Parlez Vous Vision Therapy Part Two

Ah, the River Seine, its banks so invitingly framed by magnificent Parisian architecture.  How exciting that its waters are stirring with a renaissance of European interest in vision therapy.

If you were as impressed as I was with the paper from France published in Investigative Ophthalmology & Vision Science  on vision and postural stability in children, check out the original paper on which it was based.

The paper was published 10 years ago in the journal Pediatric Neurology:

VERTIGO as Masquerade in BV – Ped Neurol 2000

The IOVS paper and the Pediatric Neurology paper have an author in common, an MD based in the Department of Otorhinolaryngolgy and Ophthalmology at the Robert Debre Hospital in Paris.     But enough name dropping – let’s get to the meat of this paper, which is that a significant number of children with seemingly inexplicable complaints of dizziness and headaches would be sent for an MRI when what they really need is a more in-depth vision evaluation.  I’m going to quote from several sections of this paper, because it is pertinent to so many aspects of what we’ve been blogging about.

In reviewing the patients in this study, the authors note the following:  “The sensation of dizziness described by the patients did not correspond to any classic vestibular abnormality.  A relation to ocular disorders was sometimes suspected because of associated headache, blurry vision during reading, or eye irritation after watching television screens or computer monitors or occurring when fatigued.  Another sign was observed during the clinical examination when obvious eye convergence insufficiency was demonstrated while maintaining the gaze at a target drawn closer to the along the midline.”

What is the relationship  between ocular disorders and vertigo?  The authors observed:  “Gaze stabilization is one of the fundamental factors necessary for equilibrium.  Abnormal refraction or a vergence insufficiency could lead to poorly adjusted visual control … Failures in binocular vision or in convergence can be responsible for gaze stabilization during movement and double or blurry vision during fixation, which could generate a sensation of imbalance and dizziness.”

The authors further note that increased efforts at visual fusion when learning to read or with increasing use of the computer may explain why in some patients adaptive mechanisms become insufficient to compensate for the ocular disorders. Vertigo of even the mild variety discussed is often associated with headaches when related to ocular disorders – in fact at a 44% rate in this study.

The authors relate that untreated hyperopia and CI can even contribute to headaches upon awkening if the visual demands of the preceding evening were severe.  They add:  “Patients fitting the aforementioned profile should first be referred tor a complete clinical ocular examination before any other costly investigations, such as MRI, are performed.  The failure to detect and identify the responsbile ocular abnormality can lead to unnecessary MRI and inappropriate therapy.

And here, their piece de resistance:

“Unfortunately, particularly in children, convergence insufficiency is not systematically investigated during standard ophthalmologic examinations, and hence vergence anomalies pass undetected.   Although headaches is a common indicator of refraction or vergence anomalies, only rarely do specialists or pediatricians recognize dizziness and vertigo as indicators.  Our study has demonstrated not only that vergence anomalies and refraction anomalies can be the cause of vertigo but also that their specific treatment alleviates the problem.”

The take home message here?  Inexplicable headaches or dizziness sometimes require an MRI when the patient isn’t responding to vision therapy (the elementary form of which is called orthoptics).  But give VT a shot first before dismissing the complaints as baseless, or patronizing the child and parent.  In overlooking the obvious, and telling parents that their child’s eyes are fine, the authors (who are MDs) are telling us that their colleagues are setting set up patients for expensive tests and blind alleys.  We subsequently see these children who struggle needlessly, and set them on the road to success.  And parents always ask us: “Why weren’t we referred to you sooner”?

This, my friends, is an important message to share, particularly considering the article’s source in Pediatric Neurology.  Vive La Difference!

8 thoughts on “Parlez Vous Vision Therapy Part Two

  1. In my 1995 COVD paper, Vision Therapy and Quality of Life, we surveyed 838 patient’s parents with the question, “What changes have you seen since beginning vision therapy. The majority of these children were seen for difficulties with vergence (near-to-far or far-to-near) eye movement problems. 128 noted improvement in sports, driving, coordination, or reduction in dizziness. While gold standard studies in ophthalmological journals have shown the reduction of symptoms in reading after vision therapy, the area’s of balance, cooridination and dizziness have been overlooked. It’s good to see that 15 years after our paper that at least some ophthalmologists are catching up. The public will be better served when they all do.

  2. Very good point, David, though the paper I cited was in 2000, so they caught up only 5 years after you published it. 😉 You are correct that the CISS done in conjunction with the CITT, as great as it is, gives this area short shrift. Where the balance — CI connection becomes obvious is with patients having experienced acquired brain injury (ABI), where the primary visual signs include dizziness and CI. There is no evidence that the paper I cited that the children had ABI, which is why it appears to be an important paper to cite. Until the follow up paper in 2009 in IOVS, there wasn’t much written about it. So as you I find this an encouraging sign, and the bottom line is for the public to be informed and properly served. Thanks again for taking the time to comment.

  3. Dr. Press:
    Thank you for the article. In California, Dr. Byron Newman operated a small VT practice in a PPO. The physicians there referred most of their persistent headache and motion sickness cases to him for vision therapy. It was more cost effective to resolve the underlying visual skills deficiency than to order MRIs and other medical probes. The article illuminates the effectiveness of checking vision first, particularly in light of the present state of medical economics reform.

  4. Thanks for the article and your comments. One of the symptoms on my history form is dizziness. Certainly when you have a CI and the print is moving around on the page it can make you feel dizzy, and when I demo that to the parents they can really understand why.

    There are way too many MRIs ordered for HA and dizziness before making sure that a vision problem isn’t causing it. Of course, at least I don’t have to worry it might be a brain tumor since by the time I see the patient they have already had an MRI. 🙂


    • You’re welcome, Carol. You are so right — the challenge is to maintain balance between an index of suspicion for disease, and not overlooking or trivializing the functional vision component. Of course, just because the patient had an MRI before they’ve seen you, doesn’t mean something can’t be brewing that didn’t show on the imaging studies prior to seeing you, but will surface subsequently.

  5. Our daughter was diagnosed about two years ago with over convergence. The optometrist recommended some bifocal reading glasses which she wore for only a short time because they did not seem to help her reading problem. She continues to struggle with reading and gets frequent headaches and motion sickness. Is the over convergence a possible cause of these symptoms? If so, should we try vision therapy?

    • Absolutely, James. bifocals can only do so much, as they are a passive way of decreasing the over-convergence. Active vision therapy is indicated if the bifocal approach is not having a significant impact on her symptoms.

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