Why Isn’t There Synergry Between Optometry & Ophthalmology in Strabismus Surgery?

Another great seminar crowd on Friday, this time in Blue Ash/Cincinnati, Ohio.  Only ventured there because it was a good opportunity to have an extended weekend with our daughter, son-in-law and our beautiful trio of granddaughters who live there.  I met a therapist, Melanie, who has coordinated seminars for our colleague Dr. Hillier along with Mary Kawar, and a number of the attendees had previously been to seminars with Dr. Scheiman or Dr. Appelbaum.  There is a real thirst in sharing knowledge about vision and collaborating on cases.  It was also great because we have colleagues in the immediate area such as Drs. Greg Kitchener and Marie Bodack, and those within traveling distance such as Drs. Carole Burns and Brenda Montecalvo, who were well-known to many of the attendees.

One of the points that we touch upon during the seminar, which resonates particularly for the PTs, is why there isn’t better synergy between Optometry and Ophthalmology in the field of strabismus.

For those not young enough to remember, back in the day when physicians wore bow ties, there were serious schisms between orthopedic surgeons and physical therapists.  If you went to an M.D. for an opinion about an injury such as a muscle tear or broken bone, you would essentially be told you either needed surgery or you didn’t.  Doing physical therapy was a waste of time and money, and there wasn’t sufficient research to support it.  If you consulted a physical therapist you would be given advice on a non-surgical approach to rehabilitation, and be cautioned about the invasiveness and lack of predictable outcomes of surgery.

Ultimately the two fields got together in the best interests of the patient, and now it is commonplace to do physical therapy prior to surgery to strengthen compensatory muscles that will be relied on more heavily, and to stabilize surgical outcomes with post-surgical therapy.  The orthopedic/PT community figured this out.  Why haven’t we?

I realize the analogy may not hold tightly for various reasons, but T. Keith Lyle, M.D., a highly respected strabismologist in his day in the U.K., well understood the utility of the question.  In a seminal paper authored in a 1973 issue of Documenta Ophthalmologica, entitled Value of Orthoptics in Pre- and Post-Surgical Management of Strabismus, Dr. Lyle wrote:  “Orthoptics as far as treatment is concerned is strictly limited to certain types of cases, although in some of these it is of the most profound importance.”

Dr. Lyle gives several case reports, and emphasizes the importance of post-operative follow up including “hand-eye exercises”, and how crucial it is to insure that the child develops good use of both eyes together in addition to the advantages of cosmetically aligned eyes.

I’ve mentioned Dr. Dominick Maino a number of times in our blogs, and in particular his wonderful editorial calling on ophthalmologists to end the double standard they have in uncritically accepting surgery as primary treatment for strabismus, having essentially discarded orthoptics yet alone any understanding of optometric vision therapy.  Adding to that is his most recent blog post on MainosMemos.  After citing a research article showing failure rate of eye muscle surgery surgery in isolation, Dr. Maino writes: “As I always state when I am reporting on research dealing with strabismus surgery, I have and will continue to refer patients to have strabismus surgery when appropriate, but I usually recommend that the patient have pre and post surgical intervention vision therapy.  We need clinical trials that show the benefit of having the patient participate in a program of optometric vision therapy both before and after surgical intervention….and that when this occurs the surgery success rates actually increase.”

We couldn’t agree more.  And it makes perfect sense to OTs, PTs, and SLPs — and the orthopedic surgeons and ENTs in their fields who grasp the natural synergy between surgery and therapy in appropriate cases.  Now let’s see if we can find some pediatric ophthalmologists with the resolve to come out of the dark ages.

– Leonard J. Press, O.D., FCOVD, FAAO







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