More Pediatric Ophthlamo-Spin

Dr. John Abbondanza is someone we’ve blogged about before. He is an esteemed colleague who does great work within our profession.  The CBS affiliate in Boston ran a generally nice piece about the work that Dr. Abbondanza is doing through optometric vision therapy, and we posted it on our Facebook site this morning.

The title of the piece seems a bit odd: Unusual Therapy Helps Kids Struggling In School.  It reminded me of the New York Times Sunday Magazine piece last year that painted vision therapy as controversial, citing the opinion of pediatric ophthalmologists who characteristically qualified vision therapy as “unproven”.  This position is a willful or unintended ignorance, based on a very selective review of available data.  Even if one were not aware of the science at hand, absence of evidence is not evidence of absence.  Lord knows pediatric ophthalmology has relied on this principle in advocating its own interventions, a double standard that Dr. Dominick Maino exposes in a recent editorial.

Sure enough, into the body of the story, comes this obligatory spin, from the local so-called expert compelled to question the science behind the therapy:

 “Vision therapy, in the vast majority of children, does not play a role in helping a child read,” said Dr. Melanie Kazlas, a pediatric ophthalmologist at Massachusetts Eye and Ear Infirmary and Children’s Hospital. Kazlas recommends traditional interventions like working with a reading specialist. “There is no harm in such treatments yet we don’t want the child to have a delay in having more effective treatment,” she said.  

In my experience, and that of many of my colleagues, there are two kinds of pediatric ophthalmologists who pass judgment on optometric vision therapy in the guise of expertise.  One is the ophthalmo-agnostic, the disbeliever who doesn’t know what she doesn’t know.   The other is the ophthalmo-atheist, the disbeliever who discounts any benefit to vision therapy because it has no fundamental redeeming value.  There would be no harm in these opinions if they did not delay the child from receiving more effective treatment.

This is reminiscent of an earlier post in which I cited one of my favorite New Yorker cartoons.  Two dogs handsomely dressed in a bar raise martini glasses to each other in a toast and declare:

It is not enough that dogs succeed; cats must also fail.”

It’s actually an adaptation of a quote from Gore Vidal who quipped that it is not enough to succeed, but others must fail.  Think about it for a moment.   Here we have the mother of a child who is also a student in her second grade class.  She is clearly more of an expert in education than a pediatric ophthalmologist.  Yet this teacher’s son already began to show signs of not keeping up in first grade.  If traditional educational intervention had helped, his mother wouldn’t have sought the optometrist who was ultimately able to help him thrive.

This is true of the majority of children with vision based learning problems that we see.  Their parents have been told by pediatric ophthalmologists that “everything is fine”.  They have 20/20 sight and their eyes are healthy.  They’ve already had “traditional interventions like working with a reading specialist”, as Dr. Kazlas suggests.  Yet they continue to struggle.  Even then, most pediatric ophthalmologists cannot bring themselves to admit that optometric vision therapy might be beneficial.

Yet despite the determination of “experts” like Dr. Kazlas to discount the benefits of optometric vision therapy, patients like Jacob Snoeyink find their way to doctors like John Abbondonza because parents like Marah Shoeyink can see through the thin veil of concern.

Now for another touch of irony.  The same institution (Mass Eye & Ear) housing the “expert” interviewed for this article publishes a newsletter that, three years ago, carried a front page article about a gentleman who had severe balance disorders.   He was diagnosed as having Meniere’s Disease, underwent rehabilitation therapy at the hospital and engaged in activities that help to develop his balance, such as becoming a student of T’ai Chi and Chi
Gung energy arts.  As you read the article in the newsletter you’ll gain the sense that the institution’s thinking regarding the ear is much broader than its thinking about the eye.  Perhaps there will be similar enlightenment for pediatric ophthalmology down the road, and a good place to begin would be to read the Clinical Practice Guidelines on Care of the Patient with Learning Related Vision Problems (CPG #20).  Then we’ll talk more.

– Leonard J. Press, O.D., FCOVD, FAAO

8 thoughts on “More Pediatric Ophthlamo-Spin

  1. Dr. Kazlas states with great certainty “Vision therapy, in the vast majority of children, does not play a role in helping a child read.” This is an odd statement because those children I treat that have been initially diagnosed as dyslexic, most often show no signs of the problem a year later. I know this to be a similar story in other OVT clinics around the world. I offer more than OEP-style VT in my clinic, but there is little doubt that visual dysfunction plays a significant role in at least 1/2 of the cases. Addressing a reading problem by forcing reading (only) is asinine and probably cruel – to recommend this as the solution exposes the significant lack of understanding on the part of the author. A camera is not a photographer, the eyes are not vision.

    In the end, her statement can only be based on two reference sources: Either she is re-quoting what she has read in the usual suspect journals (primarily US-based medical journals), or she has actually spent time following cases through VT clinics and then in classroom to document change… It safe to assume the former is the most logical choice; those who are familiar with the circular and somewhat inbred logic of the OMD/Ped research stream will understand that any conclusions based on those references are perhaps worth the paper they are printed on – but not much more. Many other journals from outside the medical domain, especially journals on neuro-rehab, vision science, and behavioural sciences will show on the one hand how visual dysfunction can and will interfere with reading, and on the other how reading remediation requires much more than just a whole lot more reading. Another swing, and another miss.

    In the end, and most importantly, the real problem in this is that teachers, counselors, and administrators look to these posers for professional guidance and standards. that messes everything up clinically, and ends up costing parents and taxpayers a lot more than is required. As Dr. Merrill Bowan would put it, it’s like filling a bucket full of holes and expecting it to fill up.

    Perhaps, Dr. Press, you have opinions on this… 😉

    Best regards.

    Dr. B

  2. Thanks as always for taking the time to read and comment, Charles. There are three levels of misinformation here:
    1) The “vast majority” of kids having reading problems don’t have vision problems.
    — even if that were true, let’s say the figure is 95%. If it were 5% of the population with reading problems, you’d still have a substantial number of kids. Show me one single child that Dr. Kazlas has referred to Dr Abbondonza for an opinion regarding the indication for optometric vision therapy. If the answer is zero, as I expect it is, then the comment is disingenuous at best, and more likely a gratuitous comment.

    2) The children to us have had all kinds of interventions. We’re typically last on the list. We’re the only thing new that the vast majority of these parents are adding to the child’s interventions. Despite this, the pediatric medical professionals can’t bear to acknowledge our contributions.

    3) Dr. Kazlas is quoted as saying “There is no harm in such treatments yet we don’t want the child to have a delay in having more effective treatment”. Interestingly, the original medical joint policy statements that she’d parroting used to say that VT was harmful precisely because it’s delaying needed/appropriate treatment. I’ll be alot more blunt. By serving parents, pediatricians, educators and anyone who’ll sip it their Kool-Aid version of VT, it is the pediatric ophthalmologists and pediatricians who are doing the child harm by denying —- not delaying, but denying them the treatment that as you note would have helped the child succeed.

    There are a handful of pediatric ophthalmologists I respect. They don’t present themselves as experts or authoritative in our field. They defer to my judgment in LRVPs much as I defer to their expertise in which muscles to operate on. It would be wonderful one day if there were some sort of synergy between our two fields. But it’ll never happen as long as the P-OMD party line is “we’re the experts on everything about visual development, and let’s keep spinning ODs to the public as non-MDs who do CLs, refract, and bend temples, or quacks who just want your money”.

    Freud would have had a field day with P-OMD insecurity over our success, in the guise of patient advocacy. Shame on these “experts”.

  3. Len,

    Thank you for your blog. I frequently pass it along to my patients.

    Recently a boy came into my office with a severe visual learning disability due to bilateral deprivation amblyopia. His ophthalmologist did a wonderful job treating the child surgically; in fact the boy could occasionally discern 20/25 size letters. His mother told me what happened next. After a few years of gradually-improving visual acuity, the mother consulted the ophthalmologist about the boy’s extreme difficulty learning letters and numbers. Dr. X told her there was no longer anything wrong with the boy’s eyes; the problem was in the connection between the eyes and the brain. As the mother relayed this story I nodded in agreement. She continued, “And then Dr. X said, ‘He’s had [an extremely challenging start to life], what do you expect? That’s as good as you’re going to get.'”

    So close, and yet so far from understanding. When mom called his office to request the child’s records in preparation for the vision therapy consultation, Dr. X dropped what he was doing to get on the phone to vociferously oppose vision therapy, on the grounds that it was a waste of time and money, and that mom should instead do intensive tutoring (which she had been doing for the prior 2 years with minimal results).

    It is very frustrating when parents are given advice from ophthalmo-atheists who have an agenda that is counter to the child receiving the best care. Especially when the ophthalmo-atheist is a superb and well-respected pediatric surgeon; I wish he would stick to what he’s good at without giving “advice” on vision issues that outside his area of expertise.

    Fortunately, this mother knows her child, sees his struggles, and realizes more tutoring is not enough. He starts VT next week and I am excited that I will get to help this very bright boy reach his potential.

    Keep writing,
    Amanda Zeller Manley, O.D.

  4. This is a wonderful blog! Thank you. It is always amazing to me why journalists in the US always feel compelled to present that “other opinion” when reporting on VT. It was quite surprising – and pleasurable – to see the interview with Susan Barry on the program REDES in Spain several months ago. It was stated, quite simply but emphatically that ophthalmologists are not qualified in this area – period. No second opinions, nothing. AMEN

  5. Ironic, isn’t it Linda? All these years ophthalmologists have opposed Optometry’s expanded scope of practice because they argue that one cannot acquire advanced skill set in an area by courses of study, or allegedly meager exposure to patient care. Yet that have no conscience in positioning themselves as “experts” in visual development and LRVPs. Based on what? Reading and parroting of their selective and biased “Joint Organizational Policy Statement” that has been repeatedly discredited and exposed? I will hand it to them, though, that they have most journalists brainwashed into believing that they’re experts. However, the Internet has changed everything, giving parents a direct voice without the filtering and spin. The paternalistic sanctimony has worn thin, and the public is seeing this double standard for what it is. Eventually the journalists will get it, and drop the need for the “but ophthalmologists say” qualifiers. In fact, they’ll expose the pediatric ophthalmologic position for what it truly is, and what it isn’t.

  6. Dear Dr. Press,

    Ophthalmology should look at work done with Diffusion Tensor MRI which tracks water in axons in the brain and then read “Left Neglected” by Lisa Genova, PHD.

    But of course Mothers know best that poor concentration is a deficiency in the motor centers of the brain, and therefore will not improve with muscle surgery, as the brain continues to train itself by building concentration, spirit of perseverance and mental poise based on salience, i.e. sensory (noise-color) decisions made bottom up and behavior decisions made top down.

    So, we know a deficit in attention to stimulus is neurological not “Your eyes are healthy, your sight is 20/20, so that is the best we can do.”

    Of course we have class rooms where the teacher has too many students without the help needed, so she/he goes from table to table giving instructions
    with no time to follow up, so if the kid can’t do the work, the parents are asked to drug the child; and then we go from single parent homes to latch key kids watching TV which does not wire the brain properly.

    I like the infantsee program and we should all belong. We have the 6 or 9 month old child in our offices to inform mom and dad about visual development
    and at the same time make appointments for the rest of the family. Now, Ophthalmology does what it does best; surgery on our patients referred for just that. Optometry then will become the first stop parents make rather than having their child visit the Dentist first.


  7. Pingback: Vision Therapy Research « abstractod

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