A colleague sent along this video tonight and though I’d seen it before, and we’ve been using the VEP unit in our office for several years, I had forgotten how much I enjoyed the clip. You may recognize the name of the pediatric ophthalmologist in the video, Dr. David Granet, from his well-known paper on the association between convergence insufficiency and ADHD reviewed on visionhelp.com.
Dr. Granet makes some nice statements on this segment of The Doctors TV Show. In describing the relevance of screening a young child for amblyopia, he states: “The eye is just a camera, and then you have to get it back to the CPU, the central processor. The brain waves tell us what she can see or can’t see. Amblyopia is when the brain isn’t using one eye.”
That’s a pretty profound statement, which says that poor vision in one eye, or what is called “lazy eye” in the vernacular, really isn’t a lazy eye at all. In fact, it’s more appropriate to call the condition “lazy brain”. But if we called it that, we’d really be casting aspersions on the person with the condition. So the concept that Dr. Granet is supporting is that vision occurs in the brain, not in the eyes.
This is also a crucial concept to grasp because the American Academy of Pediatrics and the American Academy of Ophthalmology have an absurd Policy Statement used to discredit vision therapy which states: “Although the eyes are obviously necessary for vision, the brain interprets visual symbols. Therefore, correcting subtle visual defects cannot alter the brain’s processing of visual stimuli.”
Huh? Wait a minute. If correcting visual defects cannot alter the brain’s processing of visual stimuli, how do we improve amblyopia? Aren’t we treating the connections between eye and brain? Optometry understands this, of course. Vision is a collaboration of the eyes and brain, and this serves as the basis for success in vision therapy for amblyopia as well as many other conditions.
Thankfully Dr. Granet doesn’t get tripped up on this point in his presentation. In fact, he sounds like a developmental optometrist when he comments in the video on the importance of treating amblyopia at a young age. Why? “I need to get it now, and for learning purposes, for school, I want her to be ready. I want her to have both of her eyes available to do everything she needs to do in life at this most important developmental time.”
Okay, we can forgive Dr. Granet for not appreciating that amblyopia can be treated successfully after the age of 10 or 12, as our colleague Dr. Dominick Maino pointed out in a nice review article on neuroplasticity. After all, this may prove to be a harbinger that pediatric ophthalmologists will one day grasp the full extent of vision therapy. Dr. Granet concludes that it’s unconscionable that these kids aren’t detected and treated. We couldn’t agree more.
– Leonard J. Press, O.D., FCOVD, FAAO
I’ve been using the VEP for 6 years and have found it not only useful for infant amblyopia detection, but also for Post-Trauma Vision Syndrome. It’s realy quite easy to diagnose this condition which I have found after all kinds of concusive or whiplash type injuries. When the midbrain that controls the more reflexive vision is out of synch with the central signal, all kinds of symptoms can be traced to an injury.
While I appreciate some of the sentiments on this particular blog, there are some that are off base. Pediatric Ophthalmologists are, of course, developmental specialists. Additionally Ophthalmologists are neuroscientists whether they study glaucoma or amblyopia. The idea that amblyopia affects the brain was well documented by Hubel/Wiesel and von Noorden 50-60 years ago (among many others). This research into impact of the visual system goes back several generations and pre-dates developmental Optometry. We use many interventions to impact the visual SYSTEM on a daily basis. For example, I work with an Orthoptist trained in the sensory motor system every day.
Further the implication that Ophthalmologists don’t appreciate that amblyopia can be treated after 10 to 12 years of age is simply a mis-statement. As just one of many examples see JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS July 1, 2006 Treatment Options for Anisohyperopia by David B. Granet, MD; William Christian, MD; Cintia F. Gomi, MD; Lydia Banuelos, MD; Erika Castro, OC(C) or Dr Rutsteins review 5 years ago. The ATS group did powerful work in this area.
As a specialist who was treated with a form of VT for convergence problems as a child and one who uses them in the office I am well aware of the value of building accommodative and fusional amplitudes, as are my colleagues. The reality of the disagreement between us is the scientific basis for implementation of VT in other circumstances – like reading difficulties where no ocular motor defect is involved.
Even for ADHD we were, as you noted, quite careful about drawing conclusions. In the CITT studies only SYMPTOMATIC CI was studied since we do not understand why many kids have all the physical deficits of CI with no complaints at all. Some children have the complaints but not the signs of CI. Many questions need to be answered. In the meanwhile the science of reading has exploded and the top specialists in that field do not reference back to ocular motor issues as the reason for reading deficits or dyslexia (ie Shaywitz). Sports are even more confusing. Catchers, who have more training see pitches than any other player, do not typically have the highest batting averages as a group. As the best coaches will tell you there is no substitute for practice at the task you actually want to improve in – be it sports or reading. The science in those fields agrees.
Please accept my apology in advance if it seems otherwise but I have no intent or desire to “argue” or “hijack” this discussion. This is your blog and I respect that space, but only since I was mentioned I wanted to clarify any confusion.
Just the opposite, Dr. Granet. I hope to show you how on base my remarks are. And no need to apologize. As opposed to hijacking the discussion, I wish we could have more of this kind of dialogue. It’s my firm belief that if this were to occur more often, much of the Joint Organizational rhetoric of the AAP and AAO would be put to rest. At the very least, several pediatric ophthalmologists in my area, and I know this to be true with like-minded colleagues, are very comfortable having their patients co-managed with optometric VT after we have the opportunity to talk about its scientific basis and efficacy. If nothing else, this allows them to give a more informed second opinion when patients seek their opinion, rather than making broad assumptions. Conversely, the majority still dismiss what I and my colleagues do out of hand, either through willful or unintended ignorance.
I had the experience, in 2001, of being invited to speak on a panel in front of an assemblage of 150 pediatricians and pediatric ophthalmologists at a special session of the AAP on “Why Can’t EYE Learn”. It was an extemporaneous invitation due to one of the presenters being delayed in transit, and while optometric vision therapy wasn’t part of the planned program, the questions I got during the panel discussion and ongoing discussions since that meeting have given me a good feel for how the medical pediatric community at large views optometric vision therapy. I do appreciate, however, the tenor of your remarks.
As to your comments directly:
1. You stated: “Pediatric Ophthalmologists are, of course, developmental specialists. Additionally Ophthalmologists are neuroscientists whether they study glaucoma or amblyopia.” I trust you will acknowledge that the field of Optometry pioneered in visual development as a field that encompassed more than the eyes, well before pediatric ophthalmology was born. Your field essentially emerged in the 1950s, led by Parks on the East Coast and Jampolsky on the West Coast, as an outgrowth of Strabismology. Developmental Optometry traces its origins to the early 1900s, and the discipline was formalized in 1928 when A.M. Skeffington formed a postgraduate organization dedicated principally to the influence of vision on development and behavior.
Regarding the neuroscientist element, optometrists engaged in vision therapy function in a neuroscientific framework at least as much as pediatric ophthalmologists. Entire semesters of classrooms and laboratories dedicated to the subject within physiological optics, binocular vision, strabismus and amblyopia coursework prepares the developmental optometrist to think along these lines when first gaining exposure to and then specializing in this area of clinical care. No doubt you have encountered a high level of neuroscientific thinking with optometric counterparts involved in the CITT and/or PEDIG research studies.
2. You noted that “The idea that amblyopia affects the brain was well documented by Hubel/Wiesel and von Noorden 50-60 years ago (among many others). This research into impact of the visual system goes back several generations and pre-dates developmental Optometry.”
I’m very pleased that you bring up this work, because it has been conscripted by pediatric ophthalmology for many years to justify some questionable clinical interventions. But don’t take my word for it. Let’s go right to the source. There’s a marvelous book entitled Brain and Visual Perception by Hubel & Wiesel, published in 2005, which is the story of their 25 year collaboration. As a Foreword to presenting their second group of papers on visual deprivation, specifically with regard to their amblyopia research on kittens, they write (p. 405): “We naturally worry about the implications of this result for the commonly employed treatment of the human lazy eye by placing a patch over the normal eye. That procedure does work, to the extent of improving the vision of the lazy eye, but can only impair any possible residual stereopsis. And stereopsis is presumably a large part of the reason we have two eyes.”
So what of the implications for binocular vision? With regard to the plasticity and development of monkey ocular dominance columns, the series of papers on which modern pediatric ophthalmology hangs its hat for a so-called critical period begging early surgery, the Afterword is equally telling. Hubel & Wiesel write (p. 590): “There seems to be little to add to these papers. A missing aspect of this work is knowledge of the time course of the strabismus animals, cats or monkeys, and in monkeys the possibility of recovery – but that would have required many more monkeys, and one cannot do everything. To repair an artificial strabismus would probably exceed the limitations of our ophthalmologic surgery, unfortunately, considering how useful that type of knowledge would be to clinical ophthalmology.”
One other comment in the book that has great bearing on our discussion, if I may. On p. 46 Hubel and Wiesel write, regarding today’s specializations: “We no longer try, or are asked, to read critically papers outside our immediate fields, and we all suffer for that.” I couldn’t agree more, though I daresay that the average developmental optometrist is much more widely read in the field of pediatric ophthalmology, than the average pediatric ophthalmologist is in the field of developmental optometry. The reasons why that is so would make for good discussion another day.
3. You finish the thought by adding: “We use many interventions to impact the visual SYSTEM on a daily basis. For example, I work with an Orthoptist trained in the sensory motor system every day.”
As noted above, optometric vision therapy is quite advanced over orthoptics. While orthoptics works on the sensory motor system, it is still rooted in eyeball kinematics. Taking nothing away from the work that you and your orthoptist do,
it scratches the surface of the pervasive nature of the visual system as it extends to the entire brain and subcortical structures. Indeed, you’ve given me a wonderful idea for another blog piece to amplify this.
Parenthetically I’m curious if you’ve read “Fixing My Gaze” (2009) by Susan Barry, Ph.D., a marvelous journey into the topics above, replete with journal article notes and citations, and a back jacket endorsement by David Hubel. if so, you may know that she had three eye muscle surgeries by the time she was 7, and was told she was fine by a litany of pediatric ophthalmologists. After she benefited immensely from vision therapy as an adult, she wrote this book and with a careful read I suspect it may make you and your colleagues a tad more receptive to the applications of vision therapy beyond orthoptics. I particularly liked the comment by Nigel Daw (Prof Emeritus of Ophthalmology & Neuroscience at Yale) who writes: “Magnificent … It is not yet clear what percentage of patients may be like Barry, but Fixing My Gaze will encourage eye-care practitioners to go ahead and find out, with definite benefits to their patients. Moreover, the book is fascinating reading.” The fact is that we have numerous patients who have benefited from optometric VT after being told by ophthalmologists that their eyes were “fine” and therefore no consideration should be given to optometric vision therapy. My hunch is that “fine” is defined by what one considers to be the visual system in actual practice, rather than in theory. As an added parenthetical exercise, I wonder if you took a poll among your colleagues at the next AAPOS meeting, how many would say they have ever referred a patient for optometric vision therapy?
4. You object that “The implication that Ophthalmologists don’t appreciate that amblyopia can be treated after 10 to 12 years of age is simply a mis-statement. As just one of many examples see JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS July 1, 2006 Treatment Options for Anisohyperopia by David B. Granet, MD; William Christian, MD; Cintia F. Gomi, MD; Lydia Banuelos, MD; Erika Castro, OC(C) or Dr Rutsteins review 5 years ago. The ATS group did powerful work in this area.”
I’m very familiar with the ATS work in this area, and there is not misstatement on my part. Here is what I wrote on the blog: “Okay, we can forgive Dr. Granet for not appreciating that amblyopia can be treated successfully after the age of 10 or 12, as our colleague Dr. Dominick Maino pointed out in a nice review article on neuroplasticity.”
As you can see, I was referring specifically to your views on the subject in the context of The Doctors TV segment. At the 7:30 mark of the video you state: “And if I get her with amblyopia at age 10 or 12, it’s not fixable. I need to get it now.” Suspecting that you were well aware of the ATS, I gave you a pass figuring that the hubris was due to getting caught up in the drama of making a point for the viewing public, and confusing “fixable” with “treatable”. But since you raised the issue, to what extent do your colleagues actually follow the ATS guidelines? Two recent studies based on surveys of ophthalmologists, one in the US and one in the UK, indicated that at least one third of your colleagues haven’t changed their reluctance to treat amblyopia beyond adolescence based on ATS research outcomes.
5. Next point. You wrote: “As a specialist who was treated with a form of VT for convergence problems as a child and one who uses them in the office I am well aware of the value of building accommodative and fusional amplitudes, as are my colleagues. The reality of the disagreement between us is the scientific basis for implementation of VT in other circumstances – like reading difficulties where no ocular motor defect is involved.”
Well hold on a moment. The reality of the disagreement is much greater than that, and I’ve alluded to the politics of the situation cloaked in a mantle of scientific concern previously on this blog. The experiences that I and my colleagues in developmental optometry across the country have is that in actuality, most pediatric ophthalmologists do not practice the type of treatment approach that was used in the office-based therapy paradigm of the CITT.
Now with regard to “the scientific basis for implementation of VT in other circumstances – like reading difficulties where no ocular motor defect is involved”, your model is self-limiting. For a broader scientific view, see: Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in nonstrabismic accommodative and vergence disorders. Optometry 2002;73(12):735-762. In particular, I call your attention to elements of motor learning and motor planning reviewed in that article that go well beyond “ocular motor deficit”. The pervasiveness of the visual system beyond the ocular motor deficit per se as recently shown by fMRI studies, and its implications for vision therapy, is where we principally differ.
Again, if we’re going to adopt a suitably broad definition of the visual system, including (as you agreed) brain connections with the eye, then we can’t declare by fiat that what you and your orthoptist do in your office is scientific and proven, and what I and my colleagues do in optometric vision therapy beyond orthoptics is any less scientific or proven. After all, if CI treatment the way you do it wasn’t scientifically proven until the recent CITT outcomes were published, then your use of basic orthoptic techniques for CI prior to that point was based on your personal anecdotal experience as a child, and decision to adopt this treatment modality without scientific support, wasn’t it? What I’m saying essentially is that “what’s good for the ophthalmologic goose has to be good for the optometric gander”.
6. Lastly you wrote: “Even for ADHD we were, as you noted, quite careful about drawing conclusions. In the CITT studies only SYMPTOMATIC CI was studied since we do not understand why many kids have all the physical deficits of CI with no complaints at all. Some children have the complaints but not the signs of CI. Many questions need to be answered. In the meanwhile the science of reading has exploded and the top specialists in that field do not reference back to ocular motor issues as the reason for reading deficits or dyslexia (ie Shaywitz). Sports are even more confusing. Catchers, who have more training see pitches than any other player, do not typically have the highest batting averages as a group. As the best coaches will tell you there is no substitute for practice at the task you actually want to improve in – be it sports or reading. The science in those fields agrees.”
As I think I’ve made the point adequately, it is a disingenuous if not misleading approach to equate “science” with the point of view that one wishes to adopt, and dismiss other points of view as lacking science. If we use the CI Symptom Survey (CISS) done in conjunction with the CITT, then we have quite good evidence that those with clinically significant CI are the ones more likely to have symptoms. This is not to say that it wouldn’t be nice to understand why some children are stoic and others aren’t, the same way it would be nice to know why some patients with severe dry eye don’t complain, and others with marginal dry eye have considerable complaints. (On some days I wish I had the stoicism of one of my dear long-standing patients, now in her ’80s, whose favorite saying about any abnormality [as she shrugs her shoulders] is: “Ok, dear. Whadaya gonna do?”)
Regarding Shaywitz and science, you couldn’t have picked a better can of worms to open. There are numerous reasons why Shaywitz and the anti-vision crowd don’t have the final say on the science of reading, some of which I’ve discussed here. The lack of scientific awareness in the reading field toward the visual aspects of reading in general, and the indications for vision therapy is well summarized by Solan (Solan HA. Learning-related Vision Problems: How Visual Processing Affects Reading Efficiency. Learning Disabilities: A Multi-Disciplinary Journal 2004;13(1):25-32. Scheiman & Rouse have written a textbook on learning related vision problems that bears heavily on reading, and Griffin et al wrote an optometric text on the scientific and clinical aspects of reading that should give proponents of the Shaywitizian model pause. But don’t take it on face value from a developmental optometrist. You can derive positive conclusions about the influence of the visual process in reading [beyond ocular motor, I might add] from a researcher every bit as accomplished as Shaywitz, Stanislas Deahane, in his compendium on Reading in the Brain.
On the subject of sports vision and science that you raise, our colleagues David Kirschen (optometrist) and Daniel Laby (ophthalmologist) in your neck of the woods seem to be developing a pretty good scientific handle on the subject that goes well beyond, as you put it, just practicing the sport more. They are a nice example of collaboration that should be occurring more in our fields, and you can read more about it here.
At first blush I liked your analogy about catchers, but consider the flaw in the logic. Catchers may actually be at a disadvantage in hitting because their consistent angle on the pitch is its action at a point beyond where the hitter sees it, and a considerably lower angle. What sharpens a catcher’s eye to be excellent defensively is quite different from reacting to the pitcher’s release point and spin in an upright stance. Additionally, a catcher’s visual perspective is with his body squared to the ball and both eyes straight ahead, whereas most hitters have their body at a right angle to the catcher, with considerably asymmetric convergence. Further, catchers may represent a bit of a skewed population because they are self-selected for a position where hitting or speed isn’t their main attribute. Power and accuracy of one’s arm, blocking balls in the dirt, and calling a game/handling pitchers are relatively more valued. As the best coaches will tell you, and science supports, practice doesn’t make perfect. Perfect practice makes perfect. So whether in baseball or in reading, sometimes someone with a vision therapy background can help optimize outcomes beyond what orthoptics provides.
Well, that’s quite enough for a lazy Sunday afternoon on this Coast, waiting for yet another big snowfall mid-week. Thank you again for your comments, and the respectful note at the end of your remarks. I trust this clarifies any confusion as well, and I thoroughly enjoyed the exchange. Please stay tuned to the blog, and I welcome your comments at any time in the best interests of patient care.
I am glad you were comfortable with me responding. As you are aware I have been interested and studied these issues over an extended period of time. I have no professional axe to grind but prefer clarity. I will VERY BRIEFLY comment on some of the interesting points you raised.
1- You finessed the history of the fields here a little. Strabismology was well identified as a subspecialty long before Skeffington. Simply glancing at older texts from the early 1900’s and well before would show that. See Helveston’s wonderful chapter in von Noorden’s history text for the USA component but the overall history spans thousands of years worldwide. The German’s for example were there well before us. Pediatric Ophthalmology arose differently and traces its roots to the 1800’s (see the updated text by Ken Wright, MD – I penned the history chapter). Due to the nature of the age at which amblyopia and strabismus often are identified Pediatric Ophthalmologists became the group most expert in Strabismus. However even over the World today those two fields are not always one. My comment re neurosciences was simply to counter the idea that ophthalmologists were only interested in eyes – that simply is not true.
I have enjoyed meeting many academic optometrists and count more than a few as friends. But we do not always agree! 🙂
2.I had the wonderful opportunity to chat with Hubel & Wiesel when they attended a major Pediatric Ophthalmology meeting. I could also deconstruct parts of their work but that misses the forest for the trees. We are always trying to preserve stereo acuity and approach treatment of amblyopia and strabismus in that manner. I have helped many many patients that had VT to no avail. Does that implicate the field?
3.I disagree with your characterization of Orthoptics. In fact our Orthoptist was certified in the CITT to provide VT in the study. The combination of an orthoptist and a pediatric ophthalmologist is powerful. The book you reference is really a dicussion for another day. However I have a practice thathas a very large adult component. We use orthoptic intervention all the time as well as surgical and have recovered stereo acuity in some that were told they’d never have it. They just don’t write books. We carefully investigate all options before intervening.
4. The issue here is the implication that I did not know that kids can’t be treated at an older age when I have published on this! There is no one I am aware of that disagrees that success rates drop as children age and we’d prefer strongly to get them early. FYI I offer amblyopia therapy at any age after discussing the known data. Yes, for TV this discussion is complicated, and so gets edited (not under my control). Would you disagree that we want children as early as possible?
5. Interestingly you completely missed the fact that I was treated by a developmental Optometrist as a child. In fact he was my cousin and helped teach at the Optometry school in NY. My interest in the field began then. My son too has significant CI. We are both GREAT readers. Your conclusion was flawed as to why I decide to treat. See what happens when we assume? CI alone does not have to cause deficit in understanding what you read. The CITT studies are interesting for what they did and didn’t look at. In my office we make patients aware of the options for treatment and the outcomes from the study. So far the vast majority choose the home approach (using in part a program developed by an Optometrist). We are int he midst of fMRI projects and have recently published our first foray into the field regarding a different topic. I am confident I stay on top of this work.
6.You are incorrect regarding the CITT. ONLY those with symptoms were included to begin with. We have no good data regarding those with CI mechanically but no symptoms. We also do not know how many have CISS criteria symptoms (like in a reading remediation class) but no CI. Shaywitz has no reason at all to be “anti-vision” and I have never heard her termed that way. She is only invested in the science. It is a little disappointing to hear such a terrific pioneering researcher termed biased in her approach.
I know Dan Laby quite well and David Kirschen somewhat for many years as I did my thesis in medical school on this topic. I wrote a chapter on vision in Sports for a text as well. I am sure you knew that before writing. You laid out the problem with vision and sports wonderfully – success rests on many factors. There are many examples of successful athletes with compromised vision. I am very coordinated but can’t hit a 90 mph fastball. But baseball is Darwinian. Hitting .250 is failure and .300 is success worth millions of dollars. That translates to one hit a WEEK for a major leaguer. Wade Boggs ate chicken for every meal, Michael Jordan wore his college shorts under his pro ones. They were successful – so should I go eat chicken and buy UNC shorts? Reading is similarly complicated. Shaywitz recommends 60-90 minutes a day of guided practice for reading. As you say it is properly practicing the task that matters. That’s why I like reading specialists and educators.
I suspect we could both go on and in depth quoting and characterizing arguments. I am happy to rely on science and be exposed to the data. After all if the science supports the intervention, I can combine that with surgery etc in my office and be a one stop shop for my patients. I have a financial incentive to do this. Until that time I will utilize the best science I can find and educate my patients (including letting them know other options) and make less!
I do appreciate your courtesy in inviting me onto your blog again. As a transplanted New Yorker I especially appreciated the weather report! Best wishes from the left coast.
Thanks for the reply, David. As you, I crave clarity, and though of necessity we must be brief in forums of this nature, it is refreshing to be able to disagree agreeably based on our respective knowledge of and experiences in our relative fields. I’ll maintain the numbering system to aid the reference to your latest comments on mine:
1) I wrote a history on the evolution of vision therapy as an outgrowth of orthoptics, in a textbook on Applied Concepts in Vision Therapy originally published by Mosby. This made extensive reference to the history of orthoptics from the 1800s onward, including the European influence. I finessed it here, if you will, only to make the point that orthoptics means “straightening eyes”, and as a therapeutic discipline evolved entirely from the standpoint of maintaining straight eyes. The work on amblyopia and convergence were to serve the best interest of maintaining equal vision in both eyes and equal performance primarily in the service of alignment. It had little if any interest in the components of visual behavior and visual development from a perceptual or learning standpoint. Conversely, the optometric philosophy represented by Skeffington arose entirely out of dissatisfaction with the mechanistic orthoptic approach. Again, not to diminish the sensory-motor elements of orthoptics, and von Noorden pays elegant homage to the brain and central fusion mechanisms in his book, but one can’t compare the concern of pediatric ophthalmology in blindness prevention and straight eyes to raison d’etre of developmental optometry is optimizing visual performance and function in its broadest sense. I’ll be glad to take a look at your chapter on history in Ken’s book, and encourage you to do the same with mine.
2) I didn’t deconstruct Hubel and Wiesel’s work. I quoted directly from what they wrote, and they chose their words carefully. Your point here underscores mine. We each see skewed populations. I see the failures of pediatric ophthalmology and you see the failures of developmental optometry. Which begs the question: When you say “I have helped many many patients that had VT to no avail”, how did you help the patient? What implicates the field is that you (collectively) continue to assert that the majority of your interventions are backed by the same type of science you seem to seek from vision therapy. That simply isn’t the case. Conversely, I have helped many, many patients through vision therapy who were told by their ophthalmologists that either a) they didn’t have a vision problem or b) they had a problem but it had nothing to do with their learning issues. The bottom line is that we each do what we do well. Why if we acknowledge your expertise, and don’t presume to know which surgical interventions are best, or who would benefit from botulinum, etc., is it so difficult for you (collectively) to acknowledge our expertise?
3) You’re welcome to disagree with my characterization of orthoptics. I can only give you the sum of my experiences, my travels throughout the country, and my reading of the literature. I’m citing rules here, not exceptions, though I’m pleased to learn that you are one. There are only a handful of orthoptists in my entire state who actively practice orthoptics as a therapeutic discipline. Most have been reduced to ophthalmic assistants conducting pre and post surgical measurements. Those who do therapeutic interventions monitor the results of amblyopia therapy, principally done by atropinization or occlusion, or variations of physiological diplopia procedures for CI, with accommodative interaction an afterthought rather than as part and parcel of the procedure. Perhaps the most telling sign of what goes on nationally in the field is the editorial comment that accompanied the CITT study in Archives in 2008. And I would love to discuss Sue Barry’s book with you at any time. I suspect she would love to discuss it directly with you as well, though I can’t speak for her. What I can tell you is that since Oliver Sacks wrote his piece about her, and since her NPR piece which also incorporated comments about her experiences by David Hubel, and since her book appeared, an incredible number of persons have come forward echoing the degree to which they had been patronized by their ophthalmologist in seeking something more. Does that impugn an entire field? Clearly not. Only the practitioners who would never refer a patient for vision therapy because it has nothing to offer in their eyes beyond the MD-orthoptic combo.
4) While it’s good to hear that you recommend therapy for children with amblyopia beyond age 10 or 12, it’s disappointing to see you claim that your remarks were edited to change intent. I’ll repeat it again. What you stated was: “And if I get her with amblyopia at age 10 or 12, it’s not fixable. I need to get it now. Surely, we all agree that early intervention for amblyopia is ideal. And surely we get generally better results when we intervene at a younger age. But what you espoused to the public was a scare tactic in essence.
5) I’m having trouble following your line of reasoning here. I didn’t overlook the fact that you had VT as a child. You wrote: “My son too has significant CI. We are both GREAT readers. Your conclusion was flawed as to why I decide to treat. See what happens when we assume?”
— Au contraire, my conclusion isn’t flawed at all. It’s supporting the point that what motivated you to treat in your practice at the time you began to treat wasn’t science, but anecdotal evidence. The rest of your comments here are straw man arguments. I didn’t say that “CI alone does not have to cause deficit in understanding what you read.” All you have to do is look again the CISS and note that the majority of questions center on issues with reading, including instability of print, fatigue, attention and concentration. Certainly saying “my son and I have CI and we’re both great readers” is as relevant as saying “my son and I are both smokers and we don’t have cancer”.
6) I do the same thing as you. I make patients aware of the CITT outcomes. The difference is that I emphasize the success rate with office based therapy in combination with home therapy is more than double what the success rate is with home therapy alone. Don’t get me wrong. The HTS program is wonderful and I am one of the biggest users in the country. It’s simply that many of my patients with CI don’t “just have CI”. The other procedures that we do in-office helps them integrate their visual functions more fully and transfer to a number of different areas. Your comment about fMRI helping you stay on top of the field seems irrelevant to the discussion here.
I’m quite aware that only those with a sufficient CISS score were included in the CITT treatment groups. By the way, I was part of the original group that formulated the questionnaire when I was Chief of Vision Therapy at SUNY and worked with Drs. Scheiman, Rouse and Borsting (PCO and SCCO) and others, in conjunction with Drs, Solan, Cooper and biostatisticians from SUNY. At that time our group was CIRS – the CI and Reading Study. The very reason we formulated the questions we did was because of our clinical experiences in reading problems. There were no ophthalmologists involved yet. It doesn’t surprise me that ophthalmology seems in no hurry to prove the association. We could spend countless hours on the politics vs. merits of the issues, but please let’s stop pretending this is all about science.
Regarding Shaywitz, I’m not sure of the basis for the naivete about motives. The entire reading consortium from Reid Lyon on to Shaywitz, that is invested it the “phonetic” approach to reading argues that dyslexia is a language disorder and that the role of vision is virtually non-contributory. I’m not passing judgment on Shaywitz’s research skills. I’m pointing out that her research conclusions shouldn’t be couched in purely scientific terms to support that reading problems are “only” language problems. Indeed, read Dehaene’s research and you’ll note that his support of vision is based on the role of the occipito-temporal junction. He went with the occipito and Shaywitz went with the temporal. (Dr. Seuss was only kidding when he titled his book “I Can Read With My Eyes Shut”.)
Thanks for your compliment on my sports acumen. You note that you like reading specialists and educators because they understand that practice matters. What you’re ignoring is that VT is rarely administered before children have tried other interventions. For some reason that I still can’t figure out, I suspect that the majority of ophthalmologists (not sure of your position) are so dead set against supporting a parent pursuing VT, that even after a child continues to struggle with reading and learning, and after trying various remediations, you still can’t bring yourselves (collectively) to admire our successes. When you achieve success somehow it’s science. When we achieve success, success would have come through other means in due time. How does that double standard work?
I smiled at your comment that “After all if the science supports the intervention, I can combine that with surgery etc in my office and be a one stop shop for my patients. I have a financial incentive to do this.” — I’ve heard that tired argument before. First in my area it was ped OMDs saying “VT is bogus; all they want is your money”. That evolved to your line, that if indeed it worked you would do it. I would love for you to visit my practice on a busy day. See all the work that goes on behind the scenes as well as during sessions. See all the time spent reading background reports about the child and communicating with other professionals. Talking to parents and conducing frequent re-evaluations to monitor progress and fine tune vision therapy. See what is involved in staff development in these areas. Indeed, David, these are complex areas. It ain’t your relative’s Oldsmobile, and state of the art optometric VT is different than when you did it as a kid.
Perhaps one day you’ll acknowledge that developmental optometrists have unique expertise in these domains, and that the goal isn’t necessarily “one stop shopping in your office”. Unless, of course, you’re ready to take on a developmental optometrist as an associate or partner. ;-). All good wishes in return.
A wonderful exchange between to leaders in their respective fields. If Dr. Garnet and Dr. Press can motivate their respective professions to practice at at least the level suggested in the CITT study, we will have accomplished a near miracle without having to resolve our differences.
Thank you, Dr. Cook. I am encouraged by Dr. Granet’s willingness to discuss the issues. The merits of our respective arguments will speak for themselves.
Getting the two eye doctors discussing what’s best for the patient is what we need more of…working together, the patient benefits…Dr. Granet, it’s great to have your view and we all welcome the exchange…how enlightening that you refer to an orthoptist for your patients…try to imagine that Orthoptics is to Optometric Vision Therapy much like a Physician Assistant is to an Physician…both do a really good job, but one has quite a bit more medical background, clinical training, and expertise.
Len – I ‘ll continue to be brief and also keep the numbering system for ease. For every item I could go further in depth and I know you could as well.
1- My guess is both of us know the history of our fields better than most. However you wrote, “…but one can’t compare the concern of pediatric ophthalmology in blindness prevention and straight eyes to raison d’etre of developmental optometry is optimizing visual performance and function in its broadest sense.” I disagree to these characterizations. I’d say that pediatric ophthalmologists are the most qualified and interested group to be the protectors of the child’s visual system. I suspect we need to retire this and simply understand we will disagree.
2- The H&W comment was simply that there are many interesting parts to their work and pulling some lines out does not do it justice. I wrote about my experience treating patients simply to point out the argument you made that you helped some that ophthalmologists had not is a specious one. You asked how did I help the children that were not helped by VT? I have seen many that were being treated for large angle strabismus to no avail. The combination of prism adapted surgery and orthoptics post op restored binocular function. I have seen others that were going to VT for learning problems and never were referred to a true educational specialist. I have operated on adults and restored binocular vision when years of VT failed. The list goes on. I’ll throw out a question, how do you know a child got better as a result of your intervention? Even in the CITT study there was no matched placebo group with true home intervention and placebo office therapy. In fact one could look at the success rates of home therapy and the improvement in placebo office therapy and wonder what if they were combined? That was not studied.
3- No child comes in for an evaluation related to learning etc without having accom & fusional amplitudes evaluated in addition to many other tests. My general ophthalmology residents learn this. The fellows are tired of hearing in depth discussions and reviews of the literature as well as looking at new ones from me. As to refering pts for VT evaluation, I do it regularly. Ask the folks at SCCO or many in San Diego. But I refer when I think there is something to offer beyond what we can provide.
4- Not only do I treat the older amblyope I published it a number of years ago. That’s the value of knowing the literature. I agree with you when you wrote, “Surely, we all agree that early intervention for amblyopia is ideal. And surely we get generally better results when we intervene at a younger age.” I have a lot of experience on TV but cannot control the editing process nor the time given to a topic. Thus we speak in soundbites. If the message ends up being don’t wait then I’ll accept that. It is certainly better than “don’t worry” or “we can be successful at any age” which could be dangerous. Not sure any of this should be characterized as a “scare tactic” and I wish you wouldn’t have chosen that term as it mischaracterizes the purpose of educating the public in a limited medium.
5- You wrote, “then your use of basic orthoptic techniques for CI prior to that point was based on your personal anecdotal experience as a child”. What made you think it was basic? Arnold Friedhoffer, OD was the one providing the care and Jeff Cooper has told me he was respected in the field and taught him. (I was too young to know more than I respected him.) As for straw men, the smoking argument is just such a one. What is the incidence of CI without symptoms? What is the score on the CISS in children with reading difficulties but without CI? The purpose of pointing out that my son and I are great readers is to raise the issue of when a child comes into the office with reading difficulties and CI how do you know the CI was/is the issue? Smokers save money and improve their health when they quit – good data there. Please remember I wrote the ADHD article and am the largest user of the CVS home program (I am told) in the ophthalmic world. I am not an optometric “luddite” but rather just trying to be as unbiased as I can be interpreting all this.
6- How do you know what I tell my patients? Please don’t assume. I even hand out the article and offer to refer them to VT folks. They still choose home therapy to start with. Certainly I may show a bias as may you. However I do my best to lay out the facts – and I understand the CITT quite well, as you know.
We will disagree about the reading research and where it went and why. I raised the fMRI work simply to indicate we are looking at the brain -debunking the idea ophthalmologists aren’t neuroscientists!
Perhaps you have heard the idea that my license allows me to do VT, and I’d make more money if I did before, because it is true. I have an awesome orthoptist (certified by Mitch in the CITT) and could easily do more. But please don’t paint me with a broad brush in some group that claims you are only in it for the money. That is not fair.
I have had optometric residents in my office who told me they were “surprised” at the depth of our knowledge in the field. That made me laugh! As a participant in the CITT I tried (I’ll leave it to others to say if I succeeded) to be aware of modern VT techniques. I supported Mitch coming out and speaking at our school districts. And believe me we don’t always agree, but I very deeply respect him.
For patients, like you do, I read every piece of background material and communicate with other professionals including the schools and run behind often in my office as it takes a long time to fairly discuss reading, learning etc. I stay carefully abreast of the science and reading literature. Perhaps I like Shaywitz because I went to Yale but I see the body of literature differently than you. The one thing I think you’d have trouble claiming is that I don’t care or try to be as informed as anyone in this topic.
My kids are mad at me for taking time today to write here but I think it was worth it. I truly did not intend to have an ongoing dialog but only jumped in since you mentioned me. Thanks again for the “shout out”! Once again with best regards-
Agreed, David. We both seem to be indefatigable on this subject because it is more than just a living to us; it is a passion. And I continue to welcome your insights so that we can come to a mutual understanding. This forum gives us a unique opportunity to do so.
1) You assert that pediatric ophthalmologists are the most qualified and interested group to be the protectors of the child’s visual system. I’m glad we got that out on the table, because as a group – and again you may be an exception – the pediatric ophthalmologists I and my colleagues have encountered have little if any interest or knowledge about the visual system as it relates to child development. But again, you needn’t take our word for it. Ask any of the early intervention specialists, specifically OTs, PTs, and SLPs about their experiences with children having developmental problems. Invariably they’ll tell you that when they refer a child to a pediatric ophthalmologist they get little if any useful information back that helps guide them on how a child is using her vision. Or what activities they can collaborate on that will optimize visual development.
I could go into much greater detail on what makes developmental optometrists the most qualified group to be the protectors of the child’s visual system, but you can gain a sense of this by taking a look at my blog on the subject, and my PowerPoint posted there.
2) I cited a unique source of Hubel and Wiesel’s wisdom in reflecting on how pediatric ophthalmologists have selectively interpreted or over-extrapolated their research data to support their clinical interventions. It doesn’t surprise me that you would find that uncomfortable if not unsettling, and you’ll have to find a better line of research to support tactics that rush parents to early surgery. I am very receptive to my patients undergoing strabismus surgery when indicated, and have referred patients for strabismus surgery on quite a few occasions, and in infancy as well. But I remain the arbiter of binocular potential and refractive development, and collaborate with the pediatric ophthalmologist for surgery when I need a good mechanic to re-align the pulley system.
I find it curious that you would toss out the comment to support your point of view that you’ve helped patients who didn’t benefit from VT, and when I noted that I’ve experienced the inverse you dismiss my argument as specious. The reasoning here appears to be quite selective if not circular.
3) It’s regrettable that you’ve apparently been tainted by experiences where children were being treated for large angle strabismus to no avail, but that simply reinforces my point that the treatments you render that overlap what we do is primarily kinematic in nature. I don’t sit on patients with large angle constant strabismus who aren’t making progress in VT after a couple of months. In a perfect world you and I would have the same kind of synergy that exists in the orthopedic world. Many patients in orthopedics have presurgical physical therapy to optimize compensatory muscle function after surgery, and continue to receive post-surgical therapy to stabilize the outcome.
Regarding your non-strabismic point about seeing others that were going to VT for learning problems and never were referred to a true educational specialist, I have seen many more in reverse, which supports my point that we each see skewed populations. The American Optometric Association has Clinical Practice Guidelines on Care of the Patient with Learning Related Vision Problems. Have you read that, and would you agree that those guidelines address the issues in question?
You asked how we know if a child gets better as a result of my intervention. The bottom line is that their clinical findings improve and their goals, or the parents’ goals have been met in therapy. Do you have a placebo controlled cohort for every patient you treat with CI in your practice? Your concern eludes me here.
3) Wonderful to hear that you refer patients to SCCO and to many in ODs in San Diego when you think there is something to offer beyond what we can provide. Can you be more specific? What do you feel that developmental or neuro-rehabilitative optometrists offer that you can’t provide? Knowing that would be of great benefit to the patient in advance, and would also help me conceptualize how you view the difference between our two professions.
4) I am well aware of the literature, and of what you’ve published, though I’m not quite as sure of your grasp of optometric literature. You would have to confirm that for me. Regarding your TV comments, I use “scare tactic” to characterize the point you made that amblyopia can’t be fixed after age 10 or 12. You made the comment, it wasn’t edited down, so why not simply admit that you misspoke based on the literature that you, yourself have contributed to? We’re all human, David. Not the end of the world.
Here’s the rub as I see it. We each have a tremendous responsibility to the public. All vision scientists agree now that amblyopia is a developmental disorder of spatial vision. Reduced visual acuity is the sine qua non that spatial vision is compromised, but there are many other functional deficits that are to be addressed. Age is no longer the crucial factor, and that is the beauty of the PEDIG studies thus far. The public needs to hear that message, though we still welcome the opportunity to treat appropriately as early as possible.
Here’s another interesting feature of the show while we’re on the subject. You tossed in the importance of Addie being treated so that she doesn’t encounter what her father did. Well you and I know that her father wouldn’t have been picked up with the L’Enfant testing because he had an oblique palsy and likely no amblyopia. We could get into quite a discussion on the interaction of gross motor issues and ocular motor issues, the point being that there is quite a gamut of disorder for which more collaboration instead of sound bites would be in the patient’s best interest.
5) It doesn’t matter if the OD who trained you was Friedhoffer or otherwise. The point is that your experience as a successful optometric patient apparent motivated you to go into the eyecare field. That is lovely, but it is ophthalmology that continues to dismiss the sum and substance of VT success cases as “merely anecdotal”, not I. Think about it. Even though you were young at the time, someone felt that you could benefit from doing VT, and evidently you did. You asked me earlier how I knew if a patient benefited from VT, as opposed to it being a placebo effect. How then would you know if your personal experience wasn’t merely a placebo effect?
You note that the purpose of pointing out that you and your son are great readers is to raise the issue of when a child comes into the office with reading difficulties and CI, how we know the CI was/is the issue. It’s very simple, David. We rule out other issues by a very extensive visual efficiency and visual processing battery, and carefully weigh the child’s psychoedcuational evolutions. Again, I refer you to the Clinical Practice Guidelines of the American Optometric Association on the subject. Although I’d like to accept on face value that you’re unbiased, referring to optometric literature instead of your impression of the literature would be helpful.
6) I don’t know what you tell you patients any more than you know what I tell my patients. I do know the faculty at SCCO very well, and I do know the VT community in San Diego very well, so I have some sense of what you tell patients, perhaps more so than you do of what I tell mine. I’m glad that we can agree that we’re each human and subject to bias. We welcome you as colleagues informed by neuroscience. All we ask is that you accord us the same respect.
I apologize if I offended you by painting in broad strokes, but frankly after being at this for 33 years, I can afford to be blunt. All props to you if you feel you’re an open-minded supporter of the optometric community. Since you’re a good historian you’ll know that this is quite an exception to the rule in the pediatric ophthalmologic community. “Some of my best friends are pediatric ophthalmologists”, but that doesn’t negate the damage that’s been done over the years by many who actively dissuaded patients from seeking or continuing under optometric care. It would not be fair to pretend otherwise, and you help negate the negativity when you take a positive stand as you are doing here. I would love to see your positive optometric viewpoints, in an open forum with your colleagues, and ultimately in an ophthalmologic or pediatric journal, where the eyes who need to see it will do so. Thanks again for taking the time to comment.
Thank you doctors, for civility in your dialogue. Let us continue to find more common ground, for the sake of patients.
This open discussion by two experts representing their respective fields is certainly a step in the right direction. It is much better to air out opinions as opposed to just remaining closed mouthed and harboring ill feelings.
The fact still remains that the majority of ophthalmologists automatically poo poo the idea of vision therapy as an accepted method of treatment for binocular dysfunction. Perhaps with more of these OD/OMD blogs, thanks to Lenny, we may move to a higher ground.
Thanks again Len,
I would like to thank you for your participation in this blog and, more importantly, in the CITT studies and your work from the 1990’s on the complex relationship between ADHD and CI. I also really appreciate that you went out of your way to talk up “eye exams,” never “EyeMD exams” in your segment on the TV show.
However, you must forgive me if I contend that you think about these issues far more than the average eye surgeon or even pediatric ophthalmologist. And for you to waste your time, talents, and education trying to provide a service for which you are not thoroughly trained (vision therapy of the saccadic, accommodative, fusion, and visual information processing systems), even though you have by dint of state law an unlimited license and could legally do so would be ill-advised, don’t you think, given that another profession is already well-trained to provide that therapy?
You will forgive us if, after 30 years of publishing the same old wine in new skins (the Dyslexia statement, and don’t even get me started on your profession’s use of the term “dyslexia” when sometimes you mean phonological processing disorder and sometimes you mean general difficulties with reading, which is also a major problem with Shaywitz’s work) where the AAPOS says vision problems cannot cause reading problems but if your child has a reading problem make sure he sees an ophthalmologist to rule out a vision problem, we as a profession feel just a bit sensitive about claims on the science of what WE are offering. Our problem here is that we, as a profession, hear your profession saying one thing over and over to the general public, no matter how bizarre it sounds, and it receiving credibility from the press simply because of the MD’s after your names, and then in private, or to med students who have these visual issues, or when speaking just to OD’s, you say the things you are saying in this blog.
Again, I salute your participation in these multidisciplinary studies as a monumental first step toward healing the bad blood that these thirty-plus years of inane AAO and AAPOS statements have created.
Your name is listed at the end of the latest medical joint statement about learning disabilites and vision and your article, “Reading: Do the Eyes Have it?” is cited as a reference to the statement, “Convergence insufficiency and poor accommodation, both of which are uncommon in children, can interfere with the physical act of reading but not with decoding.” There are no statistics in your article, “Reading: Do the Eyes Have It?” that support the assertion that those vision problems are uncommon in children.
Will you take the first step in improving the relationship between pediatric ophthalmology and developmental optometry and call for the retraction of the joint medical statement?
As a parent of a young child with strabismus and amblyopia, I’m following this great discussion as best I can and have to say, I’m confused! Because Dr. Granet’s representation (in the comment section here) of pediatric ophthalmologists defies my own experience and that of the many other parents/children with vision issues whose stories I’m familiar with… though a quick disclaimer: I’m rare in my pursuit of VT, and most parents stay with the ophthalmologist only and don’t pursue other opinions. I’m less satisfied, I suppose, with the status quo, and am compelled to try everything I can to help my daughter in what is a very confusing, conflicting environment. I’m not alone! All parents want the best for their children, but when it comes to vision, that’s seemingly difficult for many to determine with any confidence.
An ophthalmologist told me that my daughter would have to patch, probably for years. That’s IT, and that’s the norm–it’s patching and/or surgery. And nothing else, yet Dr. Granet claims to understand other ways to provide more comprehensive therapeutic treatment? No other options besides patching were given for treatment of my toddler’s accommodative esotropia (deemed intermittent) and then amblyopia. (Surgery was not brought up for her because by all accounts the glasses have really kept her eyes aligned–yet the amblyopia developed anyway and was detected soon after glasses were implemented.) We had to seek out other help on our own, from a developmental ophthalmologist (after two opinions–the first said no therapy could be done due to her young age) and we are now doing vision therapy. I’m glad I didn’t just “do what I was told” by our first opinion, the ophthalmologist, because by how, first-hand experience and a lot of research tells me that patching alone is far from “all we can do” and far from ideal or even adequate, long-term, in many cases. I see complacency in regards to my daughter’s care in the realm of ophthalmology and even from some optometrists (other than our current doctor, for whom I’m grateful) who say we need to catch kids young yet don’t offer vision therapy or anything else besides patching (and hoping for a good outcome?) for toddlers like mine. At our current doctor’s office, the goal is to try (yes, I know there’s no guarantee) to proactively get my daughter’s amblyopic eye up to 20/20, to match her strong eye, and then encourage the eyes to work together for long-term results–not just to hopefully achieve some level of improvement based on a passive “let’s hope years of patching (likely on and off) will work” attitude. The latter could very well lead to a situation wherein she struggles with amblyopia at an age where VT and other interventions are less potent. Why is that? We know that VT helps train the brain, which you all agree is the real source of the issue, and encourages binocular fusion. (I apologize for bringing down the high level of discussion to this more basic level, but it’s an honest question from a concerned parent.)
The difference in the two approaches has powerful repercussions, and I have a concrete example: My daughter walks on her toes, something I’d not thought much of until it was noted by our developmental optometrist immediately upon meeting her (she seems to view my daughter more holistically and therefore effectively!). The toe walking was never touched upon at all by the ophthalmologist, so I doubt she noticed. But now, when my daughter uses prism goggles in vision therapy (as happened when the optometrist put them on her in that initial appointment), the toe-walking is eliminated completely! It’s amazing and incredibly telling, obviously. Her temperament even changes in a positive way with the goggles. It’s clear we are now much closer to an optimal outcome thanks to the more proactive, holistic approach of our developmental optometrist and third opinion. Why does it have to be this hard to get there?
I’m heartened to see this discussion, though, and hope it can continue because the disconnect between these two schools of thought serves no one, and only causes a lot of confusion and painful frustration for families of young patients who get such varied messages, not to mention missed opportunities for providing the best possible outcomes to improve quality of life. Which is what every child deserves. On behalf of parents everywhere, find a way to work together, PLEASE!
Thank you again for this discussion, for reading my comment (if you made it this far), and much appreciation to my daughter’s developmental optometrist for sharing this and other news and resources with me! It means a lot.
My compliments, Amber, to your daughter’s developmental optometrist for advising you about this blog. I am impressed with your command of the situation. Hopefully Dr. Granet will read your comments as well and grasp that the reality in the marketplace is quite different than the idealized portrait he painted of his field. When I, as a developmental optometrist, relate my experiences, it is convenient to dismiss my points as self-serving. When patients and parents of patients come forward with similar experiences from all over the country, you’d have to be quite a conspiracy theorist to believe that someone with an axe to grind planted the idea.
You stated your case very elegantly, so I won’t repeat what you’ve said, other than to underscore this point: “It’s clear we are now much closer to an optimal outcome thanks to the more proactive, holistic approach of our developmental optometrist and third opinion. Why does it have to be this hard to get there?” I presume after reading what preceded this, that your question is a rhetorical one. You noted that you are unusual in that you didn’t accept the opinions of the prior ophthalmologists who told you that there was nothing further to be done for your daughter other than what they were doing. You know from reading what I wrote that the way to make it less difficult is for the ophthalmologist to say: “There’s nothing further I can do, but I have a colleague who is an optometrist specializing in this area who is knowledgeable in the field with whom you can consult.”
It’s really as straightforward as that. It isn’t Optometry that is thwarting the process. And what will force our two professions to become more synergistic is the voice of parents such as you. After you experience success through your developmental optometrist, get the ophthalmologist on the phone, or pay his office a visit, and let him know how disappointed you are that he never presented this as an option. And for any ophthalmologist that actually discouraged a parent from consulting with a developmental optometrist, a “shame on you” conversation or something more pointed might be in order.
To be sure, there are patients who have been helped by eye muscle surgery and/or patching as the principal if not sole treatment for their strabismus and/or amblyopia. But look at the experiences of just some of the recent bloggers who share the pain of having gone through multiple eye muscle surgeries in childhood, never having been given any other alternative. They are bright, they are passionate, and they will not be patronized or deterred any longer:
You thanked us for this discussion but it is we who must thank you, and patients and parents like you, for encouraging us to continue.
So a few thoughts. I think the newest position statement is quite well done. I was pleased to be a reviewer and I hope my contributions to the statement made it better! Like the CITT many of these reports are compromises and do not make anyone fully happy.
1) Pediatric Ophthalmologists are the most qualified group to care for the child’s visual system. I have asked all of the early intervention specialists you reference and gotten terrific feedback about how we can help. Take a look at Lea Hyvärinen’s work as a pediatric ophthalmologist. I talk regularly with the teacher’s for the visually impaired.
I could go into much greater detail on what makes Pediatric Ophthalmologists the best choice but I am not sure we’ll see eye to eye on this.
2) Oh I am not at all uncomfortble with looking carefully at the body of H&W’s work. Only with the selective use of a sentence here or there. I am glad you agree with your patients going for surgery! But you wrote, “But I remain the arbiter of binocular potential and refractive development”. Hmm, why? I’ll happily match my knowledge of optics, visual development and binocular potential (for which I always aim high) with anyone. Then you further write, “and collaborate with the pediatric ophthalmologist for surgery when I need a good mechanic to re-align the pulley system”. It is almost funny to hear the dismissive way you think surgery fits the “repair shop” analogy. But you do make the point that it is nice to have one person able to watch all of these issues in the form of a Physician trained for all parts.
The only reason I pointed out that I have seen many patients that were not helped by VT was to RESPOND to your initial comment. Sorry it bothered you to hear that.
3)You wrote, “I don’t sit on patients with large angle constant strabismus who aren’t making progress in VT after a couple of months.” Just wondering how many children with large angle strabismus (not corrected by spectacles) do you correct with VT?
The you wrote, “In a perfect world you and I would have the same kind of synergy that exists in the orthopedic world. Many patients in orthopedics have presurgical physical therapy to optimize compensatory muscle function after surgery, and continue to receive post-surgical therapy to stabilize the outcome.” Two thoughts on this. (1) We use prism adaptation and accom & fusional training prior to and post op all the time. (2) What if I agreed and sent my patients as I saw fit to use you as a PT equivalent (which I have done, fyi). Then you wouldn’t be the arbiter you wat to be as noted above?
I have read the AOA statement. But practice does not match that.
You wrote, “The bottom line is that their clinical findings improve and their goals, or the parents’ goals have been met in therapy.” Is that the bottom line, really? I am specifically speaking of non-strabismic issues. Parents have invested in many interventions and the school is often working with them as well. What worked? As for CI, I discuss with parents what we know and don’t know. I tell them, in part, that improving the signs of CI may not improve the reading issues. In fact I strongly suggest they combine improvement of the physical part of reading with educational intervention designed to improve reading skill sets. Given the limited resources of most parents and children for time etc they appreciate this discussion. I specifically discuss what we do not know. I run way behind on these days! 🙂
3) You wrote, “Wonderful to hear that you refer patients to SCCO and to many in ODs in San Diego when you think there is something to offer beyond what we can provide.” Thanks! In addition many of the patients I have referred have also stumped the VT’s I have worked with. In fact that’s why I like them! I always like folks who admit their limitations. In these circumstances I tell patient’s I don’t what to offer to help them. I tell them I am not sure the VT does either but it makes “common sense” to try. I have many TBI and autistic spectrum patients I’ve had this conversation with for example. I advise them to use their instincts about their child as well.
4) As to termig what I said a scare tactic I continue to think those words are unwarranted. The entire piece was edited and sound bites used. Of course I said those words but in context it was much clearer. It is also just wrong to give parents the idea that getting a child at 13 is as good as 3.
You wrote, ” Age is no longer the crucial factor, and that is the beauty of the PEDIG studies thus far.” That just is not a true reading of the PEDIG study. I append parts from the older amblyope abstract for quick reference –“RESULTS: In the 7- to 12-year-olds (n = 404), 53% of the treatment group were responders compared with 25% of the optical correction group (P<.001). In the 13- to 17-year-olds (n = 103), the responder rates were 25% and 23%, respectively, overall (adjusted P = .22) but 47% and 20%, respectively, among patients not previously treated with patching and/or atropine for amblyopia (adjusted P = .03). Most patients, including responders, were left with a residual visual acuity deficit.
I agree with your comment that, "The public needs to hear that message.." but we seem to disagree somewhat on the message! If there is a messgae I'd rather have it be come in early. I host a TV show that is 30 minutes in length because short form TV cannot be complete. But is one is to be in that situation at least get an important soundbite if you can.
As to the little girl, the message was simply that early identification of some problems can prevent later issues. That is the message for the public. Can you imagine me describing an oblique palsy which may or may not have associated amblyopia but did not cause any motor problem for her Plastic Surgeon father? We'd never have that kind of time, nor would the details be listened to by a general audience. In fact the message would be lost.
5) You wrote, "It doesn’t matter if the OD who trained you was Friedhoffer or otherwise." But it did to you originally when you termed the treatment I used in my office as basic because it was what I received as a teen. That was YOUR point and I mentioned my cousin only to clarify. It is hard to stay with the changing argument you make here and the problem with this type of discussion. Further I don't know if my improvement in fusional amplitudes was placebogenic in nature. I do know I was already a great reader and remained so.
As for CI I will say I do not think CI makes one a poor understander of what you read. I have written and think, that for some the physical impediment of CI could interfere with the normal reading development which must be addressed when the CI has improved. Len, I am not writing a scientific paper here with you and although I could refer to many papers, books and science research I am not going to re-check etc the way I would for peer review etc. I just don't have time and will apologize in advance for that if you find it problematic.
6) You wrote, "I don’t know what you tell you patients any more than you know what I tell my patients." But you did say earlier you did know what I tell my patients. That left me to respond and so I did. I am glad you know that I do refer to those places I mentioned. You "dinged" the PO's near you for not doing so – so I know you appreciate that I do. I am from your neck of the woods and know the area VERY well. I too know second hand some of the things you discuss with patients.
Since we are from the same area you can't offend me by being blunt. Nor can you make a point by simply saying it is so. No good New Yorker would ever go for either one. 🙂
You wrote, " I would love to see your positive optometric viewpoints, in an open forum with your colleagues,". Hmm, did you not know I invited Bill Rainey, OD faculty from IU to speak on VT at a pre-AAPOS meeting I ran several years ago? I don't just say stuff.
I am really enjoying our discussion but am running out of extra time as I suspect you may as well. My wife is giving me the "evil eye" (can you fix that?). I will try to respond if I can but there may be significant time delays. Please don't take that in any other way. Best, David
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The joint medical statement implied that the brain is separate from vision and yet in this blog you admitted that the brain is very much a part of the visual process. The joint medical statement asserted that accommodative/convergence problems are rare in children and inappropriately cited you as a reference. How many falsehoods have to appear in an article before you decide that it is not “quite well done”?
I too am really enjoying our conversation, David, and I look forward to it being ongoing, within the constraints of time. Have to head over to the office shortly in freezing rain, but those patients who’ve been told by pediatric ophthalmologists that I can’t help them just insist on coming in even in this nasty weather. Go figure.
I am going to argue that you’re right about some things, but also deeply wrong about other things, the principal one being number one.
1) I am well aware of Lea Hyvarinen. I’ll point you again toward my seminar on visual processing and therapy, which a national continuing education group that services OTs, PTs, SLPs and Educators keeps pushing me to give, and which is spreading like wildfire among my colleagues who’ll be giving similar seminars across the country during the coming year, from Maryland to Michigan to Montana, and part further East and West. So give your colleagues around the country a heads-up about clone seminars that will challenge confounding dogma with the facts.
In that seminar, you’ll note a slide extolling Lea Hyvarinen as a quintessential developmental/behavioral ophthalmologist, and relating her materials to early childhood visual development.
Name dropping Hyvarinen in proof of your argument that pediatric ophthalmologists are the most qualified group to care for the child’s visual system reminds me of the famous exchange between Lloyd Bentsen and Dan Quayle:
Quayle: “ I have as much experience as Jack Kennedy did when he sought the Presidency”.
Bentsen: “Senator, I served with Jack Kennedy, and you’re no Jack Kennedy”.
Quayle: “That was really uncalled for, Senator”.
Bentsen: “You’re the one that was making the comparison, Senator.”
2) Please read the material I’m referring to instead of giving me your impressions of the material. The book on the Brain and Visual Perception by Hubel and Wiesel that I’ve quoted isn’t Granet’s interpretation of H&W; or Press’s interpretation of H&W. It’s Hubel and Wiesel’s commentary on their own work, in the wisdom of hindsight. Always best to quote from the source.
Regarding strabismus surgery, I’m not being dismissive of a surgeon’s skill in realigning the pulley system whatsoever. I admire the skills of a good pediatric ophthalmologist. And the ones that I choose to interact with are the ones who accord equal admiration for my skill and expertise in non-surgical aspects of the developing visual system and how that integrates and dovetails with child development. If I may give you a construct to work with, think of our synergy as a modularity rather than a singularity. The optimal approach here isn’t “one stop shopping” with ophthalmology. The optimal approach is “there’s an app for that”. The best application for surgery is you, and the best application for visual development is me, and when we put our heads and skills together, the patient is best served.
3) You asked how many children with large angle strabismus (not corrected by spectacles) I correct with VT. The short answer is a considerable amount, though I’ve not had occasion to do a head count, but enough to keep optometric colleagues referring such patients to me. My practice outcomes mirror the results published by Ludlam & Kleinman, Getz & Etting, Cooper & Medow, Wick, Flom, Calorosso, Cotter, Coffey and others in the optometric literature. The numbers vary with the type of strabismus. We obviously do best with divergence excess even when the distance XT angle is large, if there is a point of fusion at near on which to build. When there is no fusion it is more challenging. The important point is that I never take on patients with large angle strabismus and no initial point of fusion or centration without telling them that strabismus surgery remains a viable option if at any juncture (and we conduct formal progress evaluations monthly) we or the parent don’t feel we’re making demonstrable progress. That is what makes me, in conjunction with the parent’s input, the arbiter.
You indicated that you’ve read “the AOA statement”, and that ”practice does not match that”. I don’t believe we’re talking about the same thing. I’m referring to the AOA Clinical Practice Guidelines. Read the ones on care of the patient as related to the topics we’re discussing. After you’ve read them, let me know what you think.
You wrote, “As for CI, I discuss with parents what we know and don’t know. I tell them, in part, that improving the signs of CI may not improve the reading issues”. Well of course, they may not. Just like any set of interventions they’ve had for reading difficulty may not. But you continue to overlook the fact that every single one of the 15 questions in the CISS, that is the backbone of the CITT that you’re rightly proud of having participated in, involves reading! And not in a tangential way. Nor are all the questions simply about eye strain or discomfort. Take a look again at these questions, and tell me if they might not influence progress in reading remediation, and in particular fluency:
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9.Do you feel like you read slowly?
14. Do you lose your place while reading or doing close work?
15. Do you have to re-read the same line of words when reading?
3) You indicate that you always like folks who admit their limitations. Ditto.
4) You seem really peeved that I use the term “scare tactic”. Let me re-phrase that then. Call it a tactic that misrepresents what optometrists know and do to help children. And if the drive toward catching these kids as early as possible is a goal that we share, why haven’t your colleagues embraced AOA’s InfantSEE program? Further, you continue to confound helping older amblyopes improve, with the value judgment that just because one doesn’t attain a 20/20 outcome, there isn’t success. The two aren’t synonymous, nor would I agree that the PEDIG studies don’t have limitations in their outcomes or clinical applicability. Much like you’ve tried to disavow or qualify conclusions of the CITT (your letter to the editor of OVS), I might take the same position with how you’re interpreting and applying PEDIG constructs or outcomes.
Bottom line: all this started with what you said on TV, that wasn’t edited of chopped. Context or not, it’s simply a wrong statement. I’m glad to hear that’s normally not what you tell patients.
5) My thoughts on this one are addressed in point #2.
6) I couldn’t agree more that one cannot make a point by simply saying it is so. That is why I urge you to read, not glance at the titles, of the supportive documentation I’ve cited. Wasn’t aware that you invited invited Bill Rainey to speak on VT at a pre-AAPOS meeting you ran several years ago. Bill and I email periodically and it’s the first I’m hearing of it. Did he accept? What was the outcome?
I know what you mean about your wife giving you the “evil eye”. I’ll fix yours if you fix mine. 😉
What amazes me is that these discoveries related to neuroplasticity are not new. Studies in the 60’s and 70’s proved that the brain is not hard wired at birth and also that it has the capacity to rewire itself through proper and aggressive therapy. Dr. Paul Y Rita proved several years ago that you see with your brain. My wife and I are our 4th year of rehabilitation and were told by the intensivists after 4 weeks in an induced coma that my wife would never recover from a vegetative state. Through aggressive therapy a couple of excellent therapists,a few caring doctors and the process of neuroplasticity, my wife eats, talks, paints, plays the piano, walks (with my help now) and is slowly recovering the use of her right hand. Our plan is to get it all back. Contray to Dr. Maimo’s statement in his excellent article on neuroplasticity, I have read of studies that prove the brain is not age sensitive and that it has the ability to repair itself until the day you die. I highly recommend reading Dr. Joe Dispenza’s “Evolve Your Brain” and Dr. Jill Bolt Taylor’s “My Stroke of Incite” It’s a real eye opener for someone like myself who had no idea of where to go, who to turn to or what to do to recover from a stroke. You won’t hear it from the Neurologists.
Dennis…..thanks for the kind comments regarding my paper on neuroplasticity (http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106025/) . I wanted this paper to be read by a wide variety of folks and am always thrilled when someone reads what I wrote and then remembers enough about it to comment on it….
You wrote, “Contrary to Dr. Maino’s statement in his excellent article on neuroplasticity, I have read of studies that prove the brain is not age sensitive and that it has the ability to repair itself until the day you die.”
What I actually wrote was….”…Can adult brain neurons actually exhibit neuroplasticity? The short answer: yes. Adult neural stem and/or progenitor cells are now known to continuously generate new neurons throughout life in various areas of the mammalian central nervous system. Neurogenesis is necessary for some forms of adult learning, memory and mood regulation to occur. The phrase “life-long learning” should now take on new significance for optometrists. Adults can learn throughout their entire lives….” I tried to get across to the reader that our brains can be changed (hopefully for the better) no matter what age. Now Kleim & Jones (as I noted in the article) said that plasticity is easier to achieve in the younger brain….they also noted that brains that are more chronologically enhance can also take advantage of neuroplasticity. I’m definitely of the opinion that no matter the age we can improve our brains…now, when someone has a brain injury can we ever “repair” the brain so that it functions as it did before the injury? I think this is more than likely possible ….have we figured out how to do this for all folks with brain injury? No. Will we do so in the future…yes.
Thanks again for your kind words. Don’t forget to visit my blog (if you can rip yourself away from this engaging conversation with Dr. Granet) at http://www.MainosMemos.blogspot.com Type in neuroplasticity in the search box to find some of the latest articles on this topic….
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
It has been a pleasure and an “eye opener ” to follow this discussion and as a “somewhat” older observer to read some of the historical opinions. I would like to point out to Dr. Granet that back in 1977 when Ophthalmology was OFFICIALLY stating in every forum available from the professional literature to the popular press that amblyopia COULD NOT BE TREATED AT ALL after age 6, I co-authored a paper showing that this was false and had never been anything but false. Ophthalmology totally ignored this paper (Amblyopia Therapy as a function of age : Birnbaum, Koslowe, Sanet JOPt and Phys.Opt May 1977) until tens of years later they “discovered” this fact. Over and over I have seen this story repeated, we read your literature you (as a profession not you personally) do not read ours.
Can’t tell you how impressed and pleased I am to be following this dialogue between two passionate practitioners and I hope this is just the begining of an effort to reach an understanding in the best interests of all our patients. Dr. Granet, would you please discus whom you refer to Deveolpmental Optometrists and when you do so. As Dr. Press has indicated, those of us who do V.T. in the New York /New Jersey area rarely if ever receive such a referral from a Pediatric Ophthalmologist and more frquently have to fend off attacks without even the benefit of a discussion. It would be helpful to hear from you about patients you have referred and I assume there have been positive results or you would not continue to refer. Thank you for your participation.
Bruce Meyer, O.D. FCOVD
What concerns me most about the video are the comments about the brain NOT being plastic. This is a respected Ophthalmologist who states the brain is not plastic. I think this statement was more damaging (and incorrect) than stating that amblyopia cannot be treated later in life (though I think this is also misleading). I was shocked to hear that statement coming from Dr. Granet. Developmental Optometrists have been fighting the amblyopia statement for years, but in the face of new research demonstrating neuroplasticity which has made headlines in non-medical newspapers/magazines/blogs, I am shocked to hear the comment from such a prominent and developmental doctor.
I have had a couple of patients comment on this statement who have had strokes but somehow recovered some functions…they wonder why their brains learned something that was not possible as an adult. My joking response is that their brain didn’t read the old research. (In other words, their brains didn’t know they weren’t plastic!)
I think we must educate our public. “The Doctors” is an excellent avenue, but we must all be clear and honest in our message to the public. We all want to catch amblyopia and strabismus as early as possible. We must be clear to our patients and to the public that though it is easier and less complicated to treat in an infant, all hope is not lost for the adult (even the adult with presbyopia).
Patients still trust the initials behind our names, and we must earn that trust by presenting the whole story. For Developmental Optometrists that is discussing surgical options when appropriate. For Pediatric Ophthalmologist that means discussing non-surgical options before and after surgical intervention. I am tired of CI’s being treated surgically by the esteemed ophthalomogical center in my state when the research supports therapy.
You are right on! If you think opthalmologists are not up on neuroplasticity, try discussing it with a neurologist. Of the many we have attempted to work with, not one has even mentioned the word neuroplasticity. On the contrary, all we have met have encouraged my wife to use neuro-drugs (you know, the ones that shut down the circuits of the brain) and discouraged therapy. We have been told by neurologists to “ride the waves”, “you don’t want to do all those exercises”, “try these drugs” I have had reason to study the brain for the last 4 years and have discovered that there is a huge gap between neuro-science and the practice of neurology. It’s my guess that it all starts in the universitites and continues with a huge lack of desire to keep up in their fields. Maybe like Dr. Granet! Thanks for your opinion.
Dr. Granet, you said, “I think the newest position statement is quite well done. I was pleased to be a reviewer and I hope my contributions to the statement made it better!” Having read your comments thus far, I would say I think I can see your hand at work in some of the more pro-VT concepts of that paper.
Yet, as Dan Lack’s (respondent from above)Optometry critique of this latest AAPOS/joint paper points out, the paper has serious issues. My 2002 Optometry-published critique of the 1998 position paper dissected the grave failings and single-minded anti-optometric intent of that paper. Hardly gracious and collegial, that. It called for retraction of the position paper — as has Dr. Lack’s for the latest one — and a collegial, open-minded inquiry (an historic concern with all four ophthalmological position papers has been the avoidance of supportive literature from the optometric body of literature: in contrast, both Dr. Lack and I used ophthalmological literature support for VT — >90/329 references in my paper alone).
I offered my assistance to you then (you were at the Scientic Meetings in D.C., I was headed to San Diego) to help you and the agencies to draft a proper paper, and I believe that Dr. Press, Dr. Lack, and I — among others, for sure — would be more than willing to help a proper medical response to strike a balance between what is known and what needs yet to be known, from a fair-handed review of the whole body of the literature.
Let’s start a dialogue….
In case Dr. Granet is still following this I had to add the following: While every profession has its “bad apples” I had to tell you about just one patient from this past week in my practice (and it is unfortunately very typical). I live in a country where attempts have been made to declare VT ILLLEGAL, by the way. he patient was a 14 year old female with daily headaches for the past 1.5 years. She was seen by an Ophthalmologist who prescribed -1.00, an Orthoptist who recommended an MRI and finally the head of Pediatric Ophthalmology at a major hospital who wrote “XT with myopia” and prescribed -1.75.The girl has 18 exophroia with 6 RHyper at distance and 25 exophoria with 6 RHyper at near. She also has a 15 degree head turn to the left along with a 15 degree tilt to the left shoulder. Upon explaining all this she suddenly said “Oh you mean that is probably why I have been having neck and upper back aches for the past year?”!!!
This is one of countless cases of what has become the standard Ophthalmologic care in my neck of the woods.
Ken Koslowe OD MS FCOVD-A
Great cross dialog here.
For an idea of how bewildering the differences of opinion between pediatric ophthalmology and developmental optometry can be, check out Amber’s latest post on he two-year-old daughter’s progress to see 3D:
I see Amber also was here and left an eloquent statement concerning how this philosophical divide is so frustrating to patients and parents on Feb. 1 … my thoughts and feelings exactly!
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