The selective application of de omnibus dubitandum


Attributed to Rene Descartes, the Latin phrase de omnibus dubitandum translates as “be doubtful of everything”.  You may recall that when the landmark CITT study was published in Archives of Ophthalmology in 2008, it was accompanied  by the unprecedented step of having a qualifying editorial embedded front and center on the first page of the article.

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It was not surprising at the time that the press release by the NEI/NIH heralding CITT as proof of a better way to manage CI through office-based vision therapy would be disconcerting to ophthalmologic practitioners who, by and large, offered no such treatment.  For many years the doubters dissuaded patients from pursuing optometric therapy, citing the lack of efficacious studies and the significant costs involved.  “Besides”, they opined, “if it really worked, don’t you think we’d offer it?”  Yet here was scientific proof, published in an ophthalmology journal with a high impact factor, that office-based VT not only worked – but was far superior to the conventional wisdom currently being dispensed.  When a gold standard research study shakes your paradigm, there are really only two recourses:

  1. Ignore the study
  2. Qualify the study (“let’s not jump to conclusions”)

Our colleague, Dr. Dominick Maino quickly pointed out in his editorial for OVD that same year, that the embedded Archives editorial was in essence a veiled attempt to cast doubt on the need for office-based optometric vision therapy.  The CITT Executive Committee could have chosen to ignore the embedded editorial but, to their credit, Cotter et al wrote a response detailing why the concerns about the CITT were misplaced.  Still, the fact that the original editorial was embedded in the study means that the qualifier (justified or otherwise) would remain stamped on the original paper, a reminder of how unsettling the results of the study were to a small but vocal segment of pediatric ophthalmologists.

It should therefore not be a surprise that history is repeating itself regarding another landmark NEI/NIH funded study on hyperopia and literacy, guided largely by optometry, and accompanied by a press release with unsettling implications supportive of plus lenses related to literacy.  These implications have already been grasped within educational circles.

Education Week

Quite predictably there is an editorial that will appear in the same journal publishing the NEI/NIH study, using a classic straw man argument.  The title of the editorial is “Should Glasses Be Prescribed for All Children with Moderate Hyperopia?”  The straw man of course is that this study didn’t suggest that glasses be prescribed for all children with moderate hyperopia. Reading through the editorial you’ll recognize familiar arguments:

  1. Children are self-conscious about wearing glasses, so better be sure that the benefits outweigh the psychosocial costs.
  2. In many cases the parents of these children struggle to pay for basic necessities.  When glasses are prescribed in these cases (in the absence of esotropia and amblyopia), direct costs are the examination, the glasses, and the second opinion examinations when children refuse to wear the glasses.
  3. Indirect costs to these struggling parents include time missed from work going to doctor appointments, time spent looking for glasses that children hide to avoid wearing them, or at dispensaries having the glasses repaired.
  4. Prescribing needlessly for hyperopia at a young age may interfere with the emmetropization process.

How does this sit with you?

8 thoughts on “The selective application of de omnibus dubitandum

  1. Straw man is right. The same arguments can be equally well applied to many other treatments. BTW, I for one, would be very likely to recommend glasses to anyone with moderate hyperopia, especiall those who are tied to desks/computers; waiting for damage to be seen is an outrageous ‘protocol’. I can’t recall a single case where a +3.00D did not like an Rx and ‘feel’ the difference. Even for ADHD meds, often times the rationale is ‘what might happen’, and meds are toxic. Unimpressed with the hypocrisy, scientific dishonesty, and blatant and ongoing bias. In a word: Meh.

  2. Let’s take another crack at this:

    “1. Children are self-conscious about wearing glasses, so better be sure that the benefits outweigh the psychosocial costs.” – So, we should discourage preventive care and assistive devices because children might be self-conscious? Let’s, then, discourage expression of gender, use of wheelchairs, orthodontia, orthotics, crutches, and curly red hair…
    “2. In many cases the parents of these children struggle to pay for basic necessities. When glasses are prescribed in these cases (in the absence of esotropia and amblyopia), direct costs are the examination, the glasses, and the second opinion examinations when children refuse to wear the glasses.” – This says that children should not be offered treatments that cost money. Would we make the same case for any other treatment – or wheelchairs, orthodontia, and so on?
    “3. Indirect costs to these struggling parents include time missed from work going to doctor appointments, time spent looking for glasses that children hide to avoid wearing them, or at dispensaries having the glasses repaired.” – Ditto to 1 and 2 above.
    “4. Prescribing needlessly for hyperopia at a young age may interfere with the emmetropization process.” – Or it may not. Indeed, it doesn’t, and plenty of well-designed meta-analyses and direct studies will show this is not the case. But this should also signal why professional expert prescribing is important – pediatricians, even ophthalmology, aren’t expert at prescribing. (who in the world Rx’s a full cycloplegic Rx?)

    Meh.

  3. Excellent set of meh. And of course, the double standard of worrying about “struggling parents” paying for optometric exams and glasses, while ignoring the struggle that the children will have with literacy when the Rx is withheld or discouraged, which in turns adds to the family’s struggle. And when you read the editorial, do you sense a value judgement that the results on the literacy test was poor in both groups because of socioeconomic factors – the implication being that most of these kids are going to struggle with literacy anyway, so the glasses are at best a drop in the bucket?

  4. It reads like the fine print in advertising of pharmaceutical products. The large prints says that this drug MAY help you. The fine print lists all the numerous side effects of the drug. These side effects often include death.

  5. Finally read the editorial … Again, meh, but I’ll add a harrumph. Just a few more things.

    ‘Ocular exam’ suggests a very limited appreciation of visual function, or the expertise required to assess it. Everyone’s an expert, until they learn something. Any one of these docs would Rx -3.00 for the equivalent myopia, not realizing they are neutralizing any benefit conferred by the child’s natural posture for extended near work,

    “Because approximately 4 million children are born each year in the United States and assuming that 10% of them are moderate or high hyperopes when 3 to 5 years of age, it would cost $1.8 billion to buy each of these children 1
    pair of glasses ($150/spectacles) each year.” – And in the US, insurance foots the bill, so who exactly carries this burden?

    The Pentagon has ‘lost’ a dozen TRILLION since the early 90’s, the ongoing wars in the Middle East cost additional hundreds of billions each year,… Beyond this egregious torsion in priorities, unchecked vision problems compound costs to education and healthcare well beyond 1.8B/annually. The math is also bad: Not all of those children would be prescribed glasses.

    Underlying this whole piece is the notion that ‘the risk to the child over his lifetime is not worth the pittance it would cost for prevention’, and this is repugnant and bad doctoring. EVEN IF the child does not wish to wear the Rx, it should be there, available for use. None of these docs would voluntarily walk around with a 3D hyperopia. There is no limit to the hypocrisy of the editorial.

    Finally, perhaps most importantly, the comment ignores the real physical impact of moderate/high hyperopia – from headache and asthenopia, to emotional disturbances, to problems in language development, to masquerading as ADHD-like issues. It’s like the ‘no pain’ theory of circumcision – babies don’t feel it, so it’s ok if we do it – but the observation that you need to strap the newborn down to do it is a clear indication the theory might be wrong. Kids with hyperopia suffer for it and when you take it away, they stop suffering. Pretty clear evidence to me.

    I look forward to a similar rebuttal against the use of orthodontia.

    Ok, done now.

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