A Sheep in Wolves’ Clothing

I just finished doing an evaluation on a 14 year old girl whose mother is a COTA – a Certified Occupational Therapy Assistant.  This young teen is very bright, but works incredibly hard to get Bs  in school.  Her mother loves to read, but her daugbhter struggles with anyting in print.  When listening to others read she grasps things perfectly.  Mom had attended a seminar I gave almost a year ago that discussed, among other topics, the difference between ophthalmology and optometry, and how most ophthalmologists poo-poo the relationship between vision and learning beyond eyesight.  Some ophthalmologisgts will acknowledge that convergence insufficiency can make reading more challenging, but if a child wants to succeed she will.  So mom was very specific that although there were both ophthalmologists and optometirsts in this practice, she wanted to see the optometrist.  At the end of the examination the doctor advised mother that everything was fine with her daughtger’s eyes, other than she needed a little help seeing the board.  She gave her a prescription for low nearsighted power.  It turns out that this young girl is actually a bit farsighted, even more so with drops in her eyes to relax her focus.  Not surprisingly, she resists wearing her glasses.  But that’s not where the story ends.  Mother specifically asked the doctor how her daughter’s binocular vision was, and the doctor said “Her eyes are fine”.  Mother, after having attended my course, knew enough to do a nearpoint of convergence (NPC) screening.  Her daughhter struggled mightily to converge, but couldn’t look at the target within the reading distance because it physically hurt her eyes to keep it single.  So mother again asked the doctor the question, being even more specific this time about having testied her convergence abilities.  This time the doctor was even more emphatic in her reply: “I told you, other than being a little nearsighted, her eyes are fine”. 

As it turns out, this teen’s eyes are fine.  It’s her vision that’s a problem.  She has a significant convergence insufficiency, as mother had properly detected on screening.  In a stereoscope test she uses both eyes together beautifully at distance where she sees, by the way, 20/20 letters without glasses.  But at near she experiences a double vision response because of her underconvergence.  In an objective test of reading, using the Readalyzer eye movement sensors, she visibity struggled to track effectively.  When I reviewed the findings with mom and daughter, they were relieved but pertrurbed.  Mom said to me: “I’m a COTA.  I know what to look for.  But what happens to a ‘regular’ parent?  I would have felt initmated by the doctor if I didn’t know in my heart that something was wrong. I can’t even discuss this with my husband,  because he knows the optometrist said everything is fine and he feels our daughter is just being lazy.  But I know her well and she is capable of so much more.  I hate to sit by and watch her settle for less, and I’m not goiing to do it any longer.”

We had a brief discussion about how some optometrists, particularly if they work in an ophthlamology practice, learn to adopt the mindset of their employers.  They lose sight of the role of vision in learning, and poo-poo anything beyond the need for glasses, medicadtion or surgery.  In essence, they become sheep in wolves’ clothing.  Then mom asked me a question I really couldn’t answer: “Why does it have to be this way?”

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

7 thoughts on “A Sheep in Wolves’ Clothing

  1. Dear Dr, Press,

    This was a great post. Thanks to “time pressure” at the Ophthalmologist’s style of practice, the testing of several aspects of vision may have been slighted. Patients, doctors and insurers all contribute to average medical visits in the US (face to face) with doctors being only between 4 and 7 minutes long.
    Errors aplenty result from such brief visits and missing the farsightedness probably began a chain of error resulting in a bad outcome for this young patient. The doctor clearly goofed. We doctors need to really slow down and observe more about our patients and emphasise zero error instead of patient numbers and patient dollars. It would be very difficult to keep from erring about convergence error when the refractive error is also wrong. Her case sounds like an easy fix if the diagnoses were correctly performed.and the patient was simply listened to.

    Dr. Tom Baugh
    Denison, TX

  2. Dear Lenny,

    Thank you for sharing a sad story regarding the misunderstanding of vision and learning, which is occurring every day because of the conflict between optometry and ophthalmology. I wanted to comment on several points. It is unrealistic to expect any optometrist, who works for an ophthalmologist to have any other opinion rather than the distorted medical perspective regarding eyes and reading. The true tragedy is when this overSIGHT occurs in an optometric office. The final thought is that parents need to be focused on their child’s problem and potential visual complaints. Specific visual complaints such as eye strain/fatigue, blurred vision, double vision, loss of place and headaches require a diagnosis, a treatment plan and the resolution of the dysfunction(s). The current attitude of eyes are healthy and acuity is 20/20 is outdated. Parents need to trust their own instincts and find the appropriate doctor to deal with their child’s vision problem. When a doctor attempts to intimidate a patient or their parents, it is time to seek a second opinion. Thanks again for helping clarify an obvious injustice in our health care system.

    Richard C. Laudon, O.D.

  3. Sadly there are those in Optometry and Ophthalmology who not only have poor bed side manners, they also do not take the patient’s best interest in mind. Maybe that is why they complain that their appointment
    books are not filled.
    Then there are those who listen to specific complaints and form a treatment plan that resolves the problem, or refer the patient to someone with more expertise in the treatment area needed by the patient.

    I can’t tell you how many patient’s seen in my practice, who needed a better treatment plan than they received on their last visit elsewhere, but they were not examined correctly; even fixation disparity was not tested for, and vertical prism was completely ignored.

    So, Dr. Press, maybe our colleges of Optometry would benefit students by assisting them with placement into private practice once they graduate, rather than have the commercial chain stores, and Ophthalmology hire
    these young doctors. The Optometrists I know who work for Ophthalmology are made to see way too many patients per day and like the chain stores, need to sell product and surgery rather than treating developmental and visual problems.
    Note: I just received a referral from a local Ophthalmologist, for a 2 1/2 year old alternating esotrope where the visual acuity was listed on the referral form as f & f. Well, fix and follow is not going to cut it from a person who calls himself a specialist. These so called specialists are not focused in the right areas. Let the Mom’s of the world find an Optometrist who cares, and they will.

  4. Yes-why does it have to be this way? I am often irritated by seeing patients who have seen other OD’s and not been tested adequately to find obvious (to me) tracking and eye teaming problems. This has resulted in them struggling in school or sports regardless of 20/20 eyesight. Dr. Streff used to say that until someone is sued for missing these binocular vision problems and loses a lawsuit nothing will change. I’ m afraid he was right. It will take something like this to get everyone’s attention to test and refer, just like pathology.

    • Hi Carol Scott: Well, as stated, there are many patients who visit a primary care doctor and the doctor misses the diagnosis, so the patient eventually finds a doctor who catches the diagnosis and cures the patient. The doctors who
      miss the diagnosis are not sued, but eventually lose patients. In my previous statement, some Optometrists complain that they do not have enough patients; this is the penalty for missing the mark in treatment of a patient’s complaint. So my opinion is, lawsuits are not the answer; that leads to higher insurance premiums and higher office visits. The answer is finding the right Optometrist just like finding the right Dentist or Attorney. Patients will find you by word of mouth because you are good at what you do.

      Plus, , I do not see where standard of care in Optometry includes the specialty of tracking and eye teaming problems, developmental problems, ADHD, CI, and neuro-plasticity, therefore lawsuits are not the answer, better training in Optometry School, and better assistance in placing graduating students in proper practices is part of the answer. And the best answer is Optometrists are responsible to achieve the training needed to treat patients properly or refer their patients to a properly trained Optometrist. You are correct in that all Optometrists must be able to at least check for ocular motor dysfunction and accommodative dysfunction and convergence insufficiency, even though this might not be standard of care as of yet.

      It is difficult to be the best contact lens person, the best low vision person, the best sports vision person, the best Medical Optometry person, the best developmental Optometry person and on and on.
      We as a profession need to be able to step aside in areas where an other Optometrist can do a better job…that is why we have Dr. Fortenbacher.


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