CI: The Private Eye Goes Public – Part 4

Let’s briefly review the answers to the first three questions that Dr. Fortenbacher posed in part 1 of this investigative series, before addressing the final two points on why some doctors are disregarding a visual condition that leaves children and their families struggling needlessly:

Could it be lack of training?

There is a lack of training in the background of some eye doctors, making them uncomfortable in treating patients with convergence insufficiency. This is particularly true for MDs, or eye surgeons, who do not keep pace with evidence based care in the field of Optometry or, in certain instances even in their own literature.

Could it be the lack of a viable delivery system for treatment in the doctor’s office or referral network?

Special resources are required to deliver effective vision therapy treatment for convergence insufficiency. For doctors who do not possess these resources, collaboration or co-management with Doctors of Optometry, such as those who follow guidelines through www.covd.org, should be undertaken in the best interests of the patient.

Could it be that the doctor doesn’t care?

To the contrary, most doctors are very caring. For many years, physicians felt they were safeguarding their patients by advising them not to pursue optometric vision therapy, despite the availability of clinical practice guidelines from the American Optometric Association supporting its application. We have reviewed some of the reasons for this, and to this we’ll add a very powerful set of statements from a marvelous book on chaos and organization in health care by two prominent physicians, Thomas H. Lee, M.D. and James J. Mongan, M.D.:

“Physicians’ high personal standards of excellence are of course a crucial asset to medicine. These high standards, though, can lead to psychological defense reactions that sometimes actually work against the improvement of care.”

“The stakes are also high for doctors’ reputations, so physicians often respond to worrisome information by demanding more and more data, and more and more analyses – sometimes making demands that simply cannot be met.”

Could it be that the eyecare professions don’t emphasize it in the journals or the doctor’s continuing education?

Articles on the treatment of CI have been few and far between in medical journals given the prevalence of the condition. And continuing education lectures tend to reflect information that doctors want to hear, complementing accepted information from published sources. That is why we anticipated that the publication of the gold standard science CITT study would result in a paradigm shift in the field. Yet two years later, the impact that this has had on the way doctors practice is barely detectable. The increase in continuing education course material for doctors regarding this important condition has been negligible.

Is there any evidence that the ophthalmology journal in which the CITT study was published actually tried to limit the influence that it feared the study would have? The answer is yes, and we suspect you’ll find the evidence troubling.

In the center of the first page of the published study, right in the middle of the opening paragraph, there is a highly unusual statement prominently inserted. It reads: For editorial comment see page 1455.

The gist of this editorial is that while the CITT group is to be congratulated for the rigor of their study, readers should be cautious in accepting the validity of the results. Why? Because the writer of the editorial, a pediatric ophthalmologist not involved in the study, took an informal survey among his colleagues that supports that the current way that CI is treated is adequate, and wasn’t well represented in the study.

This is truly mind boggling. For years critics of optometric vision therapy have resisted accepting its contributions because they claimed it lacked scientific rigor. The CITT study was done so well, and with the participation of prestigious institutions such as Bascom Palmer and the Mayo Clinic, that Archives of Ophthalmology – a publication of the American Medical Association – was unable to come to grips with it. They saw fit to insert an editorial flag right in the middle of the article – virtually unheard of in scientific publications – attempting to qualify evidence based outcomes from a mutlicenter NEI funded trial, with anecdotal evidence proclaimed by an editor.

Could it be because some organizations like the AAP, AAO and the AAPOS trivialize CI by lumping it in with LD and dyslexia thereby giving CI (and the treatment for CI) a misleading and “controversial bias”?

As Dr. Fortenbacher demonstrated in Part 3, the answer is yes. Ophthalmology as a rule continues to try and obscure the issues to the public. Its joint policy statements are laden with innuendo and poor science. This ongoing effort of “organized medicine” to cast aspersions on a valuable service offered by Optometry is transparent.

An added proof to Dr. Fortenbacher’s conclusions is an exchange between one of the CITT authors writing independently to the journal, Optometry and Vision science: CI – Granet_letter_8-09 OVS

and the reply by representatives of the CITT: CI – CITT_response to Granet _8-09 OVS

As you read the exchange in these letters, think back to the comments by Drs. Lee and Mongan above in the book on Chaos and Organization in Health Care:

In this instance, the demands made of vision therapy have been met despite the bar being set much higher than the demands for other aspects of eyecare. The worrisome information in this instance is that the way optometrists have been approaching vision therapy for CI all these years yields much better outcomes than the ophthalmologic approach. It must be humbling for physicians to admit they are wrong about optometric vision therapy, to advise their patients of the outcome of the CITT study, and to change their preferred practice patterns.

We are sympathetic to this plight. But to do otherwise, at this juncture, would be unconscionable.