Pediatric ophthalmologists and developmental optometrists each see skewed populations when it comes to children with vision based learning problems. Parents who, for whatever reasons, elect not to pursue optometric remediation through low power prescriptive lenses, prisms, or vision therapy may seek reassurance that nothing’s wrong by consulting with an eye surgeon. Conversely children with legitimate vision problems whose parents are assured by eye surgeons that there is nothing to be concerned about may seek clarity from a developmental optometrist because they sense that their child is not crying wolf.
In my 37 years of practice I have encountered hundreds if not thousands of instances where a parent came to me with their child, convinced that something is legitimately wrong, after having been assured by the pediatric ophthalmologist that everything is fine. Parents generally know their children best and particularly when a child who is not a complainer complains about her vision, there is usually a logical explanation. Alexandra is the most recent example, and because her case and documentation is fresh in my mind I’ll share this classic instance of the ball being dropped.
About a year and a half ago, Alexandra – who is now 11 years old – began to experience difficulty with reading. Not that it was ever easy for her, but she was now aware of the instability of print when trying to read. Her pediatrician referred Alexandra to a local pediatric ophthalmologist, who wrote the letter that you see here. The doctor found that Alexandra’s eyes were healthy, that she has normal visual acuity, no refractive error, no restriction in eye movements, no strabismus, and that convergence was intact. Despite the fact that she noted Alexandra had difficulty only with reading text, and not with math computation or i-Pad games, she concluded: “Her difficulty with reading is not resulting from her eyes in any way”. This was back in February 2013, and despite the fact that Alexandra was already receiving special help in reading in school, which did not alleviate her symptoms in any way, the pediatric ophthalmologist could only suggest that if the reading issues worsened a consult with a developmental pediatrician would be in order.
A month later the instabilities of print that Alexandra experienced were not improving, and she was becoming discouraged. Although she was receiving extra help in math and reading, her basic ability in computation was excellent as long as it did not involve word problems. As soon as print was laid out on a page like reading, the shimmering predominated and it was tough to maintain concentration yet alone comprehend what she was reading without working extremely hard at it. And even so, it was a struggle. Distressed at having no answers, Alexandra’s mother took her to a pediatric neurologist who found her complaints of visual distortion to be unusual. As indicated in her letter, she ordered an EEG, MRI, and blood work to rule out medical abnormalities. The plan, if results were normal and the instability of print continued, was to treat Alexandra as having a migraine variant, and therefore start her on drug trials.
While I have no fundamental opposition to a trial of medication when appropriate, you may have already sensed the flaw here that both doctors overlooked. One clue is that Alexandra’s visual instabilities did not exist when print was wider spaced, as with non-word math problems. Asking Alexandra if print size made a significant difference in her perception – which it does – could have easily, confirmed this. The other clue is that Alexandra experience no difficulties with i-Pad games, computers, TV, movies, and so forth – activities which should be more of a visual trigger to migraines that reading a page in a chapter book.
Sure enough, all tests including blood workup, EEG, and MRI were negative. Alexandra’s mom intuitively grasped that medication made no sense, so she decided to consult with another ophthalmologist. This time the ophthalmologist explained that Alexandra did have convergence insufficiency, and that she might benefit from vision therapy, but that there are two types of therapy and only one works. She asked him to write her a letter because she didn’t understand what he expected her to do. This was back in May, and she’s still waiting for the letter.
At her wit’s end, Alexandra’s mother searched the Internet to see if she could find more guidance and a specific course of action, ultimately bringing her to my office last week for an evaluation. For many years when people asked me what I did for a living, I’d give them either a technical description and watch their eyes glaze over, or a very simple descriptor such as working with patients who have visual problems that can’t be fully corrected with standard eyeglasses or medications. It may be even simpler, and more to the point if my answer to the question is that my job is to gather dropped balls.