Solving the Puzzle Together

Dr. Nancy Torgerson, our colleague from Washington State, and Past-President of the College of Optometrists in Vision Development, shared with us the following note she received from one of her patients.  It speaks to most if not all of the points we have raised on the blog over the past few weeks – in fact months, so I will make my introduction to it no longer than to say, lean forward and enjoy.

I was diagnosed with strabismus at a young age, and my parents were told it was too mild to treat.  I knew that my mild version of “crossed eyes” was the reason I always felt my nose was in the way when reading and writing.  I did not realize it affected me in other ways.  Either doctors did not know or just did not tell my family that there may be some mild difficulties in other areas as a result of this diagnosis.

As I got into high school, I began to understand more about the concept of depth perception.  I was able to connect that my crossed eyes were responsible for my stumbling on stairs and sometimes missing things like door handles when I reached.  Still I did not understand that strabismus might have affected other areas of my life.

I was a good student and appreciated by my parents and teachers.  I was socially capable and did fine as far as making friends and getting along.  Nothing unusual was ever noticed by my parents or by any teachers.  Yet, I sensed (but did not verbalize) that sometimes I did things that didn’t seem like me.  At times I worked much harder than the product would indicate.  Basically, I felt just a little bit different than my peers at times.

Slight difficulties showed up in handwriting and art in that my work always appeared sloppy or careless, even though I probably spent more time on it than my peers who turned in neater work.  Sometimes I was too excited and silly, such as chasing kids on the playground when they didn’t want to be chased.  I was just downright awkward when trying to learn to swim or follow an aerobics class.  I think it is important to note I was trying.  I was not afraid to go in the water or put my face in.  Effort was there, coordination was not.

Over time I accepted that some of these things were just talents that I did not have and some were just my personality.  When I recently discussed my shifting eyes with my optometrist, he suggested vision therapy.  I had no idea that anything could be done.  He gave me a referral and told me to at least check the website.  He said I would find that I was reading all about myself.

When I went to the website, many of these subtle things of the past seemed to take on new meaning.  After my vision evaluation and additional reading on the topic, more of my past seems clear.  Now I believe that my inability to relax on a bike has nothing to do with me being a “Nervous Nellie”, my rolled shoulders and tendency to lead with the left side of my body are more than just poor posture, and some of my subtle difficulties have been more than just a lack of natural talent.

I am fortunate in that I was able to achieve what I wanted in school and life.  This is all a lesson for me and exciting to piece these things together now.  Even though nothing seemed unusual to my parents or teachers, I really felt there was something different.  While my college roommate was studying special education it seemed there was so much talk about ADHD and medications. I told her that all this talk of ADHD and learning disorders made me think that if I were a child now, I would possibly be misdiagnosed for what I thought was just my personality.  I didn’t understand as I said it that the reasons I was saying it might be related to strabismus. I questioned her on the subject and wondered out loud if some kids are getting medicated for a condition they do not have.

Now I am the mother of two children.  I have noticed in my older son some subtleties that remind me of myself as a child.  I have thought that he must have inherited a bit of my “quirky” personality.  He is a bright child, but has difficulty with impulse control.  He has mild difficulties with fine and gross motor skills.  It is enough to have needed physical therapy and occupational therapy evaluations, but not enough to test abnormal or require therapy.  It has been explained that he is within normal limits, but at the later of end of normal with regards to motor development and that’s just his norm.  We all have our strengths and weaknesses.  Again, like me, it seemed it was just not a natural gift for him.

As he has progressed through preschool, it is clear that he is very smart yet struggling in some ways.  His teacher says he “lacks focus” yet is so capable and smart.  She recommended an evaluation to test for ADHD and other learning disabilities.  As I started to see my own past in light of the effects of strabismus, I started to realize that he did not inherit my personality so much but probably my eye problem.

He was examined by our doctor and tested normal.  This is a doctor who I trust and who looked extra hard for a problem, given my history.  He did not find it.  I had a second of relief that he did not have a vision problem, but knew before I reached that car that it was not possible.  I took him to the specialist that our own eye doctor had recommended for me.  She found he has accommodative esotropia.  Essentially he has an eye turn that is intermittent and shows up with close-proximity work or focus.  Though his behaviors were similar to some of mine, his problem was not as easily detected.  We now know that he sees blurry images and sometimes double up close.  He is going to get bifocals and possibly vision therapy.

We are happy that our child’s problem has been discovered before starting kindergarten.  We are happy that we did not pursue more extensive evaluations for ADHD and other conditions before starting with the obvious.  Though I do not downplay that those conditions exist and require treatment, the explanation just did not seem to fit.  The explanation that his behavior was just a discipline problem did not fit, either.  Something was different.  No matter what struggles or medical conditions a child faces, I think all parents can agree that they want it diagnosed accurately and treated appropriately.  I would never want my child medicated when he really needs glasses.

My hope is that more thorough eye screening becomes the norm.  I hope the professionals who are diagnosing learning disabilities are working cohesively with eye care specialists to ensure accurate diagnoses for all children.  Like us, our son’s teacher knew something was wrong.  She said she has never heard of this, but the explanation makes sense.  More awareness is needed.  From a parent’s perspective, here are some things that might tell you the issue is possibly vision-related:

1.        After misbehaving, your child is able to sit quietly for a time-out just like any other child. When you attempt to explain why the child was put in time-out, he becomes fidgety, silly, excited, and absolutely will not maintain eye contact.  In general, bad behavior escalates or your child seems disrespectful when eye contact is required.

2.       You or others are saying things to your child like, “You just need to focus”, “watch what you are doing”, or “can’t you see that?”  You may already have it figured out – he can’t focus (literally), can’t watch, and can’t see.

3.       Your child rubs his eyes or holds his head as if he has a headache when playing with Legos or trying to write.  Allergies are not an explanation, because allergies don’t just come on when working up close.

4.       Your child will sit still while you read several stories to him and will retain what is read.  However, if you ask him to look at words in the book, he holds his head, refuses, and no longer wants to sit for story time.

5.       Your child is a bit clumsy, spilling food when he eats, getting paint or glue everywhere when doing art.

6.       Your child is confused in team sports.  People tell you, “it’s just new to him” or “he is still young”.  You see other kids who are new to it or young doing silly things on the field, but your child is actually trying with all effort to play yet looks confused or lost.

7.       Your child does not lack effort, but the product or performance does not show the true effort.  If it goes on long enough your child will eventually get frustrated and may stop putting forth the effort, but it doesn’t start that way.

8.       Your child covers one eye at times.  With our son, we thought it was cute that rather than suck his thumb he chose to place his hand over his face as a means to self-soothe.  This started very early and went on until he was about 4 ½ years old.  Now we believe he was blocking one eye to stop double vision.

I am not suggesting that strabismus is now the answer for every one of my shortcomings or every goofy, careless mistake I have made.  I am suggesting though, it has caused much more than just the nuisance of seeing my nose when reading.  My son’s eye problem is not responsible for everything he does or every difficulty he faces.  While it might not explain everything, I think it explains certain patterns.  It is seeing the patterns that allowed me to connect the dots and suspect he had an eye turn.  It is important not to dismiss the patterns as personality or things that just happen to everyone.  At the same time, overreacting to the patterns and looking for the most serious conditions is not a good starting place.

My son and I are just beginning our exciting journey into vision therapy.  We are blessed to have this understanding now.  As for my own minor struggles, I am grateful for them.  Because my son’s condition is harder to detect than mine, I might have accepted the answer that he does not have strabismus and therefore does not have a vision problem.  Without recognizing the similarities in our behavior, I would not have “known” that it was his vision and might not have pursued a second opinion.   – Robyn

– Leonard J. Press, O.D., FCOVD, FAAO

30 thoughts on “Solving the Puzzle Together

  1. Despite the frustrations we all experience practicing optometric vision therapy, I have to say that it is the patients and parents we get to work with that make it all worthwhile. This patient – and parent – is a perfect example of why I love working with my patients, as demonstrated by her eloquence and grace.
    Thank you, Robyn, for sharing your story in such an elegant, thoughtful way. Thank you, Dr. Torgerson, for once again engaging and helping a patient in need, as you do so well. And especially thank you to our anonymous colleague in optometry who saw the difficulty and made the referral in the first place. This is the definition of a professional!

  2. Excellent point, Dr. D. Reminiscent of the point Dr. Maino and I made in the OVD issue with Sue Barry: It was Steve Markow, the primary care O.D. who was the “hero” of her story in taking the time to listen, and to guide her appropriately through the referral process to a VT-OD. Indeed, that is the definition of a professional in deed not just in word.

  3. It is incredulous that given her history she NEVER thought of her her child examined by the pediatric optometrist (VT -OD) who had treated her or the one that had referred her. The child was not examined at age 1 or 3. Even though I bet she had him at a dentist’s office before he started pre-school, to insure the proper development of his teeth, jaw, gums,etc. All of her commments regarding her developmental problems had no influence. Anyone in the medical community reading that letter might easily assume that it is fictitious and just OD propoganda; although we know that it is not. This to me is just another example of the deficiency that we (O.D) have in educating our patients about vision and eyesight. Every women that I see that either has children of preschool age, is pregnant or considering having children are introduced to InfanSee and given a “lecture” by me on its’ importance and they are encourage to share that with their female friends and relatives. Did anyone else reading this blog see the mothers failure?

    • His check by our OD was a routine exam that I wanted him to have prior to starting school. My routine exam happened a few weeks before – where I found out that VT was an option for me. My VT-OD evaluation was scheduled, but had not taken place at the time of my child’s first routine exam. With that, I asked our OD to be very sure to check my child for these issues. Even though my VT-OD evaluation had not happened, I knew right away he needed one (when nothing was found). Yes, I regret that I accepted our family doctor’s assessment of his eyes prior to his first routine eye examination. Believe me, once it is figured out parents do kick themselves for not seeing it. I am sorry that my child struggled as long as he did. Though I will not beat myself up over it, and instead will go forward doing my best as his parent.

    • I must elaborate on my last reply. You ask if anyone sees the mother’s failure, and we know the answer is yes – the mother. We can also point fingers at my parents for not seeking help for me, but they really believed what they were told – it was too mild to treat surgically and no other treatment existed. They trusted the eye doctor. It wasn’t something they considered on a daily basis, because parents do not get called into school to discuss why their honors student is not excelling in art and handwriting. Rather than be concerned, people joke she should become a doctor. Parents do not get a call to discuss why their athletic and energetic daughter isn’t catching on in P.E. with regards to team sports such as basketball. When a child is otherwise excelling, these things get dismissed as just “not being her thing”. That’s why while I sensed differences with my peers, I was not overly troubled by it.

      I made a mistake as an adult in not going out on my own to research more on the implications of strabismus. I did make sure our family doctor was aware of my history and thought her assessment of my child would show it, if present.

      I did not seek out more info on implications, because I felt I’ve been getting along fine, if not great. I did not understand. You make the point that we had probably taken our child to a dentist sooner than we did an eye doctor. While that is true, I was still following the guidelines given us by our trusted family MD. Take him before kindergarten. Given that the OD did not pick up on his eye turn at age 5, I have serious doubts his findings would have been different at 2 or 3.

      • Not that any apologies are required here, but I thought the way you approached your son’s situation was entirely understandable, Robyn. Part of the failure of our system (for which you and all parents who have the courage to speak out on should be congratulated for taking us to task!) is the implicit trust that any licensed eye doctor should be able to determine if your child has strabismus. Even an intermittent strabismus. Obviously now, in hindsight, you’ve learned the hard way that isn’t the case. To my friend and colleague Chuck I would say that if all parents handled the situation the way Robyn did, the public would be better served.

        Consider this question, asked of me by an OT at a seminar I gave last week: If the AOA has a program such as InfantSEE – and we would agree that anyone signed on for InfantSEE should be capable of detecting Robyn’s son’s intermittent esotropia – why would every pediatrician not make parents aware of the availability of such a program? You and I know the answer is ensconced in “politics” as much as in other factors, point being that educating the public is very challenging on many levels.

    • Chuck,
      I find your response perplexing at best. How is a parent to know? Our profession has a lot of work to do in order to educate the public.

      Eye doctors told Robyn that she was fine. She was told, her strabismus was small enough that it wasn’t a problem. Her son’s eyes appeared straight and she had no idea that his vision should be checked. That is where our profession as a whole need to help educate parents, teachers and other professionals. Robyn’s eyes are now wide open, as she understands that there is so much more to vision than what she previously knew.

      Robyn is an amazing person and a mom. She is willing to share her life story and this new journey with others so that they don’t have to go through what she has gone through. Please let Robyn know how much you appreciate her courage and determination. She is not only thinking about herself and her son, she wants the whole world to know! I am so grateful for patients and parents such as Robyn. Thank you Robyn– my hope is many more will have their EYES WIDE OPEN because of your help.

    • Dr. Allen, I find your comment incredulous! Let’s see… you find fault with the mother of the child who took her pre-school son to their family eye doctor, who knew the mom’s history, who “looked extra hard for a problem” and didn’t find one. Yet, she knew in her heart that something was wrong, took the initiative to take the child to the optometric specialist who diagnosed accommodative esotropia – a form of strabismus that typically doesn’t manifest until late toddlerhood. But, you find fault with the mother!? Come on man!!!

      This mother not only persisted in spite of the first opinion, but she kept looking until she found the doctor who could help her son AND THEN she has taken the time, energy and effort to try to help other parents by writing her story including a list of 8 excellent recommendations. How anyone can find fault with this mom is BEYOND incredulous! This mother is truly a Champion!

      • Thank you so much. I am going to come to Dr. Allen’s defense simply because I do not want other parents to fail to spread the word, due to fear of criticism. Perhaps my write-up was unclear on the timing of events. My failure, as I see it, was accepting as a young adult what my eye doctors told me as a child – that my strabismus was nothing more than some slight clumsiness and the inability to appreciate 3D movies.

        It was only very recently when my eye doctor said, “you will find you are reading about yourself” that I started to understand the implications of strabismus. Once I understood, I rapidly made the connection back to my past and my son’s present. There was no delay in getting help once I knew. The doctor who told me about VT is the same one who missed the problem in my son. I do not fault him. He is a hero as stated in one of the earlier comments. I never knew prior to learning from him that there are different optometrists, and that even he might not pick it up with his tests.

        I understand why Dr. Allen would question a parent who knew the implications and had gone through VT as to why she did not think to have her child checked. I hope he can understand my actions now.

    • Chuck, you may practice vision therapy, but your attitude is uncharacteristic of the critical empathy that most VT docs have for their patients. You sound insensitive, and your professional knowledge has clouded the common sense judgment under which most parents operate. Robyn, you are to be applauded for your parenting skills and your instinct to continue to look for help for your son.

    • Dr. Chuck Allen,

      I really am amazed at your response. I don’t understand how you could find fault with the parent. Are all parents supposed to know all things, medical and developmental, about their kids? In my opinion, it is our profession that needs to do a much better job educating parents, teachers and other professionals. If our colleagues have so many problems confusing eyesight problems with vision problems, how can we expect the public to understand?

      This parent, in her willingness to share this story, hopes to help other parents have a better chance of improving the quality of their children’s lives. It is parents like Robyn, that give me hope and inspire me to continue to spread the word about the power of appropriate lenses, developmental vision care, and vision therapy, helping both children and adults to better achieve their potential.

  4. I applaud Robyn for her courage to speak out!And to listen to that voice that many mothers can relate to. Vision issues(other than acuity issues)are not well known. My son had some behavior issues and was having trouble at school with reading,and math. It was my research, as his mother, that lead him to vision therapy. I knew something wasn’t right and that something needed to be done. I got no help from the school or his family doctor as to what direction to take or what help to seek. He received OT for sensory issues that I, as his mother initiated. The OT helped and we learned strategies to help when he was in sensory overload, but there was still something else not right. More of my research led to VT. He has finished his therapy and now is not needing any reading or math support and I can actually find him reading completely on his own! It was such a tremendous relief to him and our family! I too am spreading the word that VT exists and works! It is sad that schools are not more aware to have more children screened for vision issues.

  5. I want to thank Robyn for her courage to speak out and share her story as well as her son’s. I am now sending my patients to this blog so that they can FINALLY feel validated! Most mothers will exclaim after learning their child does indeed have a visual problem contributing to their difficulties functioning at school or play, “I should have listened to my own instincts.” Robyn confirmed this with her refusing that “everything was fine” with her son and taking him to the specialist. As our society continues to network through electronic media, my hope is that the word will finally spread to a broader segment of our population and children will not have to suffer so long before being appropriately diagnosed and treated. Thank you all for sharing your comments and especially to you, Robyn! You have surely touched many lives through your story and willingness to share.

  6. That’s a tough one. It might even have been that Robyn was lucky being born in that era and not being diagnosed with ADHD. Her son was fortunate to have someone as observant as his mother to recognize his deficiencies. I argued with my wife, before her stroke, that doctors could not determine what was wrong with you unless you told them. Then you were lucky if they knew what to do after you told them.

    I can see that it would be difficult to discover double vision in a child who has double vision because, to them that’s normal. The same holds true for many deficiencies in the human body if you don’t know what it’s like to be normal. It seems like the medical profession could come up with a checklist of common deficiencies and tests to discover these deficiencies and administer them as physicals. Today’s physicals leave a lot to be desired. Again, you need to find a doctor that is there to provide a real service to a patient. People like Nancy Torgerson at Alderwood Vision , Dr. Martha Devereaux at Kitsap Therapy, Dr. Alan Langman at Puget Sound Hearing, Dr. Marie Matty at the Doctors Clinic and a few others I have met.

    Advocate, Advocate, Advocate – that’s my motto!

  7. For all the binocularity experts:

    How do you detect small angle intermittent accomodative estropia? I assume the patient in question has a very subtle deviation, and is troping only very infrequently so his primary OD didn’t detect it during the first exam. If the patient is not showing any eye turn during cover test, but you are suspecting it, what tests would you perform?

    Thank you!

    • Several ways, Zoe. One is to give the patient letters or symbols to read that are sufficiently small to activate accommodation fully, typically 20/40 or smaller. That will often unmask the accommodative ET. Another way is to watch closely as you do a +/-2 flipper while the child fixates a near target. Going into the minus will likely trip the ET. If the child is old enough to do a screening such as the Telebinocular or Titmus, proximal accommodation/vergence will typically trigger eso diplopia or suppression. Lastly, if you cycloplege the child and look at them mid-way, when they are not fully cyclopleged and have residual accommodation to make the attempt to gain clarity, you’ll see the eye turn inward.

      • Zoe,
        At times, I see their eye wander inward with the +2/-2 while they are looking at a small target but they aren’t aware of double or blurry so I add the Worth 4 Dot at near, with the red/green glasses and have the child point to the symbols as you use the +2/-2. They are surprised when they get a two circles instead of one or when the symbols disappear. I love it when they can be aware of what is happening! So… if you aren’t sure, add Worth 4 Dot.

  8. Thank you Nancy for sharing this article with me. It was truly an amazing article. Isn’t it amazing the things we do not attribute to our vision

  9. First of all, I wanted to thank Robyn for sharing her story. As a 4th year optometry student, these are the types of stories that have fueled my desire to work in a practice that utilizes vision therapy. Besides the fact that as a profession, optometry has done a historically poor job educating the public and other professions on what needs to be done for children during vision exams. This is not just from my experience as it is quite limited, but rather from ODs I have spoken with; it seems like its more than just a problem that we have with educating but also has a major component of misinformation that other professions have said about optometrists. My sister-in-law, who is a PA in a family practice setting, just had a baby and needed to ask me what was recommended for eye exams for infants/toddlers. I was more than suprised (I certainly partly blame myself for assuming) to find out that she did not know that children are recomended to have eye exmas by optometrists at 6 months-1year, 2-3 years, and before entering school. Although origingally suprised, I’m sure this is not an uncommon occurence.

    As far as the orignial OD missing the problem with Robyn’s son, I decided to talk to some classmates on how they think they would do at diagnosing a problem such as this if they were in a primary care private practice and if they did diagnose it correctly, would they know what to do. Many of them said that during their fourth year rotations, they have a strong feeling that children have walked out of their room without being properly diagnosed. This is a hard thing as an intern to think there is a subtle problem but the attending dismisses it as the child not being able to correctly perform the test. My classmates have said, however, that they have so limited experience in the area, that they just can’t be sure. I was lucky enough to have a rotation in a vision therapy practice, but I am very much in the minority at my school (and at Pacific, I feel like we get as much or more binocular vision than do other schools). In fact, I think there were about 4 or 5 of us that did a VT rotation. So, most students only get vision therapy one day a week for 3 months during our internal rotation (which I also did and saw a total of 5 patients) So, they obviously said that they would have very little idea of what to do with a child that has a binocular vision problem beisdes that they would try to refer. Many of them also said that they felt like many doctors in private pracitce or commercial settings just wouldn’t take the time to do all the tests necessary to provide an appropriate diagnosis.

    But I again wanted to thank you Robyn for not ignoring that voice in your head saying that there was something wrong. It is always smart to get a second opinion. Thanks for sharing!

    • I so appreciate your response and can’t help but chime in again. We are talking a lot about the lack of education as to what is recommended for infant/child eye care. I see the other problem as the lack of education on the implications of these conditions. Even if my son’s eye turn had been detected earlier, I would not have known on my own that something should be done (before I understood implications and that there was this whole other area of optometry). Now that might sound foolish to those of you in the field. Think about it though, I have a constant eye turn that is easily detected by an MD. No eye doctor needed to find it. I can easily show it to any friend. I have been functioning at a high level all my life and have noted only what seemed to be “quirks”. I was told nothing could be done for this issue and there was no reason anything should be done. I would have falsely, but reasonably assumed that someone with an intermittent eye turn would have less trouble than I did with my constant eye turn. However, my son is showing more difficulty than I did developmentally and behaviorally, with areas of concern primarily in fine motor skills and lack of attention in close-proximity work. In hindsight it seems ridiculous to think this problem would have no significant impact on abilities, but that is how it was presented to me by at least three eye doctors.

      • Robyn,
        You bring up a great point, your son’s eye turn is not constant and therefore is causing more of a problem developmentally than you had with a constant eye turn. One of the reasons why, is with a eye constant turn, it is easier for the brain to suppress or ignore one eye. If it doesn’t, you would see double. With your son, things are constantly varied. It is harder to adjust and guess on prior experience because the experience is varying all the time.

        So even though most doctors would think his problem is less problematic because cosmetically it isn’t seen, it is just opposite. His eye turn is more troubling developmentally.

        Thank you for continuing the conversation.

    • With all due respect, Brian, I think you’re oversimplifying a very complex subject. You wrote: “Besides the fact that as a profession, optometry has done a historically poor job educating the public and other professions on what needs to be done for children during vision exams.” Firstly, the AOA has Clinical Practice Guidelines on Pediatric Care, posted on our website, indicating what needs to be done for children during vision exams. Secondly, there is an active vision screening industry in the U.S. which advocates that pediatric eye exams are overkill, and screenings suffice. They have the strong backing of organized medicine. This obviously is a source of confusion to the public. Thirdly, for the past ten years, the AOA has had a very active back in school campaign, emphasizing the importance of pediatric eye exams and what to look for. I did several of these in conjunction with Bill Nye the Science Guy. I could give you dozens more examples, the point being that we are actively opposed by medicine when we try to get our message out, try to pass legislation mandating exams prior to school entry in states, and so forth. I trust that when you graduate you will be very active in the effort to overturn, as you put it, “Optometry’s poor job in educating the public.”

      Regarding your other comments, you relate that you spoke with classmates who said they would have very little idea of what to do with a child that has a binocular vision problem and would try to refer. Frankly that would be fine. There are really three levels of optometric education:
      1) in-clinic experience adequate to recognize anomalies enabling referral
      2) doing an extern rotation such as you did that would make you feel comfortable taking on basic cases and referring complex ones
      3) doing a residency that would enable you to take on complex cases

      You also related that many of your classmates said that they felt like many doctors in private practice or commercial settings just wouldn’t take the time to do all the tests necessary to provide an appropriate diagnosis. I am fortunate to have a significant number of referrals from optometric colleagues, and can tell you that the issue in making an appropriate diagnosis and referral has little if anything to do with the setting. My referrals are equally divided between private and corporate ODs. One needn’t do “all the tests”. In fact a history that simply asks a few key questions, couple with one or two nearpoint clinical tests is all that is needed to make an intelligent referral. If we can do it for dry eye, we should be able to do it for pediatrics/VT, shouldn’t we?

  10. Oh yes, I am very much oversimplifying the subject. My point was just that in the past 50 years, our education to the public has been very limited. I like the way it is going into the future, but see that we are fighting a never ending struggle to get the message out. I have never been much of a political activist, although they are EXTREMELY important to what optometry has accomplished in the last 50 years; I see myself much more as an educator to anyone who will listen and strongly believe that we can help those who have been told there is nothing that can be done.
    As far as my classmates and many of the current graduating optometrists, I feel like the problem is that they do not even feel as though they are level one, as you put it “in-clinic experience adequate to recognize anomalies enabling referral” When talking to my classmates and sitting through the optometric educational experience, I feel like many students don’t feel VT is worthy enough of their time. The “sexy or hip” thing to go into now is ocular disease. Don’t get me wrong, I’m all for expanding our knowledge base and practicing to our full scope all the while fighting to expand our scope of practice, but this has lead to a degradation of the areas we have excelled such as vision therapy.
    I totally agree and understand that referrals come from both corporate and private practice ODs, my point was just that recent graduates hardly know the questions to ask to make the appropriate referral.
    As far as “If we can do it for dry eye, we should be able to do it for pediatrics/VT, shouldn’t we?” I defintely we should. The problem I see from my current classmates is that they would never make a referral for dry eye because we have been taught well enough how to treat it. Unfortunately, the same is not true for peds/VT, though I wish that were not the case…

    • We essentially agree, Brian. Regarding getting the word out, I feel it’s important to make a distinction between poor or limited outreach efforts to educate the public, versus effective efforts. There has been a concerted effort, particularly on the part of AOA, COVD, OEP, and PAVE in its day, to get the word out. Could we do better? Absolutely. I look forward to your generation elevating the outcomes of our outreach efforts.

      Regarding the allure of ocular disease, trust me — it was the sexy/hip thing to do even 33 years ago when I graduated. And no argument here that what our profession has done over the past 33 years has not just been to expand the scope of practice, but we have shifted the scope of practice away from functional vision. We needn’t re-invent the wheel, however. We just have to help turn it together. The AOA has impressive Clinical Practice Guidelines on Care of the Patient in all the topical areas of concern. We need to do is remind students and colleagues that VT-related areas have been supported by neuroscience and even have overlap with disease-related thinking processes. Dr. Jim Thimons and I have given a number of lectures showing this overlap and borderland, and we hope to do more.

      Let me point out one more hopeful sign. The ABO (American Board of Optometry) has not put out a template for preparatory coursework in taking its Board Certification (BC) examination. This is a BC process for Primary Care practice. The core of the exam has 10 areas, and Pediatrics/Binocular Vision/Vision Therapy comprises 8%. This includes visual perception as well as binocular and ocular motor areas. In addition to the core exam, each candidate can select 2 other areas, one of those areas is Pediatrics/Binocular Vision/Vision Therapy, to give additional weight to this subject. In addition, 16% of the exam is devoted to ametropia and ophthalmic optics, under which is anisometropia and refractive amblyopia is subsumed.

      That is making a statement to our colleagues that a basic knowledge in these content areas is important.

  11. Thank you Robyn and WOW Vision therapy for this article! In particular the comments Robyn made in reference to the great amount of effort required by Robyn and her son to obtain the end product. As a Mum with a 5 year old boy who struggles developmentally with gross and fine motor skills, speech pronounciation and volume, and is so hard on himself when he doesn’t succeed; it was a wonderful reminder.
    Ironically I envy the insight Robyn has into her son’s behaviour. I often don’t understand why my son demonstrates certain behaviour and I find it challenging to say the least in finding the most appropriate manner to respond!
    I am particularly thankful for Robyn’s 8 tips. Robyn’s comment about timeout and the child not making eye contact etc when the parent is explaining the reason of the timeout was a big eye opener to me. Thank you Robyn for making a difference to my family.
    My family lives in Malaysia and we travel 5.5 hours by plane to Perth in West Australia every 6-8 weeks to see Chris & Rachel Chong, Behavioural Optometrist and Vision Therapist. I know there is still a lot of work to be done educating parents and educators and the medical profession, but please also acknowledge how far ahead you are compared to so many countries where VT doesn’t even exist! Keep up the momentum and keep striving forwards with this education!

  12. I made a huge mistake in my write-up in failing to express my gratitude to my son’s teachers. I should have noted, that while his teacher recommended a thorough evaluation for many different conditions, her list of resources included information on proper hearing, vision, and speech evaluations. She never attempted to diagnose our son with a particular condition. She noted behaviors that indicated that something was wrong. She never wanted to be “right”, she wanted it figured out and figured quickly before kindergarten.

    She, and all the teachers at his school, are the most loving, intelligent, patient, and professional group of teachers I have ever met. I urge all parents to acknowledge these teachers who are doing their best to help the children. How difficult it is and how courageous they are to tell a parent what needs to be said rather than what the parent wants to hear. Parents, please do not shoot the messenger!

    Of course we are hoping that correcting our son’s vision problem will resolve these issues that we and his teachers have been seeing. Like his teacher, we recognize it is most important that we figure it out and not place being “right” as the priority. We will pursue more extensive evaluations if improvement is not seen. She was right to tell us her concerns and to give us those resources. Thank you, all the loving teachers who are taking care of my boys. We love you.

  13. Here’s one more voice thanking Robyn for her intelligent and courageous account. And as also a patient finally coming to the end of VT, here’s at least one preview of what she and her son can look forward to during the “exciting journey” they are starting out on.

    Looking back, I can relate to quite a few of the dots Robyn connected up into a pattern that turns out to be strabismus. I can also relate to the professional advice at the time (in my case, decades ago) that patients adapt very well, lead fine lives, and in any case once they’re past puberty, there’s nothing that can be done for them (all no doubt true at the time).

    Well, I’m here to tell you, today stereopsis is very probably within your grasp, and it’s terrific! All those seemingly unrelated deficits and lapses can be made to go away. But the rest of that story is what you get in their place. Everyone who’s been down this path speaks of the wonder and excitement of experiencing a 3-D world. This is analogous to the thrill of learning to scuba dive. After a lifetime of confinement to a 2-dimensional world, suddenly, you’re mobile vertically, too. Sue Barry says it best when she speaks of the thrill of watching a snowfall and, for the first time, seeing–experiencing, not just assuming as a matter of logic–the spaces between the snowflakes.

    These thrills don’t diminish with time, but rather get reinforced. Sure, you don’t miss when you reach for a doorknob anymore. Maybe in isolation that’s a negligible improvement in your life, but it’s a small part of your new understanding of space, and where you are in it. You have what Bill Bradley called his book, A Sense of Where You Are. His “situational awareness,” including knowing exactly where he is on the basketball court at all times, is one of his great strengths. You’re much more connected to the world than you ever were. The last thing you want to do is to go back to your old sketchy grasp of space.

    “Exciting journey” is exactly the right phrase. Robyn and her son need skilled and empathetic practitioners, and they surely have those. They also need a certain amount of discipline to get the homework done regularly, but really nothing compared to doing well in school or at a job, or getting good at a sport. And they need to experience the thrill of making progress on this journey. I wish them all the best.

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