The Double Standard of Double Vision


The first three verses of this immensely popular folk song were written by Pete Seeger in 1955.  It was Joe Hickerson who added the additional verses in 1960 to turn it into a circular song.  Each verse ends with the rhetorical question, when will they ever learn?

When you read through the comments of an earlier blog piece here you’ll be struck by the circularity of reasoning that is similarly recursive, and the conclusion is the same: when will they ever learn?  The good news is that for many, though not all of the public the outcomes of the CITT study are leading more patients to the benefits of office-based optometric vision therapy.  They are learning now.  The bad news however is that many (though not all) patients who seek an opinion about CI from an ophthalmologist (self-described “Eye MDs“), will be left scratching their heads like Pete Seeger.  What prompts me to say this?  Reports from the source presented to me by my patients.  Here is simply the most recent example given to me by a parent yesterday:

It turns out that this child, who is struggling considerably with reading, has a very classic convergence insufficiency.  Sure enough, she has exophoria at near as detected by the Eye MD.  In fact, she has 16 prism diopters of exophoria and a modest reserve to offset what would be double vision when reading if she didn’t work extremely hard to maintain single vision.  Not surprisingly her parents indicate that reading is extremely fatiguing for their daughter, and she has all but given up.  Not surprisingly, she grasps things very well when listening to someone else read.

So what guidance was this family given by the doctor?  There is nothing to be done, because this condition has nothing to do with her reading problem. When the parents related that they had learned about vision therapy from some investigating they had done, and wanted to know this doctor’s opinion of it, the advice they got was the snake oil myth. Dismissively they were told that if they wanted to do something, they should do “pencil push-ups” with their daughter.

Odd, isn’t it?  Here we have a professional claiming to be objective about optometric vision therapy, dispensing a placebo therapy for CI and trying to pull the wool over a parent’s eyes.  When will they ever learn? The circularity must end now, and you – whether you are a vision specialist or a patient – will play a huge role.  How?

I’m going to push you like my patients push me.  As Peter Finch said in his starring role in the movie Network,  I’m not going to leave you alone.  Parents of children who succeed with vision therapy get mad when they think about MDs or educators who didn’t raise the option of looking into vision therapy – or worse, deterred them from considering vision therapy.  To paraphrase Peter Finch, they want their child to be treated like a human being, whose life has value.  You don’t have to go to the window and yell, but you should be mad as hell when you encounter this double standard.  When you take action the children will blossom, the circularity will end, the Eye MDs will learn, and the double standard will end.

– Leonard J. Press, O.D., FCOVD, FAAO

11 thoughts on “The Double Standard of Double Vision

  1. As alway Len, a very well done piece with a great message. However, an analagous situation occured in my early years of practice. When patients asked why I didn’t dilate, I told them that optometrists didn’t use the poison drops that had very bad side effects. This was in spite of the fact that the risk to benefit ratio was very much in favor of the benefit. Consequently we chose not to learn fromthe literature and clinical wisdom. Then when we obtained the privilege of using DPAs was given, we suddenly learned.

    A similar thing might happen in the case of VT. We are experiencing a golden age of VT. This is no doubt due to the CITT, other research,Sue Barry’s book and the highly successful practices of people of your generation. It would be dilation in reverse. I think that as public pressure builds up for VT, it could be espoused by ophthalmology and incorporated into their practices. Ophthalmology recently “discovered” the value of vertical prism, and they can do the same with VT. It might be a boon for orthoptists, or ophthalmolgists will start hiring optometrists who can do VT. There is already some evidence of this happening in some hospital settings and in some offices. These situations require that the optometrist loses a good deal of professional independence.

    I do agree that their unwillingness to learn is contrary to their oath to heal and do no harm. However, if they continue to fight a battle that is increasingly being lost, VT will increasingly be our property. The literature and public awareness will not let them discover it. So, perhaps its best that they never learn.

    • I whole heartedly agree with Irwin. He and I are of the same ilch. It was at the Optometric Center of New York that I learned VT, developmental optometry, etc..None of this was offered at PCO at that time. I don’t think that my experience with the medical community has changed in the last 49 years even though there are more optometric practices involved in VT; Incidentally, there are O.D.’s who have VT incorporated in their practices and they do not belong to COVD. Let’s not ignore them. Those of us involved with vt in their practices, I’m sure, communicate with the child’s pediatrician regarding the optometric diagnosis and prescribed treatment. We tell the parent that we will. But the M.D. in response to the parent mentioning that their child has been progressing rapidly since receiving VT, tell the parent that it’s only because they are getting, “more attention.” Really? What were they getting for the time before they got to a optometric practice that included VT?

      • I don’t disagree with Irwin, Chuck. He and I are essentially on the same page, and I’ll reply to his comment in a moment. Nor do I disagree with you that there are practitioners like yourself out there doing credible VT who are not members of COVD. It is fair to speculate, however, that public awareness in VT has been strongly fueled by the efforts of the organization. Further, the Board Certification Process that was the impetus for the organization’s formation in 1970, certifying both dcotors and therapists, has had a major influence on the practice of VT and has kept it solvent. Lastly, i would urge you to join COVD. For those doing VT it is a way of staying connected and to keep us strong in this field. Many of the reasons that motivate you to remain a member of the AOA and NJSOP should prompt you to join COVD. Best wishes as always!

    • Thank you for the kind comments, Irwin. Years ago I wrote a guest several guest editorials for the Journal of Behavioral Optometry at the invitation of their outstanding editor. The thrust of these editorials were precisely what you have stated above. I cited some signs of what I termed behavioral ophthalmology, but in the ensuing 15 or 20 years the change has been slow. Is it best that they never learn? It is that part that I’m not so sure of. Indeed, the likes of Dr. Granet seem to do their own form of VT Lite. I would welcome some sort of biased competition, where the patient is the winner. Yet I still envision that we should have the synergy that exists in physical therapy and orthopedics, and that this synergy would ultimately accrue to the optimal benefit of the public.

    • Dr. Suchoff,
      My aunt was a patient of yours some 50 years ago in the Bronx. They would travel down from Liberty, NY, from what I remember, every week. I’m not sure exactly what she had with her eyes, but my mother said it was a condition that you discovered. My seven year old daughter is all of a sudden being afflicted with some kind of eye and eyelid control problem that comes and goes during the course of the day. I wanted to know what you thought and if what my aunt had was something that could have been passed to a great niece. I don’t want to go into detail on here, my email address is jeopardynerd@yahoo.com. I hope this reaches you, I am desperate for compitant input. Thank you.

  2. This double standard has disturbed me from my first week involved in optometry, 30 years ago. I had just joined OEP as Communications Director and asked “If this is so good, why don’t we reach out to ophthalmologists?” Within days, prominent ODs across the USA called to suggest I be fired. That was my first exposure to the conflict between the “Os.” So while I agree that most ophthalmologists are anti optometry, I find that many ODs hold equally hostile attitudes about OMDs.

    I think your call to action to patients is worthy, I think we should clean up our optometric attitudes as well. The fact that ODs are frequently insulted by OMDs makes it hard to do, but it speaks volumes to patients when they compare a respectful communication about OMDs from an optometrist who has found a significant, but overlooked vision problem.

    OMD orgnizations not long ago forbid OD attendance at medical meetings. OD meetings are open to any professional who wants to know more. What do you think about a campaign of “take your ophthalmologist to a meeting.” There are many friendly OMD/OD relationships where this might occur. No OMD meeting will cover what ODs know and OMDs do not read any behavioral journals. How can OMDs learn what they don’t know unless CE is made available and respectfully offered?

    A growing number of OMDs are setting up orthoptics services in their practices despite their lack of understanding of VT. “Take an OMD to a meeting” might help them be more successful at therapy, more respectful toward their OD colleagues and more likely to test for, identify and refer binocular and behavioral vision cases.

    Perhaps COVD, OEP, NORA, AAO, AOA might consider a “guest” tuition for MDs accompanied by an OD? What do you think, Len?

    • Interesting thought, Tom. The move to “bar” ODs from attending meetings of the AAO was simply a blatant form of biased competition taken to an extreme, and frankly it accomplished nothing but to reveal organized ophthalmology’s insecurity with ODs aggressively advancing our knowledge and skill base.

      One can make he analogy of MDs setting up shop with orthoptists to retro-fit aspects of VT that have eclipsed their origins as similar to the attempts of MDs to master optical dispensaries in their drive toward “one stop shopping”, as Dr. Granet put it. Has that been successful in the marketplace? I suppose to some degree, but it we’ll still stack our skills in Rxing against an OMD any day of the week, won’t we. Nor will many ODs “lose” patients to OMDs in the biased competition game they may set out to play by claiming they deliver VT services equivalent to the full scope of optometric VT.

      Take your OMD to CE? Catchy phrase, though it doesn’t personally excite me. Perhaps someone else reading this may find a productive win-win. NORA certainly is the multidisciplinary group to pursue this. How about NORA encouraging Physiatrists and other Rehab Med MDs to attend CE? There is joint interaction and synergy in rehab hosp settings already. I would encourage you to contact Eric Ikeda and Bob Williams to pursue this further. Thanks for raising these issues, Tom.

  3. I am also continually amazed at how at one moment parents are thanking us about what V.T. has done for their child and how well they are doing and the next minute, I am defending V.T. to the next set of parents who have been subjected to the biased views of many in the medical community. I am very appreciative of this blog and all the communication it is stimulating and in that light, I was wondering if there is a mechanism whereby my successful Therapy patients (and their teachers and therapists for that matter) and those of other COVD members can actually become “Friends of COVD” in order to have their stories more available and even potentially communicate with parents of potential patients anywhere with regard to their experiences?
    Bruce Meyer, OD, FCOVD

    • Good suggestion, Bruce. My personal feeling is that the message of parents is most valuable when coming from the source. When it’s through a COVD forum it might have the appearance of being self-serving. That’s why the Little Four Eyes, and the Strab blogs we’ve linked to are so powerful.

      I know that Sue Barry and several of the active bloggers have been discussing setting up the type of forum that you describe, where parents and others can share their success stories.

      In the current communication genre, it is these independent bloggers who cross-reference each other, and the opportunity for parents to piggyback their experiences onto those blogs that is helping the message go viral, even more so than centralizing it. But again, excellent suggestion – and I would encourage your patients to network with these other bloggers.

  4. I hope this isn’t stale, but I have some comments on the very interesting threads that were produced yesterday.
    Len hoped for a synergy between ophthalmology and optometry similar to that of othopedics and physical therapy. But there is difference: PTs and OTs can reimbursed by third parties only when the therapy is recommended by an OMD. The same holds true with physiatry, and with orthoptists and OMDs. The point being that the synergy is at the cost of independence.
    Tom suggested a taking of an OMD to an OD national meeting. Let’s look at the other side of the coin. Its been an ongoing thing that OMDs in refractive surgery practices and referral centers have invited ODs to local meetings where some degree of education is ofter provided. However,is the intent really education or is it to obtain OD referrals? Its rare for ODs to be invited to address a more geographically extended OMD meeting. Len’s recent presentation at one was as a fill in, and he did a great job.
    I’ve been retired for a decade so I’m somewhat immune to the slurs, poor scholarship, frustrations and being rejected by the medical community. However, that might be a good thing…maybe I can take a more global view. Its that since we’ve become a main stream health care profession we’ve become an economic threat to ophthalmology and pediatrics. The mistake my generation made was to try to convince ophthalmology of our expertise and value to the public was via research. Well, that didn’t work. The strength of the present generation is that it knows how to market VT to the public, and it is increasingly successful. So, keep up the good work and forget about ophthalmology. Optometry, and particularly behavioral/developmental optometry have grown up and don’t need ophtalmological approval.

    • Irwin, your comments? Stale? Never!!! The type of synergy I was referring to wouldn’t have to come at the cost of independence. It’s simply two disciplines working together who have complementary interventions. OMDs are experts in surgical ocular motor realignment and we are experts in visual-ocular sensorimotor integrative therapy.

      I agree that part of the stumbling block is that OMDs as a general rule haven’t quite figured out yet what we do well enough to refer patients to us. And then of course there’s the ego/arrogance factor we’ve beaten to death, coupled withe insecurity of referring to an independently licensed provider who isn’t under their thumb and required to work off their script.

      What I’m reiterating is that MDs conceptually don’t hold other therapies to the double standard they exhibit with VT. They demand all facets of VT be supported by gold standard studies (RCTs like CITT), yet the ENTs don’t deter patients from seeing SLPs because speech therapy lacks RCTs. Nor the orthopods to PTs, etc.

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