Can An Eye Examination Be Worse Than Useless?

visual-impairment-in-children-due-to-damage-to-the-brain-clinics-in-developmental-medicineBefore you rush to judgement about the title, because it’s intentionally provocative, let me re-assure you that it isn’t my concept.  It jumped out and grabbed me by the eyes from several different vantage points as I was reading this incredible volume of Clinics in Developmental Medicine.  The idea comes from chapter 10, written by Roger D. Freeman, M.D., who practices in a children’s hospital in Vancouver.  Regarding psychiatric considerations in cortical visual impairment, Dr. Freeman writes: “Because of great variability and complexity, a routine psychiatric evaluation by a clinician unfamiliar with CVI may be worse than useless; the delineation of biological, psychological, or social factors that constitute the basis for meaningful psychiatric formulations of problems may be severely limited or distorted.”

Now here’s the payoff.  Freeman continues by applying this to vision: “In children with multidisability, it is not uncommon for a normal eye examination to be mistakenly taken by others as proof of normal visual function.  Such beliefs are then difficult to dislodge and visual behavior is not appropriately interpreted.”


I was reminded of this yesterday during a seminar presentation to a group of professionals comprised largely of Occupational Therapists at a very lovely Embassy Suites Hotel in Blue Ash, Ohio, just outside Cincinnati.  Running through the center of the hotel is a lush garden with a stream containing fish located subtly enough that you don’t really notice unless you’re looking for them.

I now begin my seminars with an open-ended question:  “What is normal vision?”  By agreeing that it is something beyond 20/20 eyesight and healthy eyes, we open the discussion to a much deeper appreciation of the complexities of the visual process.  This quickly leads to the consideration about the extent to which eye examinations probe pertinent visual functions in the populations with whom we’re principally dealing: learning problems, dyslexia, developmental delay, autism, and acquired brain injury.


All the OTs (and PTs) present nodded their heads in the affirmative that the report form above is what they typically get back from pediatric ophthalmologists regarding examinations.  In a few words, 20/20 acuity with each eye, normal eye exam, no treatment indicated.  I then put up a slide that shows a joint report from an OT and PT in my town, indicating that a child has inefficient ocular motor skills, issues with visual attention, and intense fatigue following a few minutes of visual tasks.  The report stipulates that this child should be evaluated by a developmental optometrist.  They have learned that when the parent is given a false sense of security that visual function is normal because the eye examination is normal, the eye examination is worse than useless.

4 thoughts on “Can An Eye Examination Be Worse Than Useless?

  1. Dr. Press, I’d just like to raise my hand and nod my head in agreement that so many of the parents of the children that I see in my occupational therapy clinic have been given the same news. But, when they take my referral to our local developmental optometrist seriously, they come away with the feeling that they have found hope.

    • Thanks for commenting, Katherine. I’m optimistic that we’re reaching a tipping point of sorts, thanks to enlightened OTs as yourself, that the public will understand that pediatric ophthalmologists are very skilled in surgery and disease, but when it comes to understanding visual function – an examination for recommendations about the indications for optometric vision therapy by these professionals is pointless. Nor as I’ve blogged about previously should the narrow-mindedness of most MDs toward therapy by OTs or ODs be surprising. Particularly after the AAP came out with its manifesto against SPD and SI therapy by OTs (see:, the biases of these self-styled experts in commenting on other fields is more blatant than ever. At some point we’ll get a roundtable of MDs together who will expose these biases for what they are.

  2. Thank You for this blog. I will pin this to Pinterest. I do agree that there is so much more to the eyes then just what the initial optometry/ophthalmology exam can discover. As well as how the brain communicates with the eyes. And so much still to be learned in the medical industry about that communication. Very blunt, but very insightful and def. needed to be said. Katie Jo. (Thoughts on dyslexia from a dyslexic)

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