The JAAPOS Trifecta: How Ophthalmology Still Gets It Wrong


The April 2011 issue of the Journal of the American Association for Pediatric Ophthalmology and Strabismus is a gold mine for readers to see how ophthalmologists (MDs who are not Doctors of Optometry) are still slow on the uptake of information that we’ve been visiting in our blogs.  The first item is an editorial of sorts from Dr. David Granet.  His name may be familiar to you from a blog discussion that we had awhile back.  This piece is basically a shill for the tired and recycled party line of organized ophthalmology that vision has little if anything to do with reading, and/or parents are being duped by optometric vision therapy and should spend their money on “proven” therapies.  The fallacies inherent in this perspective have been addressed many times, and you can re-visit this in our call for voices of reason regarding1) myths and misconceptions about optometric vision therapy and dyslexia  2) the illusion of objectivity 3) how we effect real change.

Dr. Granet ends his opinion piece on a promising note:  “However science does not stand still and so it is up to us to alter our recommendations as new clinical trials and improved scientific evidence become available.”  So how well has Ophthalmology altered their recommendations based on new clinical trials and new scientific evidence?   That brings us to the second item of the JAAPOS trifecta in the April 2011 issue.

It would be very convenient if ophthalmologists could prove that office-based vision therapy wasn’t necessary to achieve success.  That would lend substance to the way most practice – not dedicating any significant staff or resources required to achieve the type of success that patients experience through optometric vision therapy.  This was the intent of the article entitled:  Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program by Serna et al.  In the discussion segment of the article, the authors write:  “Many clinicians, including our group, use home-based therapy for convergence insuffciency“.

Of course, therein lies the problem.  As we’ve pointed out in our blog before, despite the fact that research doesn’t support home-based therapy being any more effective than placebo therapy, ophthalmologists keep practicing this way.  It’s a blatant double standard.  The saving grace of item #2 in this JAAPOS trifecta is that the editors gave a Doctor of Optometry the opportunity to point out how ophthalmology still gets it wrong!   In his editorial perspective Dr. Mitchell Scheiman, Principal Investigator of the CITT study writes:

“Despite these findings and the conclusion from the recent Cochrane systematic review for convergence insufficiency that “current research suggests that office-based vision therapy/orthoptics is more effective than home-based pencil push-ups or home-based computer vision therapy/orthoptics,” some eye-care providers still prescribe home-based treatments as the primary treatment option, presumably because they do not offer office-based vision therapy/orthoptics in their offices or on account of the low cost and ease of use of home-based therapy.”

Here’s my challenge to Ophthalmology:  Either do your homework and get it right, or stop giving patients “VT Lite” in the guise of real therapy.  Patients can tell when they’re being patronized.

Now for the grand finale of the JAAPOS trifecta:  Development of motor fusion in patients with a history of strabismic amblyopia who are treated part-time with Bangerter foils.  Here’s the key conclusion of the paper:  “A child’s motor fusion status is generally believed to be established during an early formative period of visual development. The development of motor fusion in many of our patients during the course of part-time Bangerter foil treatment suggests that improvements in motor fusion status can occur at a later age than previously believed.”

Hello?  Is anybody home?  Somebody should break the news to the authors that motor fusion can be developed beyond the early formative period of visual development.  It’s called neuroplasticity, and its been plastered all over the place in optometric literature.  We’ve been doing it for years, despite the artificial limits that MDs have placed on what patients can accomplish through therapy beyond patching, drugs, or surgery in early childhood.  You can read about it here, there, and everywhere.

– Leonard J. Press, O.D., FCOVD, FAAO


24 thoughts on “The JAAPOS Trifecta: How Ophthalmology Still Gets It Wrong

  1. Thank you for reading the journal and giving us all this information. My blood pressure couldn’t take reading this myself. Of course, ophthalmologists continue to do home VT that is shown to be ineffective-otherwise they may have to refer to an optometrist. And gee-look how successful strab surgery has been for them.

    • As a pediatric optometrist working alongside a pediatric ophthalmologist for a busy HMO, it saddens me to see the comments on this forum. To make comments insinuating that strabismus surgery, as a procedure, is unsuccesful simply reinforces the habit of making claims with no supporting evidence. Practicing full scope medical optometry on a daily basis I have come to see the importance of evidence based medicine and use of the scientific method that has improved not only counless scientific diciplines, but many aspects of our daily lives. Until optometry stops making claims that vision therapy will repair everything rangning from 30 diopter exotropias to a teenager’s acne without a shred of supporting published scientific evidence (from a reputable source), we will never escape the stigma of crackpots trying to push unecessary specs and binocular flippers to pad our wallets.
      Having interned at optometric “VT sites”, as a student, I was apalled to see my future colleagues selling binocular flippers, strings with beads and other “necessary” items for 50-100 dollars to desperate parents believing claims of improved grades, cessation of headaches and unbelievable improvement in overall wellbeing. Ironic how a profession struggling to stay afloat by diminishing insurance reimbursements and retail competition turned to a “treatment” that is not covered by insurance and that targets loving parents searching for a solution for their troubled child.
      In my clinic, I have seen countless 45 diopter esotropias be returned to ortho with a simple surgery that is supported by volumes of evidence based medicine. I can hardly say the same about the results of amber tinted glasses sold to unsupecting parents for 600.00 to treat Scotopic Sensitivity Syndrome.

      • Congratulations, Vincent. If I were to ask an optometrist to write up a list of best items about vision therapy to perpetuate innuendo and sensationalism, I don’t think anyone could have done it any better. Permit me to address the points that you raised in sequence.

        1) You wrote: “To make comments insinuating that strabismus surgery, as a procedure, is unsuccesful simply reinforces the habit of making claims with no supporting evidence.”

        In no way have I suggested that strabismus surgery is unsuccessful as a procedure. The thrust of comments on this site are oriented toward the fact that strabismus surgeons rarely if ever give patients any option other than strabismus surgery. I’ll elaborate more later, but just this fact is a very important distinction to make.

        2) You wrote: ” Practicing full scope medical optometry on a daily basis I have come to see the importance of evidence based medicine and use of the scientific method that has improved not only countless scientific disciplines, but many aspects of our daily lives.”

        So are you claiming, Vincent, that in practicing “full scope medical optometry” all of the treatments you give patients are predicated on “evidence based medicine”? You’re kidding me, right? Let me give you a few for instances. When you first started using punctal plugs for dry eyes, was there “evidence based medicine” that it worked? When MDs first started using ocular hypotensive drugs for COAG, was there any evidence based medicine that it altered the progression of the disease? Where were the prospective, double blind studies done for botulinum treatment of strabismus? And of course, the very notion of such things as “fortified antibiotic” mixed proprietarily by a pharmacy, or using medications for “off label” purposes, is predicated on “we tried it, so we know it works” rather than on “evidence based medicine”.

        3) You wrote: “Until optometry stops making claims that vision therapy will repair everything ranging from 30 diopter exotropias to a teenager’s acne without a shred of supporting published scientific evidence (from a reputable source), we will never escape the stigma of crackpots trying to push unnecessary specs and binocular flippers to pad our wallets.”

        Come now, Vincent. VT for a teenager’s acne? Making outrageous statements that Optometry claims VT applies to this makes it difficult to take the rest of your comments seriously. Take a look at the AOA Clinical Practice Guidelines on Exotropia and Esotropia. Think the references cited are from reputable sources? In fact, take a look at all the AOA materials on VT (a number of which I had a hand in authoring), and I defy you to show me that this positions us as “crackpots” looking to fatten our wallets. Shame on you for perpetuating such nonsense. Now your’e really sounding like a shill for Ophthalmology..

        4) You wrote: “Having interned at optometric “VT sites”, as a student, I was appalled to see my future colleagues selling binocular flippers, strings with beads and other “necessary” items for 50-100 dollars to desperate parents believing claims of improved grades, cessation of headaches and unbelievable improvement in overall wellbeing.”

        I can’t speak to your experiences, and what appalled you. I can tell you that this characterization of VT docs preying on desperate parents is a gross misrepresentation of how many VT practices function. Frankly, it is the broad smear campaign that you’re helping to perpetuate that many of the patients whom we help find appalling. They frequently say to us “why didn’t Dr. X ever give me the option of doing this?” “Why did Billy have to struggle for some many years?” Think of the irony, Dr. Cianci. Isn’t your use of anecdotal evidence to discredit an entire field within Optometry a very unscientific approach?

        5) You wrote: “Ironic how a profession struggling to stay afloat by diminishing insurance reimbursements and retail competition turned to a “treatment” that is not covered by insurance and that targets loving parents searching for a solution for their troubled child.”

        Quite a statement. Dr. Cianci. And another sweeping one based on anecdotalism. Evidently you’re a poor student of optometric history. Vision therapy is a treatment that is an outgrowth of medicine (orthoptics). In its heyday before insurance reimbursement tightened for many medical procedures, it was covered by many major medical carriers under the umbrella of orthoptics, and in fact there are still a substantial number of carriers that reimburse for it. It was certainly not introduced as a non-covered service for the reasons that you allege. But while we’re on the topic, I can think of a cash-only procedure that was introduced by ophthalmologists specifically to offset their dwindling reimbursement from insurance companies. It’s called refractive surgery, and it certainly wasn’t backed by evidence based medicine before being accepted in the field.

        Now regarding the rubbish about targeting loving parents searching for a solution for their troubled child, you are really skating on thin ice. Here’s the problem. Many of the children that we deal with have had plenty of interventions prior to coming to us. We are rarely first on the list. Their parents have already invested considerable money and time pursuing other interventions. Don’t you give parents enough credit that they can separate substance from sales? Who appointed you as the arbiter?

        6) You wrote: “In my clinic, I have seen countless 45 diopter esotropias be returned to ortho with a simple surgery that is supported by volumes of evidence based medicine. I can hardly say the same about the results of amber tinted glasses sold to unsuspecting parents for 600.00 to treat Scotopic Sensitivity Syndrome.”

        Lovely. And in my clinic I have seen countless post-surgical exotropes with consecutive esotropias. Or induced verticals. Or who have had multiple surgeries to the point of having poor saccades. Or who decompensate as they get older. In other words, you see a skewed population, as do I. I don’t make a value judgment that surgery is seat of the pants. In fact, I refer for surgery when I feel it’s in the patient’s best interest. Let’s not kid each other, Vincent, yet alone confound the public. Strabismus surgery has been done for many years, charging full fees, with as much art as science, well before the advent of evidenced based medicine. Nice to see that it’s coming of age. But please don’t preach to us from your podium of scientific concern until what you endorse medically (dry eye treatment, glaucoma treatment, botulinum treatment, refractive surgery, etc.) passes the same level of accountability that you expect of vision therapy.

      • Since you did not allow me a reply link to your comment, I will reply to my own comment in order to respond. To your previous points:

        1. Actually I was addressing the previous Dr’s comment of “Gee, look how strabismus surgery has turned out for them”. This kind of statement not only ignores all of the published studies in REPUTABLE sources demonstrating that surgery is a safe and effective treatment for strabismus, but also makes VT supporters look just plain bitter.

        2. There are studies now; plenty of them. It is generally accepted that steroids reduce inflammation, prostglandin analogs reduce IOP, antibiotics kill bacteria and strabismus surgery reduces ocular misalginment. How long do you propose that a child with uncomfortable diplopia should sit and perform repetitive exercises? How long would you let a patient with granulomatous uveitis or microbial keratitis sit before administering sight saving medication? To encourage a patient to perform a repetitive, unproven and costly treatment with endless follow up visits when there is a much more direct, study backed and comfortable route, frankly harms the patient. Products, such as “The See Clearly Method” could be characterized as VT and came into existence for 1 reason: to make money. Fortunately, it has disappeared as it had no evidence backing it and the company responsible was sued into oblivion. This is not innuendo and sensationalism; it is people being ripped off and flat-out lied to by doctors they are supposed to trust.

        3. The acne comment was intentional exaggeration. I was referring more to the claim that a 30 diopter exotropia can be straightened by inefficient, costly and painful VT.

        4. My approach is not unscientific as I refer to reputable studies published in reputable journals such as The New England Journal of Medicine, for example and that the treatments I am referring to actually have been proven to work, save the patient time, money and discomfort. How can you possibly say that medical treatment that you have problably been the recipient of has not had to pass rigorous standards before it can be used? Do you know how difficult it is for drugs and procedures to get approved by the FDA? Phase I, II, III trials? There is a reason that meds and surgery are the primary treatment strategy in this country; they work and work quickly.

        If you feel that it is acceptable to have patients spend time, money and energy on treatments that haven’t been shown in any reputable scientific journal to work, then you are just as anecdotal as you claim I am being. The difference is I have FDA approval, published studies in reputable journals and a long track record of effacacy in my corner. You have testimonials and evangelical claims in yours. Just hope you can sleep at night.

      • I’m enjoying the exchange, Vincent, as this way we’re able to get information on the table so that the public can weigh the relative merits of our respective positions. Let me begin this time with your end note:

        A. You wrote: “If you feel that it is acceptable to have patients spend time, money and energy on treatments that haven’t been shown in any reputable scientific journal to work, then you are just as anecdotal as you claim I am being. The difference is I have FDA approval, published studies in reputable journals and a long track record of effacacy in my corner. You have testimonials and evangelical claims in yours. Just hope you can sleep at night.”

        I sleep very well at night, thank you, owing to the clinical methodologies that I employ. Now I’ll ask the same question of you. How can you sleep well at night, knowing that you’re repudiating the mainstream position in your own field? I would suggest you do some serious homework and then come back to me when your read:
        1) The AOA Clinical Practice Guidelines on the subjects in question. Specifically read guidelines No. 12, 18, 20 so that you can acquaint yourself with reputable work in our feel.
        2) Read as well the seminal article by Ciuffreda on the scientific basis and efficacy of optometric vision therapy.

        B. Regarding your comment #1 in which you wrote: “Actually I was addressing the previous Dr’s comment of “Gee, look how strabismus surgery has turned out for them”. This kind of statement not only ignores all of the published studies in REPUTABLE sources demonstrating that surgery is a safe and effective treatment for strabismus, but also makes VT supporters look just plain bitter.”

        — I know you were addressing the previous doctor’s comment, but you essentially smeared the entire VT community to which I took exception. You have evaded my question, which is to ask you whether strabismus surgery was subjected to prospective, scientific studies – the same ones you seem to insist on before changing your tune about vision therapy. Telling me that studies about strab surgery have been published in
        “reputable” sources doesn’t tell me anything about the quality of those studies. Look at the published studies that have been done through the years about the predictability of strabismus surgery outcome. Look at the quality of the studies that would allow you to counsel the patient on whether the first surgery would effect a cure, or multiple surgeries would be needed. Look at the quality of the studies that assessed sensory outcomes as related to motor outcomes, or the prevalence of patients having sensory decompensation in adulthood. After all, Vincent, we see the patients who are having problems, most of who get a pat on the back from the MD who says: “You’re doing fine, hun.” You don’t get to see them, because they’ve left you, fed up that you never acknowledged the significance of their complaints, or the option of pursuing any form of treatment address their concerns. Frankly we’re not nearly as bitter as the patients we see who have been patronized by being told either nothing’s wrong, or nothing further can be done (see again Clinical Practice Guidelines above).

        C. Regarding your comment #2 in which you wrote: “There are studies now; plenty of them. It is generally accepted that steroids reduce inflammation, prostoglandin analogs reduce IOP, antibiotics kill bacteria and strabismus surgery reduces ocular misalignment.”

        — Well sure there are studies now, but the fact that they are “generally accepted” has nothing to do with scientific efficacy. The glaucoma field still hasn’t proven that keeping IOP to a minimum is an effective cure for ON damage and field loss. You do it because that’s what’s “accepted in the field”. I’m not saying it’s wrong or bogus or an annuity to keep your pockets healthy by having patients back every 3 months. You do the best you can with the tools at your disposal. We do the same.

        You wrote: “How long would you let a patient with granulomatous uveitis or microbial keratitis sit before administering sight saving medication?”

        —- of course the answer is not at all. I’ve done it numerous times. Where did you get the impression that I wouldn’t use antibiotics or steroids as indicated? We know that medicine is at its best for acute conditions. It’s the chronic conditions for which “Medical Optometry” is typically at a loss.

        You wrote: “To encourage a patient to perform a repetitive, unproven and costly treatment with endless follow up visits when there is a much more direct, study backed and comfortable route, frankly harms the patient.”

        — Where is the evidence to show that patients have been harmed by vision therapy, Vincent? Again, more anecdotalism on your part.

        You wrote: “Products, such as “The See Clearly Method” could be characterized as VT and came into existence for 1 reason: to make money.
        Fortunately, it has disappeared as it had no evidence backing it and the company responsible was sued into oblivion. This is not innuendo and sensationalism; it is people being ripped off and flat-out lied to by doctors they are supposed to trust.”

        — So now you’re equating all VT with the “See Clearly Method?” How many of the VT docs that comprise the body of practitioners engaged in VT have ever dealt with that? That would be like me saying that all cataract surgeons are cataract cowboys who would operate on anyone with asymptomatic trace cataracts, just because I know of a few who do. Grossly unfair to judge an entire bushel by one of its apples, if you get my drift.

        While we’re on the subject of sales preceding gold standard scientific studies of benefit, multifocal IOLs are a great. Why keep dwelling on vision therapy fees, and “kidding patients”, when ophthalmologists have been upselling deluxe IOLs at $2500 a pop with mixed results and unscientifically controlled studies to make up for Medicare slashing monofocal IOL reimbursement rates? Let me reiterate:If you want to lift up the rug and look at dirt, don’t conveniently take pot shots at VT and pretend that Ophthalmology and Medical Optometry is holier than thou. Time to put down the Kool-Aid.

        D. Regarding your comment #3 in which you wrote: The acne comment was intentional exaggeration. I was referring more to the claim that a 30 diopter exotropia can be straightened by inefficient, costly and painful VT.

        — “The inefficient, costly and painful VT” — where is your evidence of this? Again, go to your own profession’s Clinical Practice Guidelines on the subject for the facts. See CPG #12 on Exotropia.

        E. Regarding your comment #4 in which you wrote “My approach is not unscientific as I refer to reputable studies published in reputable journals such as The New England Journal of Medicine, for example and that the treatments I am referring to actually have been proven to work, save the patient time, money and discomfort. How can you possibly say that medical treatment that you have problably been the recipient of has not had to pass rigorous standards before it can be used? Do you know how difficult it is for drugs and procedures to get approved by the FDA? Phase I, II, III trials? There is a reason that meds and surgery are the primary treatment strategy in this country; they work and work quickly.”

        — Sorry, but you can’t name drop the New England Journal of Medicine to prove scientific superiority. You have to give me substance, if you’re going to cast stones from your glass house. Let me give you a few more for instances. FDA device approval for a procedure simply shows that the procedure is safe. It does not necessarily speak to its claimed efficacy. Let’s take the example of Revitalvision – a treatment procedure endorsed by Ophthalmology. The device it is based on has FDA approval. Does that mean there are scientific studies to support its efficacy for Ophthalmology’s version of vision therapy?

        Another case in point, and perhaps the strongest. which you have conveniently side-stepped. The definitive scientific study in the VT field has been the CITT, published in 2008 in Archives of Ophthalmology. It’s an exquisite study that proved office-based therapy for CI is far superior to other forms of therapy, which are statistically indistinguishable from placebo therapy. Wouldn’t it be hypocritical if not unethical to withhold this form of treatment to your patients?

        Let me leave you with a final thought, one that was suggested to me by the patient of a colleague who is well versed in both the optometric and ophthalmologic fields, and has heard her share of dogma from both sides. It is not uncommon for ODs to be in a medical setting, practicing medical optometry the way you are, to paint VT dismissively with broad brush strokes. The MDs who best grasp what we do are physiatrists in rehab settings who understand the concept of therapy as we approach it. The families who come to us, and stay the course of therapy despite outrageous and unsubstantiated pot shots by Med ODs and pediatric ophthalmologists are very courageous people. So are the developmental/behavioral optometrists who help patients every day though VT despite the insults we receive from the medical establishment. .

    • Well, Dr. Press, It’s obvious we’re “arguing religion” here. The last thing I will say and then make my exit is this: Links like the following, http://www.srmhp.org/archives/vision-therapy.html, where you yourself are cited, are numerous and very easy to find on the internet. Just type in, “pseudoscience” or “quackery” with VT and a slew of articles published by both OD’s and MD’s, warning the public of the many VT scams will come up. I love this profession and simply do not want it associated with anything that could be considered quackery. I am proud of the strides optometrists have made by practicing full scope medical care and by practicing evidence based treatment. The fact that there are OD’s out there that are practicing treatments that are considered not only unproven, but unethical as well, negates the many years of hard work many ODs have spent trying to improve Optometry’s image. As an OD, I feel it is even more important for me to speak out against my fellow ODs when they are doing anything that I think hurts the credibility of our great profession. You won’t find LASIK, or strab surgery or Avastin (even it’s off-label use) or Pred Forte or Phacoemulsification, or Spectacles, or CL’s associated with quackery. These innovations also don’t make claims that they can prevent juvenile deliquency as VT does. Although medicine definitely has a dark, dark underbelly, the innovations it provides through evidence based studies have improved all of our lives. I agree that orthotics, when offered as supplemental information to give a patient another option for convergence insufficiency can be helpful, they should by no means require expensive tools or endless follow up visits. The patient should get better and get better quickly. To try to build an entire practice off of common visual imperfections that many of us, myself included, have and are generally asymptomatic, again is not only unethical, but will prevent ODs from getting the respect they so richly deserve. As for all of the VT scam stories out there, “Where there is smoke, there is fire…”

      • We aren’t really arguing religion, Vincent. You’ve chosen to ignore my substantive points. You’re not willing to read or comment on Dr. Ciuffreda’s paper on the scientific basis and efficacy of vision therapy published in the Journal of the AOA (Optometry). You’re not willing to read all the Clinical Practice Guidelines of the AOA and the Joint Policy Statement of your own profession (the AOA and the American Academy of Optometry) on the subject, which you choose to distance yourself from. Most telling, you’ve dredged up an Internet site co-authored by a Ph.D. who has no background in the field (he taught chemistry at PCO about 50 years ago) and who’s been dead for 20 years. The citation attributed to me on that site is something that I’ll gladly stand by. It reads:

        “Your eye is basically a very smart receiver and transmitter. What makes your eye so smart is that it’s retina, or screen, is a direct outgrowth of brain tissue. In fact, the optic nerve which enters and exits the back of your eye feeds information directly to the brain. Some well-meaning professionals mistakenly argue that the eyes have nothing to do with learning problems because learning disabilities are caused by faulty brain function. These professionals admit that eye muscle control problems can cause secondary problems such as headaches or double vision, but plenty of people are able to learn despite these challenges. Well … if your child is one of those people who is distracted by focusing or eye muscle problems, we think you should have an important say in determining how significant these challenges are. And further, if the problem lies in processing incoming visual information, specialized help will be needed. If you inquire about your child’s vision, and are told that vision problems don’t contribute to learning problems, just remember the jingle (“The Eye Bone’s Connected to the … Brain Bone”) while you head to the nearest informed developmental or behavioral optometrist.”

        Far from proving anything about “quackery” that passage reminds the public that regarding optometric vision therapy, some professionals have appointed themselves as authorities in a field they know little if anything about.

      • Dr. Cianci,
        Let’s see, your position is that even though vision therapy is a core curriculum in every College of Optometry, supported by the American Optometric Association, is a Board Certified specialty through the College of Optometrists in Vision Development, has Residency training in most Colleges of Optometry plus 7 private practice Residencies through the Southern College of Optometry, is validated in the AOA Clinical Practice Guidelines, has been recognized efficacious with NEI multicenter, prospective, double blind research for CI, is substantiated through several peer reviewed professionally acclaimed text books as pointed out by Dr. Press (who is one of the world’s leading authorities on the topic), your position is that, because of some extreme examples you sited, that you don’t want to be associated with quackery!?

        So, if I may ask Dr. Cianci, how do you deal with your patients who present with an accommodative, oculomotor or binocular dysfunction? What about the cases intermittent strabismus? What about the accommodative esotropes. What about the patient’s with refractive amblyopia and stereoblindness? Dr. Cianci, it is obvious that you don’t provide vision therapy. So what happens to your patients who have these conditions? Do you refer them to a fellow OD trained to offer the best practices in vision therapy? Or do you simply say to your patient…”you’re doing great see you again in a year!”

        Yes, I agree with you, “where there is smoke there is fire” and for the patients, like the cases mentioned above, who are told there is nothing wrong, or there is nothing that can be done to help (when in fact VT will help) are the ones who are getting burned!

  2. You’re welcome, Carole. I wish i could say it’s my pleasure, but it really isn’t. My heart goes out to patients caught in the middle — the ones who see MDs who intentionally skew the issues to create doubt or confusion. These include the ones in sheep’s clothing who masquerade as patient advocates but cringe at the thought of referring to you (heaven forbid that you might know something more than they). Perhaps they’ll never get over the insecurity of referring for VT; or perhaps the increasing numbers of patients who see their advice for what it is will continue to move the field closer to a tipping point. I hold out hope that at some point MDs will drop the charade that they are authoritative in this field, and stick to areas where they have true expertise.

  3. I agree that reading is a complex process. I agree that vision problems are not “causal” to reading difficulties. I agree that APPROPRIATE reading experience results in the development of reading specific eye movements. What I find amazing that you can assume that because a child can play video games then they should be visually able to maintaing attention while reading! They are in no way similar tasks. In the former the child is given the meaning and the visual image – not much has to be work out cognitively on behalf of the participant. This is why the paediatric association recommends no TV for young children! Reading on the other is a much more complex task, involving the integration of many cognitive processes and is much more demanding on the visual system. The comments in editorial become contradictions – on one hand lip service is given to making sure that binocular and accommodation disorders are managed,and yet many children with binocular and accommodation disorders happily play video games for hours and therefore should be able to manage the demands of reading. Make up your mind! The studies showing no link between binocular and accommodation disorders are reading are flawed. The methods used to assess binocular vision and accommodation in much research have been often shown to be ineffective at detecting the very dysfunctions they ASSUME to detect. The jury is still out here, as there is research that does indicate an association. Not causal but an important association all the same. A child with binocular or accommodation disorders and a reading difficulty is being hit with a double whammy. Treating the vision problem may not instantly improve reading (sometimes it does) but it certainly makes the child more comfortable – isn’t that important?
    There are many flaws in the argument about vision, language and reading. And one of the biggest factors that is overlooked in the rush to discredit what often is viewed as your “competing” profession, is that despite the strong assertions, language disorders are ASSOCIATED with reading difficulties, and have yet to be proven CAUSAL. See Coulthart’s 2004/5 paper that discusses this very point, and he is an expert in language and reading. And this is why despite the all the research into the CAUSE of reading difficulties, they are still yet to find anyone method that very effectively treats the problem. Vision scientists are discovering that there are visual search dysfunctions associated with phonological processing disorders (Vidyasagar 2010). So it’s not easy to simplify the discussion as an argument of language and vision. The whole discussion is a bit like the blind men describing the elephant.
    Finally a comment on the whole campaign that organised medicine seems to be making – Optometrist’s DO NOT assert to treat reading difficulties, they DO NOT assert to replace the educator. Why does ophthalmology continue to assert that is what optometry is claiming? They only thing optometry asserts is that undiagnosed vision problems, even when mild, can have a significant impact on some people. It doesn’t take a rocket scientist to understand that if a child cannot maintain visual attention, if the child can’t “look” for long periods of time comfortably, then they are not going to perform prolonged academic tasks as easily as the child who can.

    • Excellent points, Paul. The argument of “how can a child have relevant visual problems for reading if he’s skilled at video games” is sad commentary about ophthalmology’s simplistic lumping of all visual tasks into one basket. Aside from the reasons you cite, the more unstable one’s nearpoint function is, the more one has a competitive edge in tracking dynamic stimuli with unpredictable scanpaths. Totally different visual demand than needing to scan preprinted stimuli in a smooth and sequential fashion when reading.

      I made this point to Granet in the discussion that he and I had on the blog, but he has conveniently decided to overlook this. Either that. or he truly doesn’t get it. I’m not sure what’s more egregious: willfull ignorance or unintended ignorance.

      I just finished evaluting a 14 year old girl in 8th grade, who is an A/B student who has to work incredibly hard for her grades, quite disproportionate to her intelligence. Very bright girl, but very frustrated with reading. She has had the Cadillac Neuropsych Evaluation and has been diagnosed as dyslexic. She has had all of the following interventions already, all of which have been unsuccessful:

      1) Title 1 reading services through school
      2) Private reading tutor
      3) After school tutoring
      4) Sylvan Learning Center

      She has had eye examinations with five different ophthalmologists, all of whom considered her eye exam to be “normal”. She scopes +2.00-1.00cx90 OU, and was told that a reading Rx was optional. She has highly unstable vergence, and even with the plus in place, blur on base out ranges at near with low recovery. She has unstable alignment on fixation disparity testing, intermittent suppression on cheiroscopic tracing, intermittent blurring and instability on Van Orden Star and exo drift with phoria fluctuation on Keystone Skills at near in contrast with perfect stability at distance. Readalyzer showed Grade Level Equivalent of 2.4. Tachistocpe was performed at 13th percentile for her age level. On TVPS Visual Discrimination was at 2nd percentile and Sequential Memory at 1st percentile. The Dyslexia Screener showed no Dyslexia.
      I could go on, but you get my point. Her mother can’t wait for her daughter to start VT, and her daughter is very excited that someone finally believes her after having been told essentially that she’s crying wolf. After doing this for many years you and I know that this child will take off. For you and me these cases are bread and butter. For ophthalmology they are egg on the face. But they continue to assert that these kids just need more “proven educational therapies”, as Dr. Granet would say, even while these kids continue to struggle. It’s unconscionable, almost verging on unethical, for them to parade themselves as authorities of any kind when it comes to vision and learning. Their exams should come with this disclaimer: “No matter what I find I’m going to tell you that your child doesn’t have a vision problem. And if she does, the only one that is relevant to reading is a screaming convergence insufficiency. And if I find it, you need medical orthoptics at home. In other words, I won’t find anything abnormal that an optometrist could possibly help you with that wouldn’t have mysteriously gotten better by itself with time anyway, or that we’ll treat with a regimen shown to be no better than a placebo. .” At least that way, parents of kids with LRVPs know they’re getting a healthy does of either a) false sense of security or b) bias.

  4. Nicely put, Len. Reminds me of when they actually did print the CITT study. They still felt compelled to also print an editorial stating that, despite double-blind, well controlled evidence, we still know in our heart that home based therapy works just fine.

    • Thanks, Rob — and I fully agree. In all my years I don’t ever recall seeing a study of the stature of the CITT published in a respectable journal that saw fit to qualify if not mitigate the study’s impact by sticking a box front and center advising the reader to see an accompanying editorial that said: “Great study, but let’s not be quick to endorse its conclusions.” Paraphrasing they might just as well have said: “Let’s be careful that this study not be used to give optometric vision therapy too much credence.”

  5. Granet says, “. . .we should steer families away from unproven interventions that consume resources and thus interfere with the implementation of proven methodologies (such as educational and language-based therapy). Of course he’s talking about optometric vision therapy when he mentions unproven interventions however there has never been any double masked research confirming the efficacy of educational therapy or language-based therapy. So why doesn’t he categorize them as unproven therapies? Is it because teachers and language therapists don’t compete with ophthalmologists?

    • That would be my guess, Dr. Lack. It is no secret that the education industry experiences “theories du jour” and is in search of good science. But what about the other therapies that Dr. Granet endorses carte blanche? Dr. Granet writes: “Occupational and physical therapists are trained to deal with issues relating to motor coordination and visual motor integration. Psychologists and psychiatrists are experts at diagnosing and treating learning disorders as well as behavioral and developmental issues.

      Does Dr. Granet expect his readers to believe that all these other professionals have “evidence” for their therapeutic inteventions that are superior to optometric vision therapy, and that is why he endorses them uncritically? You and I have had enough interaction with OTs, for example, to respect them highly for their skill areas, but to know that they have the same set of clinical experiences as we in terms of “gold standard research”.

      There is one pediatric ophthalmologist in my area who I highly respect. When parents ask him about VT he says: “It’s not my field. Follow Dr. Press’s guidance – he’s an authority in the field.” In a perfect world, Granet would bring himself to acknowledge that OVT is a specialty area, and that he isn’t qualified to pass judgement just because he did VT himself as a child. It’s a simplistic and narrow view, and one that does neither the field justice, nor can any longer be defended as in the patient’s best interests. While I am not optimistic that you’ll get the Medical Organizations to retract the Joint Policy Statement, I fully agree that it is time to stop turning the other cheek.

  6. Dr Press is slightly mistaken about the CITT study, in that the “office-based” treatment group actually received more home-based computer treatment (time-wise) than office treatment. This group might accurately have been described as “home computer therapy supplemented by office therapy” or at least “combined home-office therapy”.

    The hostile tone Dr Press adopts is not productive; the 20th generation of OD-MD antagonists is going to fade, leaving the next group to take the best of both professions and dispense with the politics. We offer office and home-based therapy. Our ODs are responsible and always looking out for the patient rather than a certain dogma or financial incentive. This cooperative model is what’s going to work going forward. Stop fighting already!

    • Thanks for your thoughts and comments, Dr. Ticho. I am not slightly mistaken about the CITT study. Nor was it I who chose the terminology used in the CITT study. You can spin it any way you’d like, but here is the conclusion to be drawn from the CITT study, as issued by the NIH:

      “After 12 weeks of treatment, nearly 75% of children who received the office-based therapy along with at-home exercises achieved normal vision or had significantly fewer symptoms of convergence insufficiency. About 43% of patients who performed home-based pencil push-ups alone showed similar results, as did 33% of patients who did the home-based computer therapy and 35% of patients in the control group. Although home-based therapies may be sufficient for treating some patients who have convergence insufficiency, the more intensive office-based approach seems to offer a clear advantage. A year-long follow-up study is now being conducted to examine the long-term effectiveness of these 12-week treatment regimens.”

      That seems pretty clear to me. Isn’t that an embarrassment for those who prescribe home-alone VT? That the pencil push-up group was not different from the computer group, and that the integration of home and office VT was clearly the superior treatment? Not to take anything away from the computerized therapy program that was used. We use it very heavily in our practice as an adjunct to office based therapy and it is marvelous when used in this fashion. Yet the bulk of your colleagues still insist on practicing in a way that is at odds with the outcome of the CITT, all the while discouraging patients as best they can from pursuing VT through office-based therapy prescribed by a Doctor of Optometry. It is a good start that you have ODs working with you, and I commend you for that, though I am a bit curious.

      Who are “our ODs” that you speak of? I believe this is your practice site, and nary a mention of ODs or of vision therapy. I believe this is the hospital based site with which you’re affiliated, which is quite revealing about dogma, since you raised the issue. You’re listed as part of the CCPA, under staff at the hospital. Also listed are in-house staff, and staff. There is one person listed as “other staff”, who is an OD. Apparently they couldn’t bring themselves to call an OD staff, on a par with the MDs. Is that your version of a “cooperative model”? Again, I am not diminishing the knowledge or skill of your OD. Only how she is positioned to the public based on the website.

      Now let’s look at your hospital site’s definition of an optometrist: “An optometrist is a doctor of optometry (OD) but not a medical doctor. Optometrists can examine, diagnose and manage many visual problems and eye disease, and are specially trained to test vision in order to prescribe eyeglasses or contact lenses. ” This is the quintessential negative definition, opening with identifying an OD by what she isn’t rather than by what she is, as if that is the most important clarification.

      Contrast this with the site’s definition of an orthoptist (CO): “An orthoptist is an allied health care professional who specializes in the evaluation and treatment of patients with disorders of the visual system with an emphasis on binocular vision and eye movements. Orthoptists are uniquely skilled in diagnostic techniques and are involved in patient care, academics and clinical research.” Sounds to me like your orthoptists are being accorded much more recognition (if not respect) for their expertise in the field of discussion unless of course here I am again, in your terms, slightly mistaken.

      I would be more than glad to drop the hostile tone, Dr. Ticho, but your approach doesn’t really move my field forward. It seems to dominate it under your thumb, and after years of denying it any validity, still tires to qualify it on your terms. Look again at what I wrote to see how your field is still getting it wrong. And don’t take my word for it. Look at what Dr. Mitchell Scheiman, P.I. of the CITT wrote.

      Lastly, look at the innuendo you continue to perpetuate while proclaiming that you have a cooperative model that’s going to work going forward: “Our ODs are responsible and always looking out for the patient rather than a certain dogma or financial incentive ” That always seems to be what this boils down to, doesn’t it Dr.Ticho. For some reason that Freud would have to decipher better than we, your ilk seems to begrude Doctors of Optometry who practice independently and specialize in vision therapy for the “financial incentive” of being compensated well for the type of office-based therapy model after which the CITT was patterned. In fact, the CITT only had a 75% OBVT success rate. Impressive as that is, particularly when working with a clinic-based population, those of us in private practice enjoy a success rate with CT that is higher, one reason for which is that many of us engaged the patient in more than 12 weeks of therapy.

      So you see, Dr. Ticho, it is not we who are hung up on dogma or financial incentives. I don’t begrudge the many procedures you do in Ophthlamology that have never been backed by gold standard studies. Or the off-label prescribing of drugs for children (rampant in Pediatrics, by the way, for ADHD, but done in Ophthalmology for years with atropine for progressive myopia; PI for accommodative ET; and in adults with Botox for strabismus, etc.). For some reason, you just can’t bring yourself to give those of us who practice the way we do our due accord. Though you may think your tone polite I find it patronizing and, in its own way, no less hostile.

      Going forward, it may be more productive in terms of educating the public to adopt the model of your hospital for defining Optometry, and emphasize what you are not. You are not a Doctor of Optometry with an intense grounding in geometric optics, ophthalmic optics, physiologic optics, and their applications to visual processing, nor do you have advanced training or certification in the delivery of optometric vision therapy. Therefore your understanding of the way we practice is based on second-hand impressions, be it from patients (a skewed perspective, as you see our “second opinion” patients in the same way that we see your dissatisfied patients) or from ODs willing to practice VT in a way that comfortably allows you to declare, by ophthalmo-fiat that your approach is free of dogma and financial incentive. Quite disingenuous, Dr. Ticho. But don’t doubt for a moment that when you are ready to put aside the drum, I’ll be more than happy to stop fighting. We both have better ways to spend our time, in the best interests of patient care and welfare.

    • Dr. Ticho, I’m a bit puzzled by your interpretation of the CITT study research. In the Convergence Insufficiency Treatment Trial (CITT) the treatment protocol is defined into 4 groups. Those who did home-based pencil push-ups (HBPP 15mins/day 5d/wk), those who did home-base computer vergence/accommodative therapy and pencil push-ups (HBCVAT+HBPP- 15 mins/day 5d/wk), those who did office-base vergence/accommodative therapy with home reinforcement (OBVAT 60 min office-based VT + 15mins/day HBCVAT 5d/wk) and those who did office-based placebo therapy (OBPT 60min placebo therapy and 15 mins/day 5 days per week home placebo therapy).

      The key difference in all of the treatment groups was the office-based vergence/accommodative therapy. All of the other three groups did the same amount of home activities. All of the 3 other groups were proven ineffective. Therefore, the office-based vergence/accommodative therapy was identified as the essential theraputic element to the treatment. Not “combined home-office therapy”!

      Furthermore Dr. Mitch Scheiman (et al) summarizes the multiple CITT studies in his paper published in Optometry and Vision Science (Optom Vis Sci 2009;86:420–428) http://www.convergenceinsufficiency.net/uploads/CI_Tx_of_CI_Current_Perspective_OVS_2009.pdf where he states the researchers postion on how the data should be interpreted:

      “Office-based vergence/accommodative therapy was significantly more effective than home-based or placebo therapies. Base-in prism reading glasses were no more effective than placebo reading glasses for the treatment of symptomatic CI in children. Conclusions. Recent clinical trials showed that office-based vision therapy was successful in about 75% of patients (resulting in normal or significantly improved symptoms and signs) and was the only treatment studied which was more effective than placebo treatments for children with symptomatic CI. Eye care providers who do not currently offer this treatment may consider referring these patients to a doctor who provides this treatment or consider expanding the treatment options available within their practice to manage this condition.”

      I agree with you, it is important for the patients that we serve that 21st generation of OD-MD be patient advocates and clearly leave the past in the past. The frustration remains however. Because, even though there have been remarkable advancements in modern medicine through research, we still have “20th generation” misinformation published in a prestigious Journal (JAAPOS) article: Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program by Serna et al. where the authors write: “Many clinicians, including our group, use home-based therapy for convergence insuffciency“.

      On a positive note at least the authors are acknowledging that CI exists and needs to be treated with a form of vision therapy. Yes, even though home based computer computer orthoptic exercise programs are proven by the research to be NO BETTER THAN A PLACEBO, maybe over time and personal experience with patients our good doctors from the JAAOPS will realize, in the interest of good patient care, they must let go of the MD dogma and prescribe what is a proven treament…office-based vision therapy!

  7. Oops, I see I have to step very lightly here! The CITT point I was trying to make was that 5 days x 15 minutes /day of computer Rx = more than 60 minutes of office therapy. This is not anything against office therapy (which our practice uses), but the study did not demonstrate that computer therapy was not a critical portion of the treatment. (I’m not saying that office based therapy doesn’t work on its own, only that that is not what CITT was designed to show.) There have been suggestions (by ODs involved in the study) that the computer-only arm may have failed to adequately treat those patients; this possibility may be explored in future studies.

    So I remain open-minded that computer programs may indeed be better than a placebo for symptomatic CI patients. I don’t have a problem offering office-based therapy to these patients — the parents are usually the ones objecting and happy to consider a less inconvenient and less expensive option. To have criticisms of a given study does not negate its importance, only points out room for improvement. Anyone reading glaucoma (or breast cancer or coffee, etc) literature will agree that sometimes even large, multicenter randomized trials can contradict each other, and that for some conditions several studies are needed to clarify points of nuance, uncertainty or contention.

    Anyhow, I have long ago put away the drum! I am glad that I don’t have to write policy statements or do all the other political stuff that “organized” medicine and optometry apparently requires. I think Mitch Scheiman has done a stellar job, and continues to do so by leading the necessary work on prospective, randomized, masked clinical trials. There remain myriad questions about which components of office-based therapy are most important, and perhaps whether aspects of office therapy can still be translated effectively into a computer-based system, etc. That should provide gist for a bunch of useful future studies.

    CI treatment is obviously an easier target than some of the other VT-associated conditions. But, based on the acceptance (grudging, in some quarters, certainly) that CITT brought, the RCT approach is clearly the best path. I look forward to reading (and participating in) more of these future collaborative studies.

  8. Oh – regarding my admittedly ill-advised “dogma or financial incentive” quip, I was referring to our ODs (The Eye Specialists Center — the website is years old, sorry, Dr. Press!). Financially, this group of patients (symptomatic CI) indeed does not play a significant role in our overall practice, so I can (I believe, I hope) remove dollar signs from my decision map. Regarding dogma, well, I already have a (wonderful) wife, and I don’t want to be married to anything else. So, yes, I’ve evolved since my training, have incorporated new ideas, and even pediatric optometrists into our practice. And I must say that I enjoy working with them enormously, as much as any of the many MDs and DOs over the years.

  9. Thank you for your considered comments, Dr. Ticho. It is prudent to tread lightly here because so much damage has been done in the selective application of “science” to dissuade patients from pursuing optometric vision therapy. My practice has thrived because we carefully weigh differential diagnostic assessment, and only prescribe therapy for patients we feel are positioned to benefit by it. Many of my optometric colleagues around the country will tell you that pediatric ophthalmologists have actively bashed optometric VT as “bogus”, the quintessential position for that being the infamous Harold Koller yellow journalistic theme article in Review of Ophthalmology (1997 as I recall) with a rubber duck on the cover, as the suggestive title: “Is Vision Therapy Quackery?”.

    It is refreshing to read that you are not in that camp, although the question remains as to why so many of your colleagues have such difficulty referring patients for office-based optometric vision therapy when they have optometric colleagues in their area who offer the service?

    Regarding your specific comments about interpretations of the CITT, I agree with you that Dr. Scheiman takes a very reasoned approach. So let’s look again at what he wrote here (http://www.journals.elsevierhealth.com/periodicals/ympa/article/S1091-8531%2811%2900253-9/fulltext):

    “In fact, the percentage of patients in the placebo group who were asymptomatic or improved after treatment (35%) was not significantly different than that found in the 2 home-based treatment groups (43% and 33%).
    Because convergence insufficiency is a relatively common disorder, is often associated with significant symptoms when reading, and thus has subsequent potential negative effects on an affected person’s quality of life, it is important to continue to evaluate potential treatments. Although the results of 3 rigorously designed comparative treatment studies for convergence insufficiency demonstrated that home-based treatments were not as effective as office-based vergence-accommodative therapy, the studies did show 12 weeks of pencil-push-up alone or in conjunction with home-based computerized therapy to be effective approximately 35% to 40% of the time.”

    My point again in all this is to show that office-based therapy is clearly superior to home based therapy. I emphasize that the HTS system is a MARVELOUS tool – we use it as an adjunct to office based therapy for many, many patients. What your colleagues should not be doing, however, is representing home therapy as an adequate substitute for office-based therapy. And you know as well as I that many are still doing that. Nor would I call it dogma or excessive political activism if you would share your enlightened position with your colleagues so that they stop casting optometric VT in a questionable light, to put it politely. It would do many patients across the country a world of good. Thanks again for your considered response.

  10. Coming from the point of view of an orthoptist working in the UK, where orthoptic exercises are provided on the NHS, the CITT doesn’t tell us anything we are not already aware of – yes, home exercises are not as effective as office-based therapy. Time and again I have patients with CI, AI, reduced fusional reserves coming into the clinic and telling me their symptoms are just as bad since their last visit when they were prescribed exercises. However, closer questioning or getting them to demonstrate their exercise technique reveals usually one or both of the following: That they haven’t been doing their exercises regularly as instructed, or that they have an incorrect exercise technique. In my opinion, the biggest barrier to the success of home-based exercises, be they exercises to improve NPC/NPA, +ve/-ve relative convergence, fusion range or accommodative facility, is compliance or the patient not being correctly taught, or misunderstanding, the exercise techniques. Compliance is a big problem with home-based exercises and is reported in many studies on the matter – in my experience, the patient has to be significantly bothered by their symptoms to sufficiently comply with exercises to produce an improvement. Unfortunately once an improvement in symptoms occurs, compliance often falls by the wayside and the symptoms recur. I’m sure this experience isn’t just unique to clinicians here – no doubt it happens in America a lot as well, even when they’re paying for consultations. Patient education is a significant aspect of improving compliance – they need to be told their symptoms are likely to recur if they stop exercises before they are told to, and taught how to do the exercises properly, ensuring they understand the technique. All too frequently I watch patients demonstrating their pushup technique and find that they aren’t attempting to hold BSV at the nearest point for 10 seconds+ – they just remove the target once they reach the point, on the the basis that their eyes are sore. But that isn’t properly exercising your near point of convergence – same with fusion exercises, when they get to the point where they really struggle to hold BSV, they don’t rock back and forth between prisms to exercise at that point. In patients where compliance is good and they perform the exercises as instructed, they will achieve symptomatic relief, in my experience – it’s rare that I have to resort to prisms. Another issue with the failure of home-based therapy is frequently treatment is terminated when near point of convergence is at an acceptable level – if this is not reinforced with the use of fusion exercises and stereograms, the symptoms are quite likely to recur. Persevering with patient education in performance of exercises and what to expect from them, and properly reinforcing the improvement gained with additional exercises, will lessen the likelihood of a patient being unhappy with their treatment and feeling that they need to pay extra money to go and see an optom for another treatment course. Brock string is actually quite effective in encouraging fusional cues in CIs who struggle with a dot card, so it’s worth trying even if it may seem like a bit of a VT gimmick. Over here, the treatment offered by behavioural optoms and that offered by us is nine/tenths the same, so I try to go the extra mile for my CI patients to get them to comply and avoid extra expenditure. Unfortunately some people like to be fussed over and have more made of their condition than what it is, so they go off and pay that extra money for no real reason. That’s their lookout though – some people are just like that.

    So my overall view on the discussions here is that yes, the evidence base points to home-based exercises not being as effective unless there is an office-based element to them. However, patients may not need to pay for extra treatment if they received appropriate education about the nature of orthoptic exercises, how to perform them, and complied appropriately. It’s important to think about why home-based exercises are less effective, rather than just interpreting the CITT study findings as a straight-out manifesto for entirely office-based exercises at extra expense to the patient. It certainly won’t change my practice, as it doesn’t advocate anything that I’m not already doing.

    • MP,
      It is good to hear from you in the UK and to share an experience that I believe is universal, regardless of what part of the world we practice. I appreciate your comment about understanding why home-based treatment is ineffective. I think you stated it well when you said that unless there is appropriate education about the nature of the therapuetic activity, how to perform the treatment and comply appropriately the treatment will not be as effective. What I learned very early in my career is that it is not realistic to put the parent (and certainly not the invidual patient) in the role of being the “therapist”. First off the patient is not trained in vision therapy. It takes extensive training for anyone to learn and understand even the very elementary basics of vision therapy. That is true even for a Board Certified Vision Therapist who works under the direct supervision of a Doctor who is Board Certified in Vision Therapy. And even if the parent was trained as a vision therapist, it would be difficult for the parent to obtain the same results as a professional because of the parent/child dynamic. Therefore, since the parent is not sufficiently trained in vision therapy nor can they interact with their child in the same way as a “non-parent” professional can, the treatment approach of home-based vision therapy has little chance of getting good results.

      So, I agree with your conclusion in your first sentence, “yes, home exercises are not as effective as office treatment”. The reseach proved this as well…home VT is no more effective than a placebo.

      The next question is, if the treatment that is effective (office-based vision therapy) but has a greater cost than a treatment that is not only ineffective but wastes your time, then why compare the two as viable options? Those who suggest to the patient that they can apply a home-based treatment if they just “follow the instructions” is in effect misleading and (in my opinion) is unethical, when there is evidence based scientific research that shows the contrary. Thanks again for your thoughtful comment!

  11. Excellent, balanced, and well-supported blog entry, Dr. Press – as usual. Having entered optometry and the world of VT from a background in classroom instruction, neuropsych, and IT, I was amazed at what I heard and SAW regarding VT in dealing with a wide-array of concerns. I am especially interested in what visual training can accomplish with readers BEFORE they engage in extensive and invasive psycho-educational testing and intervention. It seems ludicrous, now, that as a teacher I was never taught that vision just might have something to do with classroom performance.

    I understand the skepticism, but feel Dr. Cianci is at the start of his journey and needs to spend some time at a VT college or clinic to find out exactly what he himself is talking about (certainly, many of his retorts are just, well, silly). While I remain (highly) skeptical regarding some ODs claims re: dyslexia (namely that it does not exist), I am continually amazed to find out how much MORE I can do as a VTOD. It’s very empowering for me and for clients, who greatly appreciate a different perspective. Do I avoid surgical intervention in strab? No, not if we have looked at VT and hit a wall. It is, however, unfair and unwise to simply jump into surgical intervention without consulting a behaviourist.

    Keep up the great work.

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