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Clinical Policy Bulletin:
Learning Disabilities, Dyslexia, and Vision
Number: 0078


Policy

Aetna considers visual training and behavioral vision therapy for members with dyslexia and/or learning disabilities experimental and investigational.  As indicated in a policy statement developed jointly by the American Academy of Pediatrics (AAP), American Academy of Ophthalmology (AAO), the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and the American Association of Certified Orthoptists (2009), there is no known eye or visual cause for dyslexia and learning disabilities and no effective visual treatment.  Multi-disciplinary evaluation and management must be based on proven procedures demonstrated by valid research.

Aetna considers the use of colored filtered/tinted lenses experimental and investigational for treatment of dyslexia or learning disabilities because their effectiveness for these indications has not been established.

See also CPB 0321- Visual Perception Training and Vision Restoration Therapy and  CPB 0489 - Vision Therapy.



Background

The issue of learning disorders, including dyslexia, has become a matter of increasing personal and public concern.  Inability to read and comprehend is a major obstacle to learning and may have far-reaching social and economic implications.  Concern for the welfare of children with dyslexia and learning disabilities has lead to a proliferation of diagnostic and remedial treatment procedures, many of which are controversial.  This policy statement addresses these issues, which are of importance to affected individuals, their families, teachers, doctors, allied health personnel, and society.

A broad-based consensus of educators, psychologists, and medical specialists has recommended that individuals with dyslexia or related learning disabilities should receive (i) early comprehensive educational, psychological, and medical assessment; and (ii) educational remediation combined with appropriate psychological and medical treatment.

Although it is obvious some children do not read well because they have trouble seeing, research has shown that the majority of children and adults with reading difficulties experience a variety of language defects that stem from complex, altered brain morphology and function, and that the reading difficulty is not due to altered visual function per se.

However, in spite of these facts, a certain number of children who experience reading difficulty may also experience a treatable visual difficulty in addition to their learning dysfunction.  Doctors can identify the majority of those who have reduced visual acuity.  However, in a small percentage of children, a visual abnormality such as farsightedness may not be detected during pediatric office screening procedures.  Therefore, doctors who evaluate children for reading difficulties should consider referral to an ophthalmologist familiar with children's eye problems.

In their position statement on learning disabilities, dyslexia, and vision, the American Academy of Pediatrics (AAP), American Academy of Ophthalmology (AAO), and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) concluded the following:

  1. Those considered to be at risk for learning disabilities, dyslexia or attention defects, should be thoroughly assessed by both educational and psychological specialists.
  2. Learning disabilities, including dyslexia and other forms of reading or academic under-achievement, require a multidisciplinary approach to diagnosis and treatment, involving educators, psychologists, and physicians.  Research has established that the basis of dyslexia and other specific learning disabilities is within the central nervous system and is multi-factorial and complex.
  3. Unfortunately, however, it has become common practice among some to attribute reading difficulties to one or more subtle ocular or visual abnormalities.  Although the eyes are obviously necessary for vision, the brain interprets visual symbols.  Therefore, correcting subtle visual defects can not alter the brain's processing of visual stimuli.  Children with dyslexia or related learning disabilities have the same ocular health statistically, as children without such conditions.  There is no peripheral eye defect that produces dyslexia or other learning disabilities and there is no eye treatment that can cure dyslexia or associated learning disabilities.
  4. Ocular defects should be identified as early as possible and when correctable, managed by the ophthalmologist.  If no ocular defect is found, the child should be referred to a primary care physician to coordinate required multi-disciplinary care.
  5. Eye defects, subtle or severe, do not cause reversal of letters, words, or numbers.  No scientific evidence supports claims that the academic abilities of dyslexic or learning disabled children can be improved with treatment based on a) visual training, including muscle exercises, ocular pursuit, tracking exercises, or “training” glasses (with or without bifocals or prisms); b) neurological organizational training (laterality training, crawling, balance board, perceptual training), or c) tinted or colored lenses.  Some controversial methods of treatment result in a false sense of security that may delay or even prevent proper instruction of remediation.  The expense of these methods is unwarranted, and they can not be substituted for appropriate remedial educational measures.  Claims of improved reading and learning after visual training, neurological organization training, or use of tinted or colored lenses, are typically based upon poorly controlled studies that rely on anecdotal information or testimony.  These studies are frequently carried out in combination with traditional educational remedial techniques.
  6. Since remediation may be more effective during the early years, early diagnosis is paramount.  The educator ultimately plays the key role in providing help for the learning disabled or dyslexic child or adult.

In a review on the applicability and effectiveness of eye exercises, Rawstron et al (2005) noted that eye exercises have been purported to improve a wide range of conditions such as vergence problems, ocular motility disorders, accommodative dysfunction, amblyopia, learning disabilities, dyslexia, asthenopia, myopia, motion sickness, sports performance, stereopsis, visual field defects, visual acuity, and general well-being.  Small controlled studies as well as a large number of case reports support the treatment of convergence insufficiency.  Less robust evidence indicates visual training may be useful in developing fine stereoscopic skills and improving visual field remnants following traumatic brain injury.  The authors concluded that, as yet, there is no clear scientific evidence published in the mainstream literature supporting the use of eye exercises in the remainder of the areas reviewed, and their use therefore remains controversial.

A technology assessment of vision therapy by the Institute for Clinical Systems Improvement (ICSI, 2003) concluded that available studies provide inadequate evidence of the effectiveness of vision therapy for learning disabilities.

Irlen syndrome (also known as scotopic sensitivity syndrome) is a visual-perception dysfunction that is thought to contribute to dyslexia and learning disabilities.  The syndrome was identified by California psychologist Helen Irlen, who published a book called Reading by the Colors, and, since 1983, has been marketing red and blue non-prescription eyeglasses to dyslexics.  A number of Irlen Clinics have been opened around the country.

There is considerable controversy over whether the treatment of dyslexia with colored lenses is effective, or whether the Irlen syndrome truly exists.  Available evidence is of poor quality, with inconsistent results.

A systematic evidence review (Albon, et al., 2008) concluded that there is insufficient evidence of the effectiveness of colored lenses for dyslexia. "Meta-analysis and qualitative assessment of eight included RCTs did not show that the use of coloured filters led to a clear improvement in reading ability in subjects with reading disability. It was not possible to comment on whether coloured filters can improve symptoms of visual stress that may be associated with reading disability due to a lack of available evidence. Based on the evidence obtained from this systematic review there can be no major implications for current practice in the treatment of reading disability. It remains a possibility that there exists a subgroup of people who may experience an improvement in reading through the use of coloured filters, while others find that there is no beneficial effect. Further well-designed research may generate clearer results."

A policy statement issued by the AAP's Committee on Children with Disabilities, AAO, and AAPOS (1992) stated that “visual problems are rarely responsible for learning difficulties.  No scientific evidence exists for the efficacy of eye exercises, vision therapy, or the use of special tinted lenses in the remediation of these complex pediatric neurological conditions”.

Skottun and Skoyles (2008) stated that it has been suggested that dyslexia is the result of a deficit in rapid sensory processing.  Several methods have been used to assess this with regards to vision: temporal contrast sensitivity, visual persistence, temporal order judgments, temporal acuity, and coherent motion.  These investigators examined these methods and found that several of them -- visual persistence, temporal order judgments, and coherent motion -- are poorly suited to evaluating the dynamic aspects of vision.  In the case of temporal contrast sensitivity and temporal acuity the results from these tests either are conflicting or provide little support for an impairment.  As far as vision is concerned there is little evidence for a specifically temporal deficit.

Kruk et al (2008) noted that the potential role of visual processing deficits in reading difficulty was brought to public attention by claims that a large proportion of children with dyslexia suffer from a perceptual dysfunction currently referred to as Meares-Irlen syndrome (MISViS).  A previous study showing that visual perceptual measures involving visual memory and discrimination predict independent variance in reading achievement provided a basis to examine their relationships with the diagnostic criteria of MISViS.  This study examined these visual processing characteristics in 8- to 10-year old children (n = 36), half of whom were experiencing reading difficulty.  Children were assessed for MISViS by Irlen screeners; approximately 50 % of the participants in each group were positively identified.  Concurrent performance on standardized visual processing tests showed that while a positive diagnosis of MISViS is not indicative of reading ability, nor in particular of a visual-processing deficit subtype identified by Watson and Willows, MISViS can indicate visual processing difficulties potentially related to visual attention inefficiency.

Hawelka and Wimmer (2008) stated that in 2 previous studies they assessed the difficulty of dyslexic readers with letter string processing by using variants of the partial report paradigm, which requires report of a letter name in response to a position cue.  The poor dyslexic performance was interpreted as evidence for a visual-attentional deficit of dyslexic readers.  In the present study, these researchers avoided verbal report by using a task that only required the detection of pre-defined targets (e.g., letters or pseudo-letters) in strings.  On this purely visual task, the dyslexic readers did not differ from non-impaired readers.  This finding speaks against a basic visual-attentional deficit; rather it suggests that the dyslexic deficit on partial report paradigms stems from a problem in establishing a string representation which includes position and name codes.

Pieh and Lagrèze (2008) stated that Irlen therapy, visual training, training of ocular motor control, and the correction method of HJ Haase represent a diversity of treatment methods that are mainly aimed at dyslexia, fatigue while reading, and general lack of concentration.  These investigators summarized the theoretical background of these methods, treatment approaches, and related clinical trials.  None of these methods, because of incorrect theoretical concepts and an attempt to simplify the underlying causes, was found to have a specific influence on the patients' complaints.  The absence of specific therapeutic effects, the high costs, and time expenditure required should discourage practitioners from recommending these methods.

In a joint statement on learning disabilities, dyslexia, and vision, the AAP, AAO, AAPOS, and the American Association of Certified Orthoptists (2009) stated that most experts believe that dyslexia is a language-based disorder.  Vision problems can interfere with the process of learning; however, vision problems are not the cause of primary dyslexia or learning disabilities.  Scientific evidence does not support the effectiveness of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions.  Diagnostic and treatment approaches that lack scientific evidence of efficacy, including eye exercises, behavioral vision therapy, or special tinted filters or lenses, are not endorsed and should not be recommended.

von Suchodoletz (2010) stated that a wide variety of methods based on very different concepts are available to treat children with dyslexia.  Basically, symptomatic and causal principles can be distinguished. Among the symptomatic methods are systematic programs based on learning theory, in which reading and spelling or precursors of these abilities are directly trained.  Causal methods promise pronounced and persistent improvement of reading and spelling abilities through elimination of the postulated reason underlying the learning disabilities.  Among the causal methods are treatment programs that train low-level functions.  Such training is based on the assumption that deficits of auditory, visual or kinesthetic perception, of motor skills or of the coordination of cerebral functional areas are at the bottom of specific learning disabilities.  Concepts of other causal methods act on the assumption that learning processes are blocked or that abnormal medical conditions or psychiatric disorders constitute the background of dyslexia.  The author reviewed treatment concepts for children with dyslexia in the German-speaking countries and the methods of treatment derived from the different concepts.  It is emphasized that effectiveness is proven only for symptomatic training programs but not for causal methods.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
92065
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
299.00 - 299.01 Pervasive developmental disorders
307.9 Other and unspecified special symptoms or syndromes, not elsewhere classified
314.00 - 314.01 Attention deficit disorder
315.00 - 315.9 Specific delays in development
317 - 319 Mental retardation
781.3 Lack of coordination
784.61 Alexia and dyslexia
784.69 Other symbolic dysfunction
799.51 - 799.55 Signs and symptoms involving cognition
799.59 Other signs and symptoms involving cognition
V40.0 - V40.9 Mental and behavioral problems
V41.0 Problems with sight


The above policy is based on the following references:
  1. American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Pediatrics. Specific Learning Disabilities: Dyslexia and Reading Problems. Elk Grove Village, IL: American Academy of Pediatrics; March 1992.
  2. American Academy of Pediatrics (AAP) Committee on Children with Disabilities, American Academy of Ophthalmology (AAO), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Learning disabilities, dyslexia, and vision: A subject review. Pediatrics. 1998;102(5):1217-1219.
  3. American Academy of Pediatrics Committee on Children with Learning Disabilities, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology. Learning disabilities, dyslexia, and vision. Pediatrics. 1992;90(1 Pt 1):124-126.
  4. American Academy of Ophthalmology. Policy statement: Learning disabilities, dyslexia, and vision. J Learn Disabil. 1987;20(7):412-413.
  5. Beauchamp GR. Background information: Learning disabilities, dyslexia, and vision. J Learn Disabil. 1987;20(7):411-412.
  6. Christenson GN, Griffin JR, Taylor M. Failure of blue-tinted lenses to change reading scores of dyslexic individuals. Optometry. 2001;72(10):627-633.
  7. Olitsky SE, Nelson LB. Reading disorders in children. Pediatr Clin North Am.  2003;50(1):213-224.
  8. Schulte-Korne G, Bartling J, Deimel W, Remschmidt H. Spatial-frequency- and contrast-dependent visible persistence and reading disorder: No evidence for a basic perceptual deficit. J Neural Transm. 2004;111(7):941-950.
  9. Rawstron JA, Burley CD, Elder MJ. A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus. 2005;42(2):82-88.
  10. Coyle B. Use of filters to treat visual-perceptive problem creates adherents and skeptics. CMAJ. 1995;152(5):749-750.
  11. Evans BJ, Cook A, Richards IL, et al. Effect of pattern glare and colored overlays on a stimulated-reading task in dyslexics and normal readers. Optom Vis Sci. 1994;71(10):619-628.
  12. American Optometric Association. The use of tinted lenses for the treatment of dyslexia and other related reading and learning difficulties. AOA Position Statement, St. Louis, MO: American Optometric Association; June 1991.
  13. Blaskey P, Scheiman M, Parisi M, et al. The effectiveness of Irlen lenses for improving reading performance: A pilot study. J Learning Disabil. 1990;23(10):604-612.
  14. Solan HA, Richman J. Irlen lenses: A critical appraisal. J Am Optomet Assoc. 1990;61:789-796.
  15. Scheiman M, Blasky P, Ciner EB, et al. Vision characteristics of individuals identified as Irlen filter candidates. J Am Optomet Assoc. 1990;61:600-605.
  16. Hoyt CS. Irlen lenses and reading difficulties. J Learning Disabil. 1990;23(10):624-626.
  17. Williams MC, LeCluyse K, Rock-Faucheux A. Effective intervention for reading disability. J Am Optomet Assoc. 1992;63:411-417.
  18. Carmean SL, Regeth Rebecca A. Optimum level of visual contrast sensitivity for reading comprehension. Perceptual Motor Skills. 1990;71:755-762.
  19. Institute for Clinical Systems Improvement (ICSI). Vision therapy. Technology Assessment Report. Bloomington, MN: ICSI; 2003.
  20. Markham R. Developmental dyslexia. Focus: Occasional Update from the Royal College of Ophthalmologists. Issue No. 23. London, UK: Royal College of Ophthalmologists; Autumn 2002. Available at: http://www.rcophth.ac.uk/docs/members/focus-collegenews/FocusAutumn02.pdf. Accessed April 9, 2007.
  21. Wilkins AJ, Evans BJ, Brwon JA, et al. Double-masked placebo-controlled trial of precision spectral filters in children who use coloured overlays. Ophthal Physiol Opt. 1994;14(4):365-370.
  22. Cardinal DN, Griffin JR, Christenson GN. Do tinted lenses really help students with reading disabilities? Intervention School Clinic. 1993;28:275-279.
  23. Woerz M, Maples WC. Test retest reliability of colored filter testing. J Learning Disabil. 1997;30:214-221.
  24. Evans BJ, Patel R, Wilkins AJ, et al. A review of the management of 323 consecutive patients seen in a specific learning difficulties clinic. Ophthal Physiol Opt. 1999;19(6):454-466.
  25. Robinson GL, Foreman PJ. Scotopic sensitivity/Irlen syndrome and the use of coloured filters: A long-term placebo controlled and masked study of reading achievement and perception of ability. Perceptual Motor Skills. 1999;89:83-113.
  26. Gole GA, Dibden SN, Pearson CC, et al. Tinted lenses and dyslexics -- a controlled study. SPELD (S.A.) Tinted Lenses Study Group. Aust New Zealand J Ophthal. 1989;17(2):137-141.
  27. American Academy of Ophthalmology (AAO). Vision therapy for learning disabilities. Complementary Therapy Assessmemt. San Francisco, CA: AAO;September2001. Available at: http://www.aao.org/education/library/cta/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=1224. Accessed April 9, 2007.
  28. UK National Health Service (NHS), Cambridgeshire and Peterborough Public Health Network. Scotopic sensitivity syndrome (Mears-Irlen syndrome) and coloured filters/tinted lenses. Cambridgeshire NHS Clinical Policies. Policy 23. Cambridshire, UK: NHS; December 2003.
  29. Helveston EM. Visual training: Current status in ophthalmology. Am J Ophthalmol. 2005;140(5):903-910.
  30. Williams GJ, Kitchener G, Press LJ, et al. The use of tinted lenses and colored overlays for the treatment of dyslexia and other related reading and learning disorders. Optometry. 2004;75(11):720-722.
  31. Skottun BC, Skoyles JR. Dyslexia and rapid visual processing: A commentary. J Clin Exp Neuropsychol. 2008;30(6):666-673.
  32. Kruk R, Sumbler K, Willows D. Visual processing characteristics of children with Meares-Irlen syndrome. Ophthalmic Physiol Opt. 2008;28(1):35-46.
  33. Hawelka S, Wimmer H. Visual target detection is not impaired in dyslexic readers. Vision Res. 2008;48(6):850-852.
  34. Pieh Ch, Lagrèze WA. A critical view of alternative methods for treating visual complaints. Ophthalmologe. 2008;105(3):281-284.
  35. Albon E, Adi Y, Hyde C. The effectiveness and cost-effectiveness of coloured filters for reading disability: A systematic review. DPHE Report No.67. Birmingham, UK: West Midlands Health Technology Assessment Collaboration (WMHTAC); 2008.
  36. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Joint statement -- Learning disabilities, dyslexia, and vision. Pediatrics. 2009;124(2):837-844.
  37. von Suchodoletz W. Concepts of therapy for children with dyslexia. Z Kinder Jugendpsychiatr Psychother. 2010;38(5):329-337.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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