The Unorthodox Prescribing of Prism in the Orthodox Community


Several years ago I blogged about the pilgrimage of people to England to receive “special prism glasses” for reading.  Rather than abating, the concept has intensified.  It is both interesting and insightful to see some of the discussions around this on forums in the public domain.  Here is one thread that began in 2012 with more active discussion in 2017, as well as a parallel thread addressing the same topic.  Social media is progressively fueling interest in visual issues, particularly among populations who place a premium on reading and learning.

Shain Zero to Hero

A parent recently acquainted me with a book written this year by reading specialist Sara Shain, a member of the Orthodox Jewish Community in the metro New York region.  From Zero to Hero has a brief section mentioning the possible help that struggling students can derive from prism glasses or vision therapy, and I particualrly like the header of this section noting that the persistence of these problems poses emotional health risks:

Screen Shot 2017-12-01 at 8.24.16 AM

Because we are seeing progressively increasing numbers of Orthodox patients, I thought it might be of interest to add an historical footnote to the discussion.  I was raised in an Orthodox home in the Logan section of Philadelphia, a ten block radius encompassing nearly as many houses of worship as there are Starbucks stores in Manhattan.  My father was an optometrist who had his office in our house, and I attended the Pennsylvania College of Optometry located only a mile from his office.  This afforded a unique opportunity to incorporate what I was learning into the flow of a private practice.

ben_franklin_writing_desk_18999

At the same time there was an ophthalmologist practicing nearby by the name of Samuel I. Askovitz.  Naturally in a small neighborhood with only two ophthalmic practices, there were times when Dr. Askovitz would examine our patients and vice-versa.  I noticed that we were consistently seeing patients of Dr. Askovitz who had small amounts of prism in their glasses.  The prisms were in interesting combinations, both in direction and magnitude that I was at a loss to explain based on anything that I was learning in school which focused on prescribing prism only to compensate for double vision or eye strain.  I asked my father about it, who scratched his head and said with dry wit that perhaps Dr. Askovitz’s phoropter was miscalibrated.

phoropter

It turned out that Dr. Askovitz had an unorthodox intuition that he was successfully applying to his orthodox population over fifty years ago.  Nor was this a coincidence.  In the bio of an article that he authored for the Journal of the American Statistical Association in 1959, Dr. Askovitz listed his main fields of interest in this order:

  • The Bible, Talmud and Rabbinic Law
  • Graphic Methods in Pure Mathematics and Statistics
  • Geometric and Visual Optics
  • Application of Electronic and Optical Instruments in Medical Research
  • General Medicine and Ophthalmology
  • Tumor Statistics

Around this same time, in the 1950s, optometrists working in the field of learning issues actively promoted the prescribing of low power plus lenses for near, in single vision or bifocal form.  The prescribing of analogous low power prisms was generally frowned upon, with the concern about “prism adaptation”.  Dr. Askovitz favored low power prisms, which had the advantage of being incorporable into a single vision lens (or multifocal) without any concern for distance vision blur.  The type of adaptation that might occur for patients using prism to offset double vision did not occur with this population.  To inure against this, patients would return to his practice to have the power, direction, and symmetry between right and left eyes fine tuned.  With a nod to the pioneering principles of Dr. Askovitz, we have come full circle in combining all the modern means at our disposal: creative prescribing of lens and prism power and orientation including lens coatings and tints (and speciality considerations such as the Shaw Lens), as well as optometric vision therapy.

11 thoughts on “The Unorthodox Prescribing of Prism in the Orthodox Community

  1. Len, That is not a Horopter pictured above. The Horopter was made by American Optical Company. I think that the one made by B & L was called a Refractor.

    Michael

  2. Dr. Press:

    As an Orthodox optometrist that works almost exclusively within the Orthodox community I deal with this issue on an almost daily basis. Although I only remember Dr. Askovitz vaguely having met him only perhaps once or twice, I was not aware of his interest in prism glasses. When I was at PCO in the late seventies and early eighties I used to go to Rabbi Lipschitz’s shul. He would frequently mention Dr. Askovitz. Dr. Askovitz was also known as a mathematical genius and I believe he was also gifted in playing the piano.
    I have many patients that have gone to London for their “prism glasses”. Some have gone to other doctors here in the states as well.
    Some think miraculous results have occurred using these glasses. Others have had no positive results.
    I have many more questions regarding “prism glasses” or “micro-prism glasses” than I have answers. The biggest problem is that I cannot find one single study documenting results. Certainly there is not even one controlled study I could refer to. There are many anecdotes.
    A patient wanted to pay my way to London so I can learn from the “prism Dr.” over there due to the miraculous results he said his son had achieved.
    I myself have seen plenty of patients that came in with prism glasses that they said did not do anything for them.
    I wish there is something in the literature I could read to understand the methodology and the theory behind it.
    Thanks for the interesting blog. I passed this article on to a friend of mine who was also raised in Logan around the corner from Rabbi Lipschitz.

  3. You’re welcome, Joel. Like any other purported panacea, we tend to hear from people who have miraculous stories to tell and not as much from those who do not. That is why on the social media site I cited, you’ll see mothers exchanging stories about how much their children have been helped by prisms, but very little from those who have been disappointed – yet we know from seeing many patients for whom prism has been prescribed for reading problems, that it is not a panacea. I believe in the wisdom of the old masters who referred to the “judicious application of lenses and prisms”. Why the emphasis on “judicious”? Those of us who Rx prism for this population need to do a better job articulating how we derive it. Although there have been no formal studies, that’s not how clinical innovation occurs. The clinical observations come first – often “off label” applications – and the research follows. For example, it makes not sense that 0.02% atropine would slow the progression of myopia based on a “homeopathic” type does. Yet that’s what some clinicians were observing, and ultimately research is bearing that out. Just because the research isn’t there yet doesn’t mean those who are comfortable with their observations shouldn’t be Rxing. The problem of course is that none of the “prism Rebbes” here or overseas have written up a structured protocol to follow. It remains shrouded in mystique, which is unfortunate, and it neither has to nor should remain that way.

  4. As too many practitioners in healthcare today insist, if the evidence isn’t there it doesn’t work/isn’t valid/can’t be prescribed. But if we don’t try it/prescribe it/observe it/collect data/share that information there will never be advances in healthcare.

    • “But if we don’t try it/prescribe it/observe it/collect data/share that information there will never be advances in healthcare.”

      I don’t have any problem with trying it/describing it observing it etc. What I do have a problem with is promoting it and believing it as gospel without any collection of data or sharing of information regarding the results of the treatment.

      As far as I’ve been able to discover there are no studies documenting results, establishing protocols, determining which treatments work for which type of patients etc. etc. All I hear are anecdotal results. It is the responsibility of those prescribing treatments and collecting significant fees as clinical scientists to document the results and prove that the treatments are working.

      That there are no randomized, controlled double-blind studies regarding these treatments which have apparently been around for decades, should be an embarrassment for our profession.

  5. have never ever read a ”double-blind-study” in vision related research, and since we can only pay attention to / work on one eye at the time and the pt Hx is as important as his health (fysically and mentally ) and seeing is all about function and attention, we should step away from ‘stereo’ typing (pi) our pts and find ways to document and teach the different approaches that there are in ophthalmology, orthoptical approaches of optometric research, posturology approaches of optometric research.
    my thoughts: do NOT follow the misleading route of the ”evidence based lobbyist”
    AAAALLL science has started with anecdotal evidence and pt-rapport
    we might call it double masked studies to get closer to reality
    we might find it undoable to get all input in any kind of form of global protocol
    genetics is still in its early years…….and expanding and cannot be ignored in this
    position on the globe or in the air or out in space will be of influence
    even water runs in a different direction on the other side of the globe…….i’ve heard

  6. Onno:

    Thank you for your reply.

    I think I really need to disagree with you to some extent.

    We have a responsibility to our patients and to our profession to as rigorously and thoroughly as possible investigate potentially beneficial therapies for patients.

    We should not take the easy way out and blithely dismiss the importance of scientific investigation regarding vision treatments.

    For example, someone, either those doctors actively prescribing “prism” therapies or schools of optometry with larger patient bases and resources could perform the following experiment.

    First of all, patients must be grouped according to various vision problems. Then, 3 pairs of lenses should be made for these patients. One without prism; one with the recommended prism; and one with a prism opposite to the recommended prism. Neither the patient nor the dispenser not even the doctor should know which glasses the patient is getting. That way there will be no misleading discussion. (I guess you could say this is a triple blind study) The patient should have each pair of glasses for a certain amount of time. There should be some benchmark (s) to measure the patient’s performance response to each set of lenses.

    I believe such an experiment as I’ve outlined above is the professional responsibility of those taking (lots of) money to treat patients with vision and learning problems.

    As I stated earlier, I believe it is an embarrassment for our profession that such studies have not been done. Great harm is done to our professional prestige and image by not having the requisite research to back up our clinical practice.

    Whether it is due to lack of resources or lack of interest or lack of research experience or simple laziness, I think it makes optometry look like quackery even if there is validity to the procedure.

  7. I’m intrigued, Joel, by your thought that the lack of controlled of trials of prism Rxing “makes optometry look like quackery even if there is validity to the procedure”. I’d like you to take a look at the application of the Neurolens (https://www.neurolenses.com), a low amount of progressive prism (0.375^ per eye) marketed by an impressive consortium of MDs & ODs, with a very high price tag to the practitioner (which obviously must be passed on to the patient) – and tell me if you think that smacks of quackery. And if you do not, I’d like you to explain why you feel otherwise about the topic above. Thanks in advance.

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