Show Us the Love

Thanks for all the great comments posted as well as those I received off line to our most recent blog post about underinformed and misleading statements made by ophthalmologists about optometric vision therapy.  In that vein, a colleague asked if I had seen the latest information on the Children’s Hospital Boston website about vision therapy.  I hadn’t, and it’s worth sharing some observations about it.

Firstly the logo is inviting and implies that “Love + Science” = Great Doctor/Patient Collaboration.  Very noble, but lets dig deeper.  In a section on Vision Therapy the website notes:

Children’s Hospital Boston is one of the few pediatric hospitals in the country to venture into the field of vision therapy.  David G. Hunter, MD, PhD, ophthalmologist-in-chief at Children’s, explains: “While many ophthalmologists think vision therapy doesn’t work—they truly believe that practitioners are taking advantage of patients who need help—I have seen enough treatment successes that I think it has to be studied. Here at Children’s, we want to offer this service to our patients rather than give them no choice but to seek help elsewhere, and at the same time study its effectiveness.”

Excuse me?  “Give them no choice but to seek help elsewhere”?  My goodness!  Talk about walking a tightrope.  Hard to tell if this is a left-handed compliment, or a prominent ophthalmologist feeling his way cautiously.  To paraphrase, “many of my buddies think you’re shysters preying on an unsuspecting public, but I think you folks may actually have some substance, as elusive at it is to figure out how or why. ”  This very much reminds me of a guest editorial I wrote for the Journal of Behavioral Optometry 21 years ago.  (Perhaps this is one of those concepts that takes many years to come of age.)  In it I cited the opinions of two prominent pediatric ophthalmologists, Leonard Apt and David Guyton, in the discussion section of an article in the Transactions of the American Ophthalmologic Society.  Dr. Apt stated that the unsophisticated approach of ophthalmologists brought to bear on these issues (reading and learning problems) oftentimes is not helpful, and the patient leaves dissatisfied.   When proper care isn’t given, and the problems persist, the patient winds up under the care of an optometrist.  Dr. Guyton suggests that ophthalmologists may not be measuring pertinent functions during their exams, and perhaps that’s why the ophthalmologist feels the patient’s vision is normal.

Now here’s the kicker.  The Children’s Hosptial Boston website continues:  “For this reason, Children’s recruited Aparna Raghuram, OD, PhD, to offer some types of basic vision therapy while charging just enough to cover our costs. Raghuram is trying to simplify vision therapy and offer only the most promising treatments. Children’s is also planning to set up clinical trials to use science in order to see what works. ”

How curious.  Let me give Children’s Hospital Boston another clinical pearl, one that comes from a concept I explored in significant detail in another JBO guest editorial.  It would be best not to cloak patient advocacy purely in the trappings of scientific concern.  What you’re implying is that any treatment rendered in your hospital should be provided at cost, rather than for profit, until it has met the same criteria for clinical trials that you are setting up for vision therapy.  If so I would venture to say, as Ricky said to Lucy, you gotta lotta ‘splainin’ to do.

Perhaps we’re finally starting to speak the same language.  As the CITT showed, it takes many, many years to conduct a gold standard clinical trial.  And even when the trial is conducted, and it proves that office-based vision therapy is far superior to home-based vision therapy (which is tantamount to placebo therapy), ophthalmologists are still slow to let go of the dogma.

I admire your foray into this field, and ultimately you’ll grow more comfortable in understanding how to keep the baby in clear bathwater.  It takes years to become proficient in optometric vision therapy, and there is a board certification process that you should consider for your staff.  In the interim, and this is the key, don’t begrudge patients for seeking care elsewhere.  While love and science are important ingredients in good clinical care, it also requires a serious investment of time and resources.  Don’t be shy about charging reasonable fees for your optometric vision therapy.  Patients understand that you often get what you pay for.  And to do vision therapy well, one needs to make a significant investment in staff, in equipment, in knowledge, and in management skills.  We and our predecessors in developmental and behavioral optometry have pioneered and excelled in this field.  It’s time to show us some love.  Your patients will hug you for it.

– Leonard J. Press, O.D., FCOVD, FAAO

10 thoughts on “Show Us the Love

  1. Len,
    I like your style. I am fed up with the double standard that persists by our OMD counterparts. There are no “gold standard” studies for many of the common procedures they perform, like strabismus surgery, yet they are accepted as standard of care.
    Did you know that there is only one “gold standard” study in all of therapy? The CITT (20 years in the making)is the only gold standard study of any kind for any therapy and many surgeries. There are no “gold standard” studies for OT, PT, SLP or any other therapy. It is very difficult to placebo therapy. Therapy is not a pill, and it effects the entire body, not just one organ. Maybe it is just too difficult for some of our OMD and OD friends to understand that the human body works as a whole with every sensory system effecting every other sensory system. Thank you for your work.

  2. Well put, Jason. Let’s stop the charade, and call a spade a spade. We don’t have to be apologetic about the work that we do, nor about our level of evidence as compared with what’s accepted in other fields — particularly ophthalmology. While we always welcome more and better research, we also know that the better one is at therapy, the more one is flexible in modifying instructional sets or procedures to continually function at a level at which a patient can achieve. This is the antithesis of research design, where procedures must be adhered to rigorously, irrespective of the patient’s cognitive or behavioral issues. Thanks again for your comments.

  3. I agree with Jason Clopton about the “double standard” that persists by many physicians, especially pediatricians, regarding optometric vision therapy.

    These physicians are often the first to tell parents that there is no scientific evidence to support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance. They quote the 2009 American Academy of Pediatrics position paper (FROM THE AMERICAN ACADEMY OF PEDIATRICS; Learning Disabilities, Dyslexia, and Vision; Pediatrics Vol. 124 No. 2 August 1, 2009:pp. 837 -844 )

    Yet, they are the very people that ignore scientific evidence and evidence based research when it comes to prescribing medications to thousands of children nationwide endangering their health.
    In a brilliant article that shows the hypocrisy of the Academy of Pediatrics position , Dr. Bazzano and his colleagues (Bazzano AT, Mangione-Smith R, Schonlau M, Suttorp MJ, Brook RH. Off-label prescribing to children in the United States outpatient setting. Acad Pediatr. 2009 Mar-Apr;9(2):81-8. ) demonstrated that Sixty-two percent of outpatient pediatric visits included off-label prescribing in the United States. Off-label prescribing occurs when a child receives a medication that has not received FDA approval for the child’s age or diagnosis. Off-label prescribing is concerning because of lack of information on medication safety, efficacy, and proper use in children (e.g., dosing, interactions). Furthermore, off-label prescribing has been associated with adverse drug events.
    Despite recent studies and labeling changes of pediatric medications, the majority of pediatric outpatient visits involve off-label prescribing across all medication categories. Off-label prescribing is more frequent for younger children and those receiving care from specialist pediatricians.

    I also agree with Len Press that we should not be apologetic about the work that we do, nor about our level of evidence as compared with what’s accepted in other fields —particularly pediatrics, for what is accepted as scientifically based care!

    • A very nice article to reference, Jack, and thanks for providing that. The detractors of our work appear to have exchanged their Hippocratic Oath for a Hypocritic one.

  4. Well said Len,
    Tired of this nonsense. The CITT shows that what we do works. Suck it up and move on. I worked in a hospital in the UK for years where the ophthalmologists loved what I was doing. When asked in public however they did not want to openly support it. Yet – they were quite happy to attribute the 40″ arc after VT to their “surgical skills” even though the patients were in the 200″ range when they landed in my chair after surgery!
    Best regards,

    • Quite amazing that even despite experiencing your success with their patients first-hand, they have to withhold support of what you do publicly for fear of being ostracized by their peers. Shows you how most ophthalmologists (and sadly some optometrists)are more wedded to anti-VT ideology than concerns about patients when it comes to giving them the option of doing VT.

  5. I must say that I did have a recent positive experience with this hospital. A teen with a post-concussion ET was taken there by her mother this past year. Unlike the local pediatric ophthalmologists, there the mother was told that I was doing a great job with the yoked prisms and VT I was providing. She was encouraged to return to me for further care. This was most refreshing, indeed. If only this was the norm.

  6. FYI….I just sent this email to Dr. Raghuram…the OD who will be doing the OVT. DM

    Dear Dr. Raghuram

    I would like to invite you to become a member of the College of Optometrists in Vision Development ( the only organization in the US to certify doctors in the area of optometric vision therapy. As a Professor of Pediatrics/Binocular Vision at the Illinois College of Optometry and editor of Optometry & Vision Development, I would be most honored to assist you in this endeavor. Let me know how I can help.

    BTW I read on the hospital website that you won’t be appropriately paid for your services and expertise. I’m sure our OMD colleagues are paid well for what they do. Shouldn’t you also be paid appropriately?

    In any case, please let me know how I can help. Also if you happen to see Dr. Bruce Moore…give him my very best!

    Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

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