Do Physicians Have a Blind Spot When it Comes to Understanding Optometric Vision Therapy?

We understand that neither pediatricians nor ophthalmologists have had the benefit of coursework in optometric vision therapy during medical school.  But is it really that difficult to accurately represent the core concepts in our field?  Once again, the Section on Ophthalmology of the American Academy of Pediatrics has  trotted out a Joint Statement – this one in 2011 just two years on the heels of their last Joint Policy Statement.  Enough with the Joint Policies already – even Goliath recognized when he was sufficiently stoned to move on.  Listen, I’m as sympathetic to the Going Green movement as anyone else.  But shouldn’t there be a limit as to how much the same item can be recycled?  This latest Joint Statement has now taken on the air of science by calling itself a “Technical Report”, perhaps because it has added significantly more references than its forerunners, yet its agenda remains the same as its prior iterations:  A shallow attempt to discredit optometric vision therapy, thoroughly exposed by Dr. Bowan’s rebuttal article published in the journal Optometry 2002, and by Dr. Lack’s rebuttal paper in the journal Optometry 2010.

The re-cycled and re-packaged Pediatrics/Ophthalmology Joint Statements are flawed for reasons that we have been very clear about.   Given that the American Academy of Pediatrics, and specifically its Section on Ophthalmology’s “Learning Disabilities Subcommittee” chooses to ignore any legitimate criticisms of its Policy Statements published in peer reviewed optometric journals, perhaps we can make this a bit simpler to grasp.

Here is what we, in science, refer to as a Venn Diagram.  Dyslexia is the subject in question, and it is a catch-all descriptor for a very heterogeneous set of reading disabilities .  No onehas ever posited that dyslexia is “caused” by visual disorders, nor has anyone ever established that it is “caused” by auditory disorders.  It’s treatment is therefore not strictly in the domain of vision or of audition or of phonology, or of any other singular approach.  Optometry has been very clear about this, and the Venn Diagram you see was used by two leading physicians quite knowledgable in the field, devoid of politics and turf wars, who grasped this.  Referring to the Joint Policy Statement of the American Academy of Pediatrics they note:

Although the authors of the recent consensus statement on Vision and Dyslexia were trying to clarify the most effective approach to diagnosing and treating visual processing issues in dyslexia, their statement is more likely to misinform than inform.

The public appears to have grasped the realities of optometric vision therapy far better than most pediatricians and ophthalmologists.  They do not seek our services as a replacement for educational interventions, and they understand the cost of allowing their children to continue to struggle when other interventions have not proven effective.  The deaf ear of the public to the distortions in the AAP/Ophthalmology Joint Statements seems to be prompting only more vigorous recycling, leading one to ponder what their true agenda is.  The most accurate statement in this latest Technical Report may be a throw away disclaimer that reads:

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

An optometric colleague, whose son graduated West Point a couple of years ahead of mine, summed things up succinctly after reading the latest Joint Report when he wondered aloud whether it wouldn’t be best if ophthalmologists advised patients prior to seeing them that vision plays little if any role in learning and reading disabilities from their perspective.

I was in attendance at my son’s graduation from West Point in 2004 when the Class was addressed by its commencement speaker, Donald Rumsfeld, then Secretary of Defense, and was moved by his remarks.  I’m reading his  memoir, Known and Unknown, in which he relates that if you’re not being criticized, perhaps it’s because you’re not doing much.  We must therefore be having a significant impact on the field.  That thought came to mind as I read the Joint Technical Report, as well as another thought prompted by Rumsfeld’s depiction of Ehrlichman in the Nixon White House, who seemed to have a high degree of certainty about his views that bordered on arrogance.  Rumsfeld writes:  Certainty without power can be interesting, and even amusing.  Certainty with power can be dangerous.  When it comes to second opinions about optometric vision therapy, caveat emptor.

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

15 thoughts on “Do Physicians Have a Blind Spot When it Comes to Understanding Optometric Vision Therapy?

  1. Len,

    I could hardly get past “…perhaps we can make this a bit simpler to grasp.”;so funny, and so sad for their profession. Their attempts to confabulate, as you pointed out, are so easily dissipated by the public. They want clarity, and this is what you have provided. Thanks!


  2. The quote at the end really sums it up.
    Basically, optometrists believe they understand the visual process better than ophthalmologists, ophthalmologists are certain they know more than optometrists on anything eye or vision related.

  3. Brilliant! One of my favorite moments at this year’s COVD meeting in Puerto Rico was listening to Dr. Michael Earley’s lecture. Loved watching him stamp his foot on the stage in frustration saying “Why do we have to keep going over this? Because this JUST WON’T DIE” The “this” he was referring to being these infamous joint policy statements and other similar rhetoric. Great blog!

  4. “If you’re not being criticized, perhaps it’s because you’re not doing much.”

    This is a great quote, and makes me feel a tiny bit less frustrated when yet another patient gets confusing input from their pediatrician. Just a tiny bit. How many children do we not get the opportunity to help because their pediatricians “don’t believe” in vision therapy? As if it’s a matter of faith rather than science.


  5. Dr. Press,
    It is with a troubled heart that I impress upon you the first problem. Our Optometric colleagues. I had a young OD ask me once, “Do you really believe in that vision therapy stuff?” To which I asked him, “Do you really believe that vision is just acuity and health?”
    We are our own worst enemy when it comes to vision. Those that follow the medical model don’t have an inkling of understanding when it comes to how vision truly works. I think that vision is so complex that no one truly understands in complexities of vision and visual function. When something doesn’t fit, you had better change your model or find out why.

  6. I think Jason really hit this one on the head. I have had many young ODs tell me that “cure” all binocular vision problems by doing a cycloplegic exam and Rx’ing that extra 0.25 or 0.50 of plus they find. As a result they don’t see the need to refer for VT. (I assume that they assume that their patients don’t return to them because they are “cured”, not because they have gone elsewhere seeing answers). We do ask patients to bring in charts from their previous eye exams when possible. It is pretty scary to see what our colleagues are doing.

    • Rob and Jason – a very complex issue you’ve touched upon here, and one that will difficult to do justice. I’ve touched upon it before on the blog here citing Jim Thimons, and Dan Fortebacher and I addressed the issue very directly in a 5 part series that starts here.

      On SOVOTO I posed a provocative question, and I’ll put it to both of you here. Aside from the effort we put in on our end to create science and substance behind VT, is there any reason either of you can think of that our colleagues have the reactions you both describe about VT. but apparently not to any other area of optometric care? In other words, have we matured enough collectively where we can actually say that in some instances the perceptions of our critics – even within our own profession – is any any way justified?

  7. Dr. Press –

    An excellent post, and I appreciate your links to past statements and positions. The blinders of physicians to VT is not unique to the field of optometry. In a world of specialists, few medical practioners seem willingly to collaborate (except maybe in a culture like the Mayo clinic.) Not only do we have figure out how change this mindset, we need to become skilled at making patients demand a seismic shift.

  8. I’m not Rob or Jason but I’ll throw my $0.02 in. I’m not sure if “justified” is the answer I’d choose but perhaps “understandable.” Let’s be honest, being on the fighting side of this debate isn’t easy. It’s only possible if the passion you feel for the profession outweighs the constant barrage of external criticism and challenges. You must have a thick skin and a core belief that the work you do, matters, AND elicits change in and for these patients. To be exact, you have to have actually DONE vision therapy to fall in love with it, or at least respect it. If you didn’t receive a strong and supportive exposure in Optometry school you’re already starting off on the wrong foot. I distinctly remember a Pathology department doc at my Optometry school describing VT as “voodoo” under her breath. This was a doctor I respected and whose opinion I valued and she was nullifying the work of the VT docs.

    Luckily, I had the blessed opportunity to do an extern with Dr. Ron Berger. An extern I had chosen simply based on the area in which he practiced. Through this “accidental” placement he opened my eyes to the beauty of this segment of Optometry. Without him, I’d be practicing primary care and referring very little to Vision Therapy doctors. I had to SEE it work, hear the parents praises and read, read, read on my own to find the science behind the art of Vision Therapy. So, I “understand” that the much easier road is to practice Primary (which isn’t really) Care Optometry and follow the traditional medical model. It certainly allows for less fight, less controversy, less defending of your knowledge and credentials, less presenting of research articles and less ego and turf battling.

    Fortunately, I’m a big fan of the Gandhi quote that states…

    “First they ignore you, then they laugh at you, then they fight you, then you win.”

    I’m smelling more and more “fight” from the critics as they lose their foothold on the public’s opinion. I find this invigorating and thrilling and magnificient because the patients will be the one’s that are soon “winning” this battle as the misinformation will begin to be viewed as lack of knowledge and understanding of this powerful work.

    • Very well said, Suzy, and the only reason I invited comment from Rob and Jason was based on their specific comments about ODs not referring for VT.

      So I’ll ask you to elaborate. Now that you know what you do, how do you account for: “I distinctly remember a Pathology department doc at my Optometry school describing VT as “voodoo” under her breath. This was a doctor I respected and whose opinion I valued and she was nullifying the work of the VT docs.”

      In other words, what specifically do you think it is about VT that made this doc, whose opinion you value, have this impression? I find it inadequate to say that until you do it you can’t appreciate it, because the Path doc wouldn’t necessarily say, for example, that Rxing prism for diplopia is voodoo even though she may have never done. Probably wouldn’t say Rxing an X-Chrom contact lens for color deficiency is voodoo, even though she may have never experienced. Probably wouldn’t say speech therapy is voodoo, even though she may never have known anyone who went through it.

      If my premises are correct, what is it about VT that engenders this negativity?

  9. Yes, I think that’s a great point. I also know that very few doctors understand the mechanism of action of every pharmaceutical that they prescribe and are listening to the non-medically trained sales reps for prescriptive suggestions more intently than they listen to a behaviorial vision OD on learning related vision disorders. I think to really find the source of the issue you have to go back to the beginning. I haven’t been in an Optometry school for over 10 years so please take my comments as being based solely on my education at that time as I can’t accurately comment on the environment as it is today. Vision Therapy was presented in clinical relevance as a distant fourth in importance to pathology, contact lenses, and primary care/glasses. We had some amazing VT instructors but the general feeling from the institution at the time was pathology, pathology, pathology…increase our scope of practice, learn the “real doctors” language, dabble in minor surgical procedures and work to forge relationships with OMDs by proving that you can talk the talk of medical eyecare. Don’t get me wrong, I fully support the pathology education, the increased scope of practice, and the acknowledgement that we can identify and treat a conjunctivitis, blepharitis and glaucoma with the same proficiency as an MD. The thing that bothers me about this is that no matter how well we can speak the pathology language, we’ll still be viewed as the little brother/sister of eyecare by them. It’s inevitable. I’m by nature an optimist so I don’t say this in an “everything stinks” fashion…I say it from a reality perspective. No matter how many times someone tells me an Optician can learn to do a refraction, in my mind, they’ll never be able to do with the art of an OD. Do you see what I mean? I’m as guilty of that ego inflated, limiting thought as an MD is about our abilities.

    So, long story getting longer…I believe the skepticism comes from lack of importance of Vision Therapy that was presented for so many years in Optometry schools. It really does seem that the efforts of COVD in the Optometry schools in recent years may have a HUGE impact on shifting this perspective. At current though, we are battling decades of the importance of the medical model being shoved down our throats, Behavioral Optometry being given the backseat coupled with the lack, at the time, of valid studies on it’s efficacy. You are then left with judgment and loud criticism from the almighty MDs that we were trying so hard to emulate. Our profession has worked for the past few decades to get legitimacy from a group that will never give it to us and by doing so abandoned some of our “roots.” So, why did the pathology doctor mentioned above not consider out-of-the-ordinary prescriptions “voodoo”? I would assume because we are considered, even from the MDs, the experts in glasses and contact lenses. They’ve never really wanted to be a part of that world as it entailed retail and “real doctors” don’t do retail. Without criticism from external forces that we were working against, the “out-of-the-ordinary” prescriptive options were viewed as “pioneering and innovative” rather than “voodoo”.

    For a sunnier ending…I very much feel this tide turning. We are reaching a tipping point and it’s coming from exactly where it’s the most important, the public. I am certain that an internal shift by Optometry schools is already or will soon be occurring.

    Please excuse my lengthy comment. 🙂

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