Ophthalmo-Minimalism: “His eyes are fine”

I saw a young boy as a patient in the office this morning who is almost five years of age.  His history is amazing, and suffice it to say that he had a rough start in life.  In the NICU for the first six days after birth, neonatologists recognized that he had severe motor weaknesses.  He doesn’t really fit into any pattern of a known syndrome, and currently bears the diagnostic entity of “neuromuscular problems of unknown origin”.  Sociable and articulate, he’s been talking since 9 months of age, and has received significant amounts of occupational and physical therapy.  As the early intervention period came to a close at age three, someone decided it would be a good time for him to have an eye examination.  His parents took him to an ophthalmologist, and here is a copy of the report sent to his other physician providers:

OPHTHALMOLOGY – Minimalist Repor t 2010

Now that’s what I call “ophthalmo-minimalism”.  20/20 visual acuity.  Eye exam normal.  See you in two years, and don’t let the door hit you on the way out.

As was the case with this young man, we get many referrals from OTs and PTs who understand how the eyes are interconnected with the rest of the body’s motor systems.  Both the OT and PT recognized that this child had difficulty with copying, switching focus from near to far, and with visual motor testing relative to gross motor testing.  They suggested to mom that her son be examined by a developmental optometrist, and impressed upon her that although “his eyes are fine”, that’s not where the visual system begins or ends.  And when mom brought in her son’s report from the ophthalmologist, I was reminded of the extent to which we miss more by not looking than by not seeing.

So we looked deeper into Jonathan’s visual system, as closely as one can look without peering directly into the rest of his brain.  He showed a low amount of hyperopia on manifest retinoscopy but +2.50-0.75 cx 180 OU after just 15 minutes of one drop of  1% cylopentolate having been instilled.  His Keystone Visual Skills showed a high dergee of binocular instability, with eso at distance compatible with latent hyperopia, and exo at near compatible with accommodative stress and lag.  He also exhibited a small but significant variable vertical drift, compatible with his overall motor history, and his strereopsis was reduced.  The WACS (Wachs Analysis of Cognitive Structures) Test showed that his visual cognition was substantially lagging behind his superior verbal intellect and reasoning skills.

I’ll be meeting with his parents on Monday to gain a bigger picture, and will stay in touch with his developmental pediatrician, physical therapist, and occupational therapist.  Though I haven’t decided as yet what course of action we’ll take, I do know one thing for sure.  His eyes may be fine, but his vision isn’t “normal”.

Leonard J. Press, O.D., FCOVD, FAAO

5 thoughts on “Ophthalmo-Minimalism: “His eyes are fine”

  1. I just reviewed a “second opinion” that a parent decided to have in a similar case. That letter was very similar except it include the note: “I find it very unlikely that he is actually having any visual difficulties.” I guess it’s hard to find things you don’t test for.

    • Precisely, Jenna. In most cases, arrogance borne of ignorance. Consider this: For years, ophthalmologists said CI can be treated fine by reassurance or pencil pushups. The CITT study published in their own journal proved conclusively that CI not involving office based therapy is no better than placebo. The CITT is gold standard evidence-based medicine (EBM). So that means any ophthalmologist not Rxing office based VT for CI isn’t practicing evidence based medicine. Despite this, you won’t find a single ophthalmologist Rxing office-based VT. How’s that for the height of hypocrisy?

  2. Another case of if you don’t look for the problem, you won’t find it. Unfortunately, Opthalmologists don’t know what they don’t know. They arenn’t trained in the diagnosis and treatment of these problems. They don’t know about the testing that can be done to diagnose anything other than gross eye movement defects and look at them as an eyeball problem rather than a brain control of the eye problem.

    • Very true, Don. In a perfect world ophthalmologists would have the security to admit that this is not their field. For myriad of reasons, they’ve felt compelled to present themselves as the authorities. Consider the hypocrisy: The outcome of the CITT in which they participated makes it clear that non office based VT is no better than placebo for CI. Has that changed ophthalmologic practice?

  3. I run into this whenever I speak with parents about their children. It is also an issue with senior citizens whose OMD “exam” resulted in an Rx that made them unstable, wobbly and increased their risk of falls. I wrote the first OEP response to the terrible joint statement in 1984 and they still publish a version. Frustrating, and it makes it difficult to grant OMDs their due for the things they do right. Modern cataract surgery is a miracle compared to the crude technique my father suffered in 1970. Too bad they can’t make the same advancements in their understanding of binocular vision issues. Perhaps their binocular brain cells need a dose of Sue Barry.

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