The Real Reason Ophthalmology Abandoned Orthoptics

In the course of looking for something else today, I came across a book that has been dormant on my shelves for quite awhile.  It is a richly illustrated history of Strabismology, edited by Gunter K. von Noorden.  Published in 2002, a free flip-book version is available online.

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Among the many interesting perspectives in the book, two in particular caught my eye:

  1. “In the seventies, orthoptic therapy fell somewhat by the wayside as orthoptics became more interested in diagnosis and other skills like retinoscopy, perimetry, ophthalmic photography, and electrophysiology.  In addition, time and financial constraints in pediatric ophthalmology practices often did not allow for extensive therapy sessions.”  (p. 276)
  2. “Not many orthoptists have been taught, or still retain the skills to perform detailed and intensive orthoptic exercises.  Few know how to utilize therapeutic instruments such as the synoptophore, stereoscopes, the diploscope or a septum or have had enough clinical experience to understand in practice, rather than in theory from various books or lectures, the nuances, which permit that knowledge to be conveyed to patients and future orthoptists.  Secondly, even if those skills are acquired, few orthoptists have the time to offer these often worthwhile but time-consuming treatment sessions.  Aside from therapy for convergence insufficiency, not many orthoptists nowadays are true therapists.”   (p. 281)

In that context, consider the following article published in July of this year titled “Beyond Rehabilitation of Acuity, Ocular Alignment, and Binocularity in Infantile Strabismus“.

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The article is co-authored by Chantal Milleret, who is at the Center for Interdisciplinary Research in Biology, Centre National de la Recherche Scientifique, College de France, in Paris, together with Emmanuel Bui Quoc of the Department of Ophthalmology, Robert Debré University Hospital, also in Paris.  In their introduction they write:

“The visual scene may be decomposed into what are referred to as visual attributes, i.e., image location, orientations (horizontal, vertical, oblique), spatial frequencies (ranked from low to high, corresponding to gross to fine details respectively), velocities/directions of movement, binocularity (subtending 2D and 3D perception), contrasts and colors).  In infantile strabismus, i.e., strabismus occurring during childhood, the perception of each of these visual attributes can be altered as well are vision-dependent processes such as postural stability. But presently rehabilitative therapies by ophthalmologists, orthoptists and optometrists are restricted to preventing or curing only a few perceptual deficits among these. In the interest of helping these medical and paramedical practitioners evolve these therapies, we (i.e., a fundamental researcher and an ophthalmologist) hypothesize here that rehabilitation after infantile strabismus should be extended further, and we develop arguments in favor of such hypothesis.”

It’s interesting that the authors of this paper, a basic researcher and an ophthalmologist, purport to be knowledgable about the rehabilitative therapies of optometrists.  We welcome their expansive hypotheses, but clearly they’ve missed the fact that developmental optometrists have spent a considerable part of the last 40 years expanding the approach to strabismus therapy beyond alignment of the eyes and into postural mechanisms and perceptual processing.  In this instance, I’m siding with von Noorden that the reason pediatric ophthalmologists and orthoptists became more restrictive in their approach was a pragmatic one dictated by practice economics and a philosophical shift in the field.  It was never about a lack of information or research.

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From: Applied Concepts in Vision Therapy. Ridgevue Publishing, 2017. iBooks.

Why do I feel a Gomer Pyle “Shazam!” coming on?


9 thoughts on “The Real Reason Ophthalmology Abandoned Orthoptics

  1. Len,
    Thank you. There have been historical similarities in the relationship between optometry and ophthalmology and that between psychology and psychiatry. In the realms of both vision and in mental health, the importance of incremental care to enhance function is undergoing a resurgence. like most things in life, the most effective approach is not all of one or the other.

  2. I believe that in addition to economics, that institutional politics also comes into play. During the 1980s, I sat in on discussions of curriculum changes at SCCO to emphasize medical optometry and reduce training and education in VT. The incursion of optometry into ophthalmology’s territory resulted in lowering of dispensary revenue. During that decade, average earnings for OMDs dropped from more than $600,000 to just over $300,000. The ophthalmological organizations went on the attack and looked closely at optometry and focused their attacks on the financially weakest and most “far out” aspects of the profession (vision therapy).

    In 1984, with the help and guidance of Charles Margach, O.D., wrote a detailed rebuttal to the joint statement of pediatricians and pediatric ophthalmological organizations. One of the cited “studies” was actually testimony before a congressional committee! That same year, I testified before a committee on behalf of the OEPF, which tells you how little that citation meant. That battle over money was disgusting to me and is part of what has moved me to spend 37 years doing what I can for the profession and specialty.
    I am now semi retired yet I still love what VTODs do to change young lives in particular. So I’ve started a project called “10,000 More.” The idea is that all our various efforts to generate new VT ODs can fall under this message. We need at least 10,000 More VT ODs to even begin to handle the unmet need for such care. It is a unified message that embraces all efforts, and anyone doing anything in that realm can freely use the title and the message. It is a simple form of branding, one of the most powerful ways to make something happen. I invite you to adopt it–leaders are needed to make something happen, and you certainly qualify. We could all use a unifying message that promotes what patients sorely need.

    What’s the use of promoting VT if we don’t have enough VT ODs to deliver care to more than two percent of those who need it.

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