A VTPU Kind of Case

Many of you are familiar with an excellent Facebook page, Vision Therapy Parents Unite (VTPU), administered by Michele Hillman.  VTPU has grown to the staggering number of 9,154 members, and counting!  The parents of VTPU often struggle with conflicting opinions about how to manage their young ones, and a recurrent theme is the difference in approach to strabismus between ophthalmologists and optometrists.


Ivan is a child who we might refer to as a classic kind of VTPU case.  His mother first contacted us last September, right after his third birthday in August.  She related that he had strabismus surgery in March, but that his eyes were still turning inward intermittently.  She had gone back to the surgeon, who reassured his parents that Ivan was doing fine.  She went to a different pediatric ophthalmologist for a second opinion, and he too reassured her not to worry.  When she asked both of them about vision therapy, they advised that it could be of no help in Ivan’s case.

When I saw Ivan initially in October of last year, and he had a +1.50 Rx OU that he wasn’t wearing.  The surgeon’s record showed that Ivan was originally more eso at distance than near, but on my visit he was ortho at distance and 10^ E(T)’ at near.  His parents agreed that Ivan was “having a good day” that day,  but there were other days that his eye turn was more noticeable.  I encouraged them to have him wear the glasses full-time, and to return in a month at which time we would consider binasal tapes and home abduction therapy calisthenics if indicated.

Ivan’s parents didn’t return with him in a month.  They came back in April, having decided to see yet another pediatric ophthalmologist (their third) who prescribed a bifocal of +1.50 OU with a +3.50 add.  That is the pair of glasses you see above and, as you might guess, Ivan looks above the line when fixating at near.  At that time Ivan had just received the glasses, but on that day in April when I evaluated him his esotropia had increased to a constant alternating esotropia of 30 prism diopters at distance and near.  They had consulted again with the original surgeon, who said the only alternative was to try another eye muscle surgery.

I advised his parents that they would have to be very aggressive about doing the abduction calisthenics we demonstrated, and to use a combination of the plus lens Rx and binasal occlusion.  They undertook this with vigor and when I saw him the office today he was perfectly aligned at distance and near through the carrier of his Rx will excellent stereopsis.  Without the lens Rx he was aligned a distance although intermittently small angle eso at near, and not as confident on his Random Dot responses as with the Rx.

His parents thanked me this evening, and said they decided to continue seeing me because I was the first doctor that took the time to explain things to them in detail.  More importantly to them, I had written a letter to them summarizing Ivan’s case for their files.  They found that immensely helpful in organizing their thoughts about the various opinions they had received.  It appears that with is plus lenses in place, and with some light ABD calisthenic reinforcement, Ivan is well in the road to stable binocular development.  Although his parents aren’t “Facebook people”, they have experienced the type of outcome that most VTPU parents look forward to.

6 thoughts on “A VTPU Kind of Case

  1. So glad to see recognition of Michele Hillman’s hard work. As the schools, state/federal lawmakers start learning and addressing the need to identify these visual impairments, the world is starting to see vision is more than 20/20.

  2. Dear Lenny,

    Excellent case from a number of perspectives. It is obvious that pediatric ophthalmologists don’t understand strabismus especially accommodative esotropia. It also ironic that the one ophthalmologist, who understood the concept of bifocals in this case, didn’t understand HOW to determine an appropriate add. The medical approach of more is not always the best approach. Besides their limited knowledge of binocularity, they completely ignore all other functions related to vision from accommodation to eye movements to visual attention etc/etc.

    The parents were lucky to have found you and you are lucky that they followed your advice. Many children have undergone multiple surgeries because parents have been intimidated by the medical community. Insurance companies shares in this insanity since they pay for the procedure without questioning the outcome. Thank you for sharing this important case and communicating to other the value of optometric vision therapy.


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