children themselves are seldom aware of their
vision problems, so several states in the United States have rules for checking
childrens’ vision during the years in school [52].
Teachers can learn to screen VA for near and far [4, 14] and other visual functions
in their classrooms and identify visible eye health problems, for example, changes
of the eye appearance, eye movement problems such as eyes moving in different
directions and squinting. However, often the vision screening is incomplete, not
addressing those latter problems [40]. Metsing et al. [13] also point out that in vision
screening programs around the world, there often is a priority to identify problems
related to distance vision to detect amblyopia and related problems, such as strabis-
mus, in preschool children. Accommodation and convergence are often not screened
for even though those functions are very important for reading and writing in older
children. An issue, however, is also about training of the screeners. Screeners need
to be educated well to be able to screen properly for many visual functions and avoid
high false-positive or high false-negative identification [13].
Early on, Rogers [3] was convinced that teachers would identify many pupils
with vision problems if they were better observers. Signs like making mistakes
with letters and figures, holding the text abnormally close or leaning forward when
reading something far away, and complaining about headache or blurry vision are
still signs that a teacher has to take seriously. They can observe and notice light
sensitivities in their students and become alarmed if a student is copying from their
neighbors instead directly from the blackboard. When students are easily bored of
doing near work or read slowly, teachers could become aware that the student may
have vision disturbances. Equipped with knowledge and skills, teachers can com-
municate their findings to parents and the eye health system and ensure that there is
follow-through with recommendations.
Students with accommodation and convergence problems may need structured
vision training of the eyes in order to improve their reading skills. Even though
there is still controversy about the main cause of reading problems, whether
they are phonetic or visual in nature, there is evidence that visual training does
improve reading outcomes, especially in poor readers and even children with
dyslexia [5355]. This training is usually done by experts in the field of behavioral
optometry. However, there may also be a lack of optometrists, ophthalmolo-
gists, and eye health-care workers in many countries, particularly in developing
countries [56, 57], so children may not have access to such training. There is also
evidence that teachers can be educated to systematically stimulate childrens’
visual capacities in a structured way [42].
From the literature, it appears that particularly eye movement disorders, accom-
modation, and convergence problems are often not screened for in vision screening
programs. This is true for many countries around the world. These problems also
cannot be changed through glasses alone but may need more structured vision
training to improve.
6. Results and discussion of the literature review
In the next paragraphs, results and discussion of the results are presented. Each
major result of the literature review is discussed separately.
Vision is a learnt and developing sense and can be stimulated by teachers and
caregivers to improve best developmental outcome.
Learning Is Visual: Why Teachers Need to Know about Vision
Possibly all teachers should have knowledge about the role of vision in learning as
part of their education. Such information can be delivered through teacher training
and continuing education programs for teachers. Just even greater awareness of the
importance of vision may be important to provide better learning environments.
Teachers sometimes can prevent visual problems if they offer a visually stimulating
environment and pedagogy particularly in preschools. They can educate students,
parents, and caretakers about the importance of eye health and intact visual func-
tions. Especially in developing countries, parents may not know about the signs and
symptoms of visual problems or eye diseases, such as conjunctivitis [58]. Teachers
can also provide an environment that is conducive to learning, with good lighting
conditions, for example, and materials that have universally good visual features in
form and contrast, such as clearly legible materials. Improved teacher training in the
area of vision may be an important prerequisite to higher academic achievement in
children. This however requires governments to invest in Continuing Professional
Development (CPD) courses and in teacher training at the preservice level in the
area of vision.
Academic learning such as reading can be negatively impacted by visual problems.
Intact visual functions such as visual acuity, visual field, ocular motor control,
accommodation, and convergence are necessary for learning.
Even though there is debate about the role of vision in areas such as reading dif-
ficulties and dyslexia, evidence was provided in how impaired visual functions can
have an impact on reading. Reading difficulties cannot be attributed solely on visual
problems, however, when children do exhibit reading problems, a thorough screening
and assessment should take place [59]. This requires teachers being aware of the effect
of visual problems on learning. It also needs a functioning networking system where
teachers can refer children to for screening and intervention.
Teachers can learn to screen for visual functions. School screenings need to encompass
all visual functions involved in learning, not just visual acuity testing for distance
In different parts of the world, teachers have been trained in VA screenings
[4, 14], but screening for many different visual functions, evaluating the results,
making decisions for further steps, and ensuring follow-through does not fully
occur [40]. However, for teachers to be able to do this and become successful
screeners, it seems obvious that they have to be trained well [60]. There are several
questions that must be answered regarding the training and who should be trained.
In many countries, teachers of the visually impaired/blind (TVI) teach children
with visual impairments, that means children who have a VA loss or a VF loss after
correction of refractive error. These teachers have a foundation of knowledge in
vision. They, however, would have to undergo a role change in that they would
not only be responsible for children with significant visual impairment due to VA
and VF loss, but they would also have to get involved with children that may have
problems in learning due to eye movement problems, accommodation, or conver-
gence problems. It would need to be researched further whether ordinary classroom
teachers or specialist teachers, such as teachers of the visually impaired, should be
educated further to conduct a comprehensive vision screening for all children. The
exact manner through which school-based screenings are organized is also depen-
dent on the specific context and country. Historically vision screening was primarily
done by eye health professionals, which is the medical sector. The medical and
Education at the Intersection of Globalization and Technology
educational system in a specific country would have to begin to work together in
a more coordinated way, also to ensure valid screening results and follow up in
children. The issue of false-positive or false-negative identification of children
through screening by teachers when compared with screening results conducted
by ophthalmologists is a concern. However, it appears that with training this can
improve, and the benefits outweigh the risks [61].
Teachers can learn to intervene when visual problems occur. They can network and
collaborate with eye health-care providers. A child may need more structured vision
training/intervention to improve vision for learning.
The issue of intervention can be even more challenging. Children with significant
visual impairment or blindness classified by ICD-11 (after correction for refractive
error) usually receive services by a TVI and often are taught compensatory skills
and receive alternative materials to print reading. Children who need correction for
refractive error only receive eyeglasses.
As we pointed out before, some problems that affect reading can be ameliorated
with spectacles, but not all. Eyeglasses which are important in treating refractive
errors such as myopia and hyperopia are necessary in many cases. The World Health
Organization estimates that globally over 1 billion people have visual impairment
due to uncorrected refractive error [62]. However, eyeglasses do not solve all visual
problems that impact learning, such as accommodation and convergence problems.
Teachers need to come to realize that even though a child is wearing eyeglasses and
has seen an eye doctor, they may still struggle visually and need a different plan of
intervention. Even children who have had their eyes checked but did not receive
glasses may still have vision challenges. Eyeglasses may also not be sustainable for
many children, particularly those from families that lack the financial resources to
see an ophthalmologist or optician on a regular basis. For example, in some African
countries peer pressure, costs, and availability of optical services were identified as
the main barriers to spectacle wear in children [63].
There is also controversy with regard to vision training or vision therapy” as it
is also often called. Usually, this training is conducted not by medical eye doctors
or teachers but by optometrists. There is a continuous debate about the benefits of
vision training besides the controversy about who should actually do it [64]. There
is however a consensus that vision therapy does work for visual disorders such as
convergence insufficiencies. This leads to reading problems and reading aversions
[65]. Much of this chapter is focused on precisely those types of problems, namely,
of both eyes working together, which can have adverse effects on learning.
Eye health professionals may not always realize the impact of vision problems
relevant to learning. For teachers to begin to address childrens’ vision problems in
the school setting, this also would require a whole system wide approach and again
collaboration between the medical and educational sectors.
Methodologically, this study was an integrated literature review. This also poses
some limitations of the study, mainly the question whether all relevant information
and studies on the topics were included. Further studies using different methodolo-
gies should continue to explore the relationship between vision and learning and
particularly the relationship between the medical and educational systems when it
comes to the area of vision screening and intervention. This study aimed at opening
the discussion about a possible model of training teachers in the area of vision.
Further studies and research must occur to identify benefits and problems/barriers
of teachers conducting vision screenings and interventions in schools. However, the
results of this review could help to inform the design of such a model of teachers’
training, while taking also into account the country and regional specifications.
Learning Is Visual: Why Teachers Need to Know about Vision
7. Conclusion
Experiment and test out new ideas. The basic mode of classroom pedagogy today in
most schools has not changed much for decades. It may be worthwhile to consciously
create a culture and room for ‘disruptive’ ideas and technologies and test whether
innovations and different approaches work better than the status quo ([], p. ).
Teachers may need to take on a more active role in the prevention, assessment,
and intervention in visual problems in children due to the role of vision in all
academic activities.
Just like Sumra et al. [66], quoted above, this may be a somewhat disruptive
“idea” since the educational and eye health systems must converge to address the
visual problems that occur in learning. The eye health sector and the education
system have to become partners in working together continuously for the benefit of
children with visual problems. Future studies need to explore the exact mechanisms
of such collaboration and respective roles further. In any case, more thorough
training and education in the area of vision, vision screening, and intervention is a
prerequisite for teachers so that they become competent in those areas.
Professional development courses may be a good vehicle to increase knowledge
in the area of vision and learning in addition to advanced degrees and more research
into this area of education. Collaboration between the education and the eye health-
care system is fundamental for education in the twenty-first century, with educators
taking the lead for vision-related problems affecting learning in school.
Before concluding this chapter, an example of a Continuous Professional
Development (CPD) course in the area of vision is presented. This CPD program
was originally developed at the Western Norway University of Applied Sciences in
Bergen for teachers in Norway. This program then was taught to the primary school
teachers and faculty staff from Patandi Teachers College in Arusha, Tanzania. In the
last paragraph, the elements of the course are highlighted.
7.1 The CPD course, Vision for reading and learning
The CPD course, Vision for reading and learning, has been taught at the Western
Norway University of Applied Sciences, HVL, to teachers in Norway since 2010.
In 2016, HVL, was awarded project funds for the project, Securing education for
children in Tanzania (2017–2021), from the Research Council of Norway, NRF,
in cooperation with Innovation Norway and NORAD, the Norwegian Agency
for Development Cooperation. Project partners were Patandi Teachers College
for Special Needs Education, Tanzania, and University of Applied Sciences in
Koblenz, Germany. The project team included teachers of the visually impaired,
vision specialists, social scientists, and engineers. The project aimed to contribute
to poverty reduction in Tanzania through improved teacher training in the area
of vision through the CPD course. Thirty teachers were educated in the 30-credit
post-BA blended learning course Vision for reading and learning took place over a
period of 2years (15 students completed the course each year). Instructors from
Patandi Teachers College together with the teachers and headmasters from primary
schools participated in the course. They all held at least a BA degree or a MA degree
from an accredited institution in Tanzania. Most of the students had a teaching
endorsement in a special education category, such as visual, intellectual, or hearing
impairment. The theoretical foundations of the CPD course consist of elements
that were described in this chapter: sensory, attentional, and motoric aspects of
vision [38]; principles from rehabilitation programs for vision problems follow-
ing brain injuries [36]; vision teacher methodology [7, 27, 37]; and behavioral
Education at the Intersection of Globalization and Technology
Author details
Gunvor BirkelandWilhelmsen1* and MarionFelder2
1 Department of Pedagogy, Religion and Social Studies, Western Norway University
of Applied Sciences, Norway
2 Department of Social Sciences, Koblenz University of Applied Sciences, Germany
*Address all correspondence to:
optometry [6, 33]. In addition, age-appropriate pedagogical principles [67] were
considered since students completed their practical training with children in
selected primary schools. The goal was that the participants of the course were able
to assess a variety of visual functions and plan and administer visual stimulation
and education programs and/or refer children to health care, eye clinics, or optom-
etrists for further assessment or refraction when necessary.
The course lectures and classes took place at the college, combined with periods
of self-study, and were taught by professors from HVL, Norway, and Koblenz
University of Applied Sciences, Germany. Four colleagues from Patandi College,
who had successfully completed the first year with Vision for reading and learning,
assisted in the second round of the course with lectures and hands-on supervision
in the following year. In addition, a close 1: 1 supervision was provided by profes-
sors and other professionals who had completed the course in Norway previously.
The course content consisted of a challenging theoretical basis but also practical
component. Students had to learn hands-on how to do assessments and tests and
critically evaluate the outcomes and design intervention programs. Examinations
were rigorous and aligned with the expectations of HVL. All participants passed the
course and used their new knowledge and skills in various positions throughout the
school system of Tanzania. All participants grew professionally from the course as
it gave them new perspectives on childrens’ learning and the important role vision
has for education. The new knowledge also influenced the curriculum at Patandi
Teachers College of Special Needs for all disciplines including preservice teachers.
Currently, a vision assessment center is being developed at Patandi Teachers College
to assess children in collaboration with eye health-care providers. In addition,
Patandi Teachers College is now planning to conduct CPD courses about vision for
in-service teachers throughout Tanzania.
Funded by the research council of Norway, project no: 267524/H30.
© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
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... In the absence of vision screening, children may have unnoticed vision problems and academic challenges which often are attributed to other problems, such as learning or cognitive disabilities (Wilhelmsen & Felder, 2020). Due to the fact that vision inputs are involved in nearly 70 % of all activities in school (Narayanasamy et al., 2016), disturbed vision qualities can be a hindrance to educational achievements and have lifelong consequences. ...
Conference Paper
Good vision is essential in children’s learning and development. Pupils with vision problems might mistakenly be evaluated as hyperactive, passive or having dyslexia. The aim of this study was to detect pupils with disturbed vision in primary schools in Tanzania. Specifically, the study intended to evaluate if vision qualities would improve through vision stimulation. The study was a quasiexperiment with a descriptive design. Twenty-one (21) pupils were identified with vision disturbances, and four of them were involved in the study. After the vision assessment, the participants went through a structured individual vision program. Each lesson lasted for 45 minutes and all had one lesson daily for 21 days. All four cases represented various issues of disturbed vision before intervention and reached improved vision due to the stimulation. The stimulation focused on better controlled and coordinated eye movements before the next assessment. Descriptive analysis was used through basic statistics with measures of the central tendency and disparity to study eventually vision changes. From this study, the most significant finding is that vision can be improved through structured vision exercises in schools. Improving vision will make learning easier. The study concludes that functional vision assessment of children prior school enrolment and of pupils struggling in school is important for establishing intensive adapted education for better learning.
... The novel aspect in the study presented here was that training, or vision lessons, was performed in school, by qualified teachers trained extensively in vision theory, assessment and intervention procedures (Wilhelmsen & Felder, 2020;Felder, Wilhelmsen & Schneiders, 2021). Children were taught by teachers in their natural environment. ...
Vision impairments in children are harmful to their learning process, cognitive development, social interaction, and scholar performance. In recent years, new technologies have been applied for vision screening tests, sharpening traditional techniques and enabling the early diagnosis of different kinds of debilitation on the visual system functionality. Eye-tracking is a widely used technique applied for different purposes, and when it comes to vision assessment and training, it is greatly suitable. This work aims to apply feature engineering and cluster analysis techniques within eye-tracking data collected from children performing structured visual tasks. Feature engineering creates meaningful attributes for the recordings in terms of performance and data quality, and the exploratory analysis covers different configurations for the clustering methods and their hyper-parameters. Cluster validation metrics evaluate the clustering results’ quality, and domain expert acknowledgment is essencial for trustful inferences regarding the children’s oculomotor system’s health. In order to streamline the exploratory analysis and facilitate the experiments, we also propose a framework for Cluster Analysis of the eye-tracking data.
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We designed a school-based, nationwide program called the 'New Era in Eye Health' to strengthen teacher training and to examine whether the existence of a government vision care policy influenced teachers' vision care knowledge and students' behavior. Baseline data and 3-month follow-up data were compared. A random sample of teachers (n=660) from school vision health clusters in 22 cities/counties in Taiwan were invited to participate in our study and 436 agreed to participate (response rate=66.1%). The mean age of participant teachers was 41.2 years, while the length of service mean was 14.6 years. For monitoring teacher outcomes, five cities/counties were selected as the intensely monitored group based on certain criteria. Sunlight diaries (n=5434) were distributed and 3342 (61.5%) were returned. Teachers showed significant improvements in knowledge and behavior on the school vision health questionnaire. At the 3-month follow-up, the number of recesses as recorded by students' 'sunlight diary' increased. When teachers had better knowledge and behavior, recesses also increased. This study provided valuable insights to guide dissemination efforts for school vision health interventions and to help teachers implement research into their school vision health activities.
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Purpose: Visual acuity (VA) screening in schools has been widely adopted by eye programs around the world. This review evaluates the efficacy and cost of alternate VA screening methods to identify school-age children with undetected visual deficits due to refractive error and other visual disorders. Methods: Published studies were identified from Ovid MEDLINE, MEDLINE In-Process, and EMBASE for trials from 1974 to March 2015 as well as from reference and author searches. All controlled studies were included. Data extraction tables were developed a priori for key screening test performance indicators, including compliance. Results: Three trials met the inclusion criteria, two comparing alternate teacher models and one compared teachers to primary eye care workers using three different VA thresholds. School vision screening using ‘all class teachers’ (ACTs) found significantly fewer screen-positive children than select teachers (STs) (9.9% versus 16.6% [p<0.001] respectively) and significantly more children with visual disorders (5.7% versus 4.0% [p<0.001] respectively) at 30% of the cost and improved compliance. Teachers performed similarly to primary eye care workers in detecting children with visual disorders with 6/12 the optimal cut-off level. Conclusions: Using detection of children with visual disorders as outcome, evidence supports school screening using ‘ACTs’ and a 6/12 VA threshold. Using the proportion of students with visual disorders who attend follow up at the referral hospital within three months as outcome, one study supports use of ACTs. Using cost per child detected with visual disorders as outcome, one study supports use of ACTs.
Learning is multisensory, thus impaired vision may impact on classroom learning and subsequently, academic achievement. This research investigated the impact of impaired vision on academic achievement in a sample of 109 Grade 3 Australian children. Approximately 30% of the sample were identified as borderline or unsatisfactory by a vision screening and were referred for a full eye examination. Children who were referred at the vision screening scored significantly lower on national standardised tests of reading, grammar and punctuation, spelling and numeracy, when compared to their not referred peers. This research has important implications for teachers and eye health professionals, as the findings highlight the importance of early vision screening in identifying children who may be achieving below their potential.