Anti-Optometry Policy Statements: The Organization vs. The Individual

Any time you see a joint policy statement from the following groups, you can bet that you won’t find anything positive in it about Optometry or optometric vision therapy. They are, the AAP (American Academy of Pediatrics) SECTION ON OPHTHALMOLOGY; AMERICAN ACADEMY OF OPHTHALMOLOGY (AAO); AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS (AAPOS); and the AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS (AACO).

This has been going on for 50 years, stemming from the AAP’s policy statement in 1972 titled “The Eye and Learning Disabilities“. Despite refutations of these biased opinion pieces under the guise of science or public interest (see Bowan and Lack for example), they continue to be re-packaged at least once each decade. It was therefore no real surprise when these groups issued their latest joint policy statement last week, this time focused more specifically on concussions rather than learning disabilities or dyslexia. You can access the opinion piece, titled Vision and Concussion: Symptoms, Signs, Evaluation and Treatment here. There are two key revelatory statements in its conclusion:

1. “For the minority of patients who continue to have ongoing visual symptoms, referral to appropriate specialty care (ie, sports medicine, physiatry, neurology, neuropsychology, ophthalmology, otorhinolaryngology) may be beneficial, and additional study is needed to establish best practices.”
2. “There remains a lack of high-quality evidence to support isolated treatment of visual symptoms, such as double vision or blurred vision, after concussion with vision therapy; additional study is needed.”

The problem with these two statements are obvious. The first one ignores optometry. That might at least be understandable, though still indefensible, if the authors were limiting their suggestions to seeing specialist physicians (used here in the context of MDs). But neuropsychologists are listed, so that argument goes by the wayside. The second one is countermanded or at least qualified by a statement that follows on its heels: “Temporary base-in prism combined with refractive correction for near vision can improve symptoms of blurred vision and diplopia associated with accommodative and convergence dysfunction”, which the authors refer to as supportive care apparently to differentiate it from more active vision therapy. Yet the authors present no high quality evidence indicating that this supportive care is any more effective for this population than vision therapy.

Kudos to NORA (the Neuro-Optomertric Rehabilitation Association) and its president, Dr. DeAnn Fitzgerald, for quickly issuing a release calling these medical organizations on the carpet. You can access that statement here. Adding to that, I would like to point out the difference between organizational policy statements of this nature in which facts are often obscured or distorted by politics and various hidden agendas, as compared to peer-reviewed articles by authors untrammeled by these concessions.

Nowhere is this more apparent than in looking at the name of corresponding author of the current Joint Policy Statement in question. It is Christina L. Master, M.D., an individual familiar to many optometrists through the fact that she:

1. Collaborated with an optometrist, Dr. Michael Gallaway in presenting a continuing education program at the 47th annual COVD meeting detailing the multidisciplinary role of Optometry and vision therapy (see here).
2. Co-authored an oral research presentation presented at the 44th annual COVD meeting with an optometrist, Dr. Mitchell Scheiman on The Impact of Concussion on the Visual System of Children 11 to 17 Years Old (see here).

You must be thinking to yourself: Based on that, how is it possible that Dr. Master could be the corresponding author of a Policy Statement that overlooks or trivializes the role of Optometry? Doesn’t she know better? Well of course she does. Here is a masterful analytic review she just co-authored in a PubMed indexed journal, the American Journal of Lifestyle Medicine, titled Pediatric Sports-Related Concussion: An Approach to Care. The paper has 187 references.

In the section on Vision and Vestibular Therapy, Dr. Master and her colleagues write: “A subset of children and adolescents may require additional referral for vision rehabilitation for persistent visual symptoms and deficits. Trained developmental optometrists assess visual function and develop a customized neuro-optometric rehabilitation program. The American Optometric Association defines vision therapy as a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate, and enhance visual skills and processing.  Following concussion, eye movements, convergence and accommodative amplitude are common targets for vision rehabilitation, which retrains the visual system to return the child to baseline visual function improving speed, accuracy and oculomotor functions. Research has shown binocular vision rehabilitation improves convergence in adults suffering from mTBI. Similarly, recent data from adolescents showed improvement in convergence and accommodation with the utilization of vision rehabilitation as an intervention for common vision disorders after pediatric concussion.”

Had that series of cogent statements giving due accord to the role of developmental optometry and neuro-optometric rehabilitation been incorporated into the Joint Policy Statement of the AAP Section on Ophthalmology, AAO, AAPOS, and AACO, there would be no issue here. But clearly something very different is operative at the organizational level that speaks to its bias. The organizational agenda is apparently quite distinct from the scholarship of its individual authors.