A Chester County boy was told he had a learning disability. Vision screening missed the real problem.

Nathan Koenig was articulate, with an impressive vocabulary. As early as age 3 in preschool, he showed a knack for storytelling, creating detailed characters and plotlines. But once he started school, he had trouble with reading and writing. He brought home class worksheets that were all blank.

Eventually, Nathan was diagnosed with a learning disability. Even with extra support, he never caught up to his peers.

It was only after years of struggling at school that his family discovered what was really going on. Nathan didn’t have a learning disability — he had an issue with his eyes.

Nathan’s condition took a long time to diagnose because he had always passed vision screenings offered at his school, in which he read back increasingly tiny letters from a distance. He didn’t need glasses. His family did not know that typical school-based vision screens miss 75% of children with vision problems, according to the American Optometric Association.

Now, Nathan’s mom, Laura, is fighting for a new law in Pennsylvania to require kids to undergo more comprehensive eye health exams that would pick up on vision problems like Nathan’s, all to save other families from what hers went through. “If I could spare other kids and parents, that would be great.”

When Nathan’s reading issues in school became apparent, he obtained an IEP, or individualized education plan. Still, even with the extra support, even with his mother working with him over the summer, he was always reading at least one grade level below his peers.

The constant struggle with no payoff left Nathan feeling demoralized. After he finished third grade, Laura Koenig had enough. “He’s so smart, and he’s so sad,” she said. “There has to be something more.”

The Chester County mom joined some parent dyslexia groups on Facebook, and saw one piece of advice repeated over and over: Get your child’s vision checked. She knew Nathan had passed typical vision screens, but the posts talked about “vision therapy.”

“And they’re like, sometimes the kid needs vision therapy and not reading support,” said Koenig. She had never heard of vision therapy, but something about it clicked for her. Nathan, then almost 10 years old, also couldn’t tie his shoes or ride a bike. Could he have a problem with his eyes?

She booked an appointment for an eye health exam, which is more comprehensive than vision screens. During an eye health exam, an ophthalmologist or optometrist checks, for instance, the health of the structures of the eye, and how well the eyes focus, move, and work together.

Because children’s eyes change a lot in the first years of life, the American Optometric Association recommends that all children receive comprehensive eye exams from an optometrist or ophthalmologist between 6 and 12 months of age, once between the ages of 3 and 5, and then every year after age 6. But according to the CDC, fewer than half of preschool-aged children ever receive an eye exam from an eye doctor.

During Nathan’s test, the doctor determined that Nathan had a severe form of ocular motor dysfunction, in which his eyes darted around, unable to stay along a line of text, such as in a book. “It’s like you’re riding on a roller coaster when you’re sitting still,” said Koenig.

These types of eye movement disorders aren’t rare. Between 2% and 13% of school-aged children have convergence insufficiency, one of the conditions Nathan was diagnosed with, in which the eyes struggle to work together.

Nathan started vision therapy, doing exercises to train his eyes to remain where he wanted them. After eight or nine sessions, he asked his mom to show him how to tie a shoe again.

“I’d show him. And he’s like, ‘Oh, yeah.’ And then he could just do it,” Koenig said.

When she asked him why he couldn’t do it before, he told her: “‘I just didn’t know where to look.’”

When Nathan started fourth grade in September 2021, he was reading at a first- or second-grade level. But as he continued his vision therapy sessions, his reading dramatically improved; by the end of fourth grade, he was reading as well as his peers. “The teachers are calling and the reading specialist is calling, and they’re like, ‘Oh my God,’ ” Koenig said.

Koenig unfollowed the dyslexia parent groups on Facebook and started following the vision therapy groups, where she saw “so many, so many, so many stories” like his, of families who thought their child had a learning disability when the real issue was eye problems that school-based vision screenings had missed.

Unfortunately, addressing the issue isn’t cheap: Vision therapy is often not covered by insurance, and each session costs more than $100. Koenig estimated she spent $5,000 on 38 sessions. Without it, “the possibilities of [Nathan’s] life were diminished,” she said.

To widen access to eye health exams, Koenig is supporting legislation championed by State Sen. Chris Gebhard (R., Lebanon) to require a comprehensive eye health exam when children enroll in public school, then again in fourth and eighth grades.

Gebhard introduced Senate Bill 780 last year, which stalled in committee, and will likely be reintroduced next year.

The bill seeks to identify kids who have eye problems, so they — like Nathan Koenig — can get the appropriate treatment, not struggle through school without addressing the root cause of their issue.

“Basically, it changes their life,” said Jesse Jones, an optometrist at East Falls Eye Associates, who is advocating for this legislation.

Pennsylvania wouldn’t be the first state to enact this kind of law. Since 2000, Kentucky has required that all children who start public school have an eye examination by an optometrist or ophthalmologist. Among more than 5,000 children who underwent the exam in Kentucky after the law was passed, hundreds were diagnosed with eye issues such as amblyopia, in which the brain doesn’t recognize vision information from one eye.

Years after he was diagnosed, Nathan is now in seventh grade, and still reading at grade level. Recently, he started writing a short story. “He’s doing terrific,” Koenig said.