Not All Eye Tests Are Created Equal

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You’ve had your child’s eyes checked with a free NHS eye test, so that’s that.  Sorted.  No eye disease and no refractive error.  20/20 vision.

But they lose their place, skip lines or miss out words.  They get headaches, or they blink, or rub their eyes.  Or they dislike small font or crowded pages and shiny white paper. They struggle to copy off the board or they space their words strangely.  They tilt their head, move their body to the side or hunch over to read or write.

The problem is there are five different reasons why children can be struggling and our NHS eye test only tests two of the five things!

It often misses near vision issues affecting reading or writing because it doesn’t really test how the eyes work together, close up and how they are moving.

Perfect eyesight isn’t the same as perfect vision. I can attest to that. I’ve always had perfect eyesight, but I still read very slowly, I am clumsy and struggle to play ball sports – all down to my rubbish vision, despite my 20/20 eyesight.

What are the five things you are looking for in an eye test?

  1. Eye health (vital, but thankfully sight and life-threatening problems are relatively uncommon in children) – covered by NHS eye test. Opthalmologists in hospitals tend to specialise in this area.

2. Visual acuity and refractive error. Optometrists (the people who should do the eye tests) and opticians (the people who dispense glasses) cover this as part of NHS eye test. The following issues are corrected with glasses:

Myopia – short-sightedness (can see short distances but problems far away).

Hypermetropia – long-sightedness (can see a long way away, but problems close up)

Astigmatism – problems with both, depending on the type and amount of astigmatism

3. Ocular Motor Functions – how the eyes are moving.  These are not covered by a standard NHS eye test and where a lot of the problems arise.  These can be tested by most good optometrists or an orthoptist in hospital. The following problems are corrected with glasses and eye exercises (physiotherapy for the eye muscles):

Accommodation – focussing (headache, eye strain or print going in and out of focus)

Convergence – fixing (skipping lines, headache, eye strain, print moving or doubling)

NB: Aspects of 2 and 3 can combine to make things even trickier

4. Visual Sensation – Pattern related visual stress

Coloured overlays and coloured lenses may help brilliantly with this, but too often issues with 2, 3 and 5 are missed and people jump only to coloured filters.  Some optometrists argue convincingly that you might ideally need different colours for each eyes.  This might be assessed by optometrists, orthoptists or opticians – be really, really sure that this is the only vision problem!

5. Visual Perception

Causing problems such as crowding, positioning, object perception, figure-ground.  This tends to be assessed by orthoptists.  Some occupational therapists or dyslexia assessors also offer some tests of visual processing and visual-motor integration.  Again, be really, really sure that this is the only vision problem!

Why don’t NHS eye tests test more than the very bare minimum?! 

The standard reasons: time and money.  Optometrists get paid very little for an NHS eye test, so (sadly) they tend to check very little.  l know from reputation that one in a million optometrsists, like Richard Fantom in Bidford on Avon check more if you flag up concerns, but they don’t get paid any more than the average optometrist where you’re in and out.

The other reason is almost certainly expertise.  Eyes are very complicated and it takes a lot of extra training and equipment to be able to test the other 3 areas, and it takes even more to be able to fix the other areas!  Some NHS eye tests are undertaken by the equivalent of staff at an NHS walk-in centre and others are more like surgeons.  Talk to different providers and ask around.

Who tests for all areas of vision?  

I used to have three answers: universities, hospitals and behavioural optometrists   Theoretically your GP or optometrist can refer you to the hospital for free NHS assessments.  But lately I have been bitterly disappointed by how rubbish my local hospitals have been in diagnosing and treating my eldest son and pupils I have assessed and taught.

By all means follow this hospital route, but I would also consider saving up for a private eye test (approx £100) from a behavioural optometrist, to be sure you have all the answers.  Or try an indepth test at a university hospital, such as Aston where they are training their final year optometrists. It takes ages, being shunted from student to student, but is normally low-cost.

What on earth is a behavioural optometrist?  

Behavioural optometrists have extra training and specialise in resolving any visual processing (rather than eyesight) issues. There are only a limited number of behavioural optometrists, the closest are Jason Rice in Nuneaton, Keith Murphy in Kenilworth, Mark Menezes in Moseley, Daryl Halsey in Wellingborough, Clare Holland or James Turner in Cheltenham, Kathryn Batchelor-Dove in Bicester. It is important to note that colleagues at their firms will not have the same knowledge and expertise as them.

What’s the point in having an in-depth eye test?  

If you go to someone good enough, have the right lenses or do the right exercises, a lot of vision problems are FIXABLE!  What?!  I know.  It helps the younger they are.  And you need your child to actually wear the special lenses or to actually do exactly the right targeted exercises – which is easier said than done.  Getting my (then) six-year-old to do daily eye exercises almost broke me!  Most parents give up and then say exercises don’t work. You could say the same about diets or running.


How much does it cost?  

That varies wildly from place to place. I only have direct experience of Jason Rice and Keith Murphy.

Jason charges about £75 for an in-depth hour for children or adults – he calls it a school vision assessment.  Some people go to him for an NHS eye test initially to see whether it is worth spending the money on something more in-depth.  Jason is particularly practical, having done this with his own son.  He is kind and explains tricky concepts well, he often refers people to Keith if a person is particularly tricky.

Keith charges about £100 for the initial assessment, has some amazing machines and produces a report which you can take to school.  But it’s impossible to get an NHS appointment with him. He may need you to sign up for another report or a few expensive sessions of vision therapy.   Beware, his staff do not have the same knowledge as him.  Keith is amazingly wise, but is very, very busy.  The problem is that you have to already know that you really need him.  

Can’t afford an in-depth eye test?  

Your child’s gross motor skills tend to be hugely bound up in many visual problems. Daily work on balance, coordination, ball skills etc. can be transformative.

How can I work out if my child/teen needs an in-depth test?  

  1. Show them some examples of visual distortion and see if any of these things ring bells.  Everyone is convinced that everyone sees the same way they do.  The number of kids that swear blind that the words don’t move, but then see this great video and suddenly say “oh, is that not supposed to happen?!”   Beware, this video is made by Irlen but Irlen is rarely the right complete solution – don’t jump to conclusions, unfortunately this subject is more complicated than we/they would like.  The science has developed since the discoveries of Meares and Irlen in the 1980s.
  2. The downloadable Wilkins Rate of Reading test aims to bring on visual symptoms quickly, by getting a child to read simple words, crowded together, in small font, on white paper. In schools or dyslexia tests, it might be used to see if we can measure the effect of different overlays on reading speed or accuracy.
  3. Get them to watch the top of a pen or pencil.   Hold it at the distance they’d read and write at (maybe just over a ruler length 30cm).  Move it slowly left and right, up and down, diagonally, plus in and out.  Get them to keep their head still and see how their eyes move.
  4. If you suspect they can just about do it ok, but seem overly stressed/overwhelmed, you could pop a cheap pulse oximeter on their finger (which measures heart-rate and oxygen levels in your blood).  You might see their heart rate suddenly increase, showing how stressful it really is.
  5. Finally, have a look at questionnaires like this one.

Need a plan to pinpoint exactly how to help?