The Double Standard of Double Vision

The first three verses of this immensely popular folk song were written by Pete Seeger in 1955.  It was Joe Hickerson who added the additional verses in 1960 to turn it into a circular song.  Each verse ends with the rhetorical question, when will they ever learn?

When you read through the comments of an earlier blog piece here you’ll be struck by the circularity of reasoning that is similarly recursive, and the conclusion is the same: when will they ever learn?  The good news is that for many, though not all of the public the outcomes of the CITT study are leading more patients to the benefits of office-based optometric vision therapy.  They are learning now.  The bad news however is that many (though not all) patients who seek an opinion about CI from an ophthalmologist (self-described “Eye MDs“), will be left scratching their heads like Pete Seeger.  What prompts me to say this?  Reports from the source presented to me by my patients.  Here is simply the most recent example given to me by a parent yesterday:

It turns out that this child, who is struggling considerably with reading, has a very classic convergence insufficiency.  Sure enough, she has exophoria at near as detected by the Eye MD.  In fact, she has 16 prism diopters of exophoria and a modest reserve to offset what would be double vision when reading if she didn’t work extremely hard to maintain single vision.  Not surprisingly her parents indicate that reading is extremely fatiguing for their daughter, and she has all but given up.  Not surprisingly, she grasps things very well when listening to someone else read.

So what guidance was this family given by the doctor?  There is nothing to be done, because this condition has nothing to do with her reading problem. When the parents related that they had learned about vision therapy from some investigating they had done, and wanted to know this doctor’s opinion of it, the advice they got was the snake oil myth. Dismissively they were told that if they wanted to do something, they should do “pencil push-ups” with their daughter.

Odd, isn’t it?  Here we have a professional claiming to be objective about optometric vision therapy, dispensing a placebo therapy for CI and trying to pull the wool over a parent’s eyes.  When will they ever learn? The circularity must end now, and you – whether you are a vision specialist or a patient – will play a huge role.  How?

I’m going to push you like my patients push me.  As Peter Finch said in his starring role in the movie Network,  I’m not going to leave you alone.  Parents of children who succeed with vision therapy get mad when they think about MDs or educators who didn’t raise the option of looking into vision therapy – or worse, deterred them from considering vision therapy.  To paraphrase Peter Finch, they want their child to be treated like a human being, whose life has value.  You don’t have to go to the window and yell, but you should be mad as hell when you encounter this double standard.  When you take action the children will blossom, the circularity will end, the Eye MDs will learn, and the double standard will end.

– Leonard J. Press, O.D., FCOVD, FAAO

When will identifying vision problems that affect learning become a new standard of care?

Why do certain well documented and frequently occurring vision problems, that have been found to affect a child’s reading, learning and attention, seemingly get overlooked as if irrelevant?  Indeed, those of us who have practiced in this field over the years have heard this all too often, “they just fell through the cracks”. Yes, a child can have 20/20 sight but still has a serious vision problem. In fact, passing the 20/20 eyesight test alone does not rule out a vision problem that can affect learning. Indeed, with well documented  research that shows a correlation between vision and learning, why isn’t it considered to be the medical/optometric “standard of care” to first rule out binocular vision disorder, accommodative disorder, oculomotor disorder and/or visual processing disorders when a child is struggling in reading, learning and/or attention and concentration?

Recently drawing a spotlight  in the medical and rehabilitation arena are the vision problems associated with concussion (mTBI). It is now well documented in neurology, sports medicine, rehabilitative medicine and optometry that binocular vision (eye teaming) disorders, such as convergence insufficiency, accommodative (eye focusing) disorders and oculomotor (eye movement)disorders are commonly linked with concussion (mTBI). As a result of these conditions a patient will experience symptoms of double vision, blurred vision at near, difficulty keeping the place when reading, poor reading fluency, difficulty with attention and concentration for reading tasks among much more. An example was published in Lancet Neurol 2014; 13: 1006–16 Neuro ophthalmology of Head Trauma.

The treatment prescribed that has been shown to successfully treat the visual problems associated with concussion (mTBI) is vision therapy as outlined in a recent paper entitled: Vision Therapy for Post-Concussion Vision Disorders

Therefore, given that these very same visual disorders occur with an even greater degree of prevalence in the general population due to delays in visual development, often negatively impacting  a child’s learning, reading and inducing behaviors of reduced attention/concentration including emotional side effects; why is there insufficient public and professional awareness for vision related learning problems?

Oh yes, there is plenty of evidence. For example, The American Optometric Association (AOA), The College of Optometrists in Vision Development (COVD) and the Optometric Extension Program Foundation (OEPF) have published numerous scholarly, evidence-based papers with descriptions and clinical practice guidelines, with one of the most notable being from the AOA entitled: Care of the Patient with Learning Related Vision Problems. Yet, in spite of the educational sphere of literature available to doctors, too many children senselessly struggle due to undetected and unaddressed developmental vision problems.

Is it possible that the attention of the optometric and medical community as a whole needs to have a “blow to the head” to realize that vision problems can frequently exist even without having a concussion (mTBI)?  And is that “blow to the head” metaphorically brought about by someone outside of the optometric  and medical community such as a professional who works in the educational community and also has personally seen and felt the impact of these conditions?

Would the wakeup call for doctors occur when the message comes from the well articulated words of an allied professional who has lived with the problem and witnessed the results of  vision therapy in the life of her own child? Wendy Rosen is an education consultant specializing in vision-related learning problems, metacognition, and environmental education and wrote the new book, The Hidden Link Between Vision and Learning, Why Millions of Learning-Disabled Children Are Misdiagnosed. Listen to an interview with Wendy Rosen along with Jason Flom, director of Cornerstone Learning Community in Tallahassee, Florida, on Student Centricity by Rae Pica by clicking here.

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How many children’s lives must be affected before the “standard of care” becomes looking for the cause instead of blaming the behavior? The time has come to end the senseless struggle of developmental vision problems with proper diagnosis and appropriate evidence-based treatment.

Dan L. Fortenbacher, O.D. FCOVD

Through the Looking Glass

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”
“The question is,” said Alice, “whether you can make words mean so many different things.”

through-the-looking-glass

Ever notice how physicians and third parties mean so many different things when referring to “scientific evidence”?  We’ve heard the refrain many times, regarding optometric vision therapy, that there isn’t sufficient evidence that it works.  And you know from reading this blog that now that the CITT has presented an airtight case for the significant superiority of office based vision therapy to other treatment modalities, which fare not better than a placebo.  So now our critics have decided that they’ll yield on that, but it’s not relevant because CI is uncommon in children.  (I kid you not – we blogged about that in August.)

I was reminded this morning, when reading an article in the New York Times, that Humpty Dumpty and Alice might have easily shared their exchange regarding the double standard applied to the words”evidence based medicine”.  It’s become a familiar refrain that physicians feel very comfortable with off-label Rxing of drugs, well off the beaten path of Randomized Clinical Trials (RCTs), but think nothing of denigrating other treatment approaches because “there’s insufficient evidence that it works”

drugs

Consider the opening of the article:

Neither of the two drugs used most frequently to prevent migraines in children is more effective than a sugar pill, according to a study published on Thursday in The New England Journal of Medicine.  Researchers stopped the large trial early, saying the evidence was clear even though the drugs — the antidepressant amitriptyline (Elavil) and the epilepsy drug topiramate (Topamax)— had been shown to prevent migraines in adults.

“The medication didn’t perform as well as we thought it would, and the placebo performed better than you would think,” said Scott Powers, the lead author of the study and a director of the Headache Center at Cincinnati Children’s Hospital Medical Center.

Now here’s where the article really gets interesting.  You would think that with this data in hand from a randomized clinical trial, including the significant side effects that can accompany these drugs, physicians would be convinced to stop the off-lable use of these drugs with children.  Or at least to advise parents that using these drugs is no better than a placebo.  Not so fast … the article continues:

“Am I now going to feel obligated to tell patients that these drugs are no better than a placebo? No,” said Dr. Eugene R. Schnitzler, a professor of neurology and pediatrics at Loyola University Chicago Stritch School of Medicine.  “I’ll simply say, ‘We have data in adults that it’s effective, but less convincing data in children and adolescents.’”

Even if the drugs are not effective for children over all, “that doesn’t mean for any one individual, a drug might not work,” said Dr. David Gloss, a neurologist and a methodologist for the American Academy of Neurology.

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Don’t you just love the selective Humpty Dumpty-ism here?

Evidence-Biased Medicine: Part 2

GerdWe posed the question in Part 1 as to why so many pediatric ophthalmologists harbor a bias against office-based vision therapy, discouraging the patient from undertaking it despite the striking evidence-based medicine of the CITT.  We provided some clues from the work of Professor Gerd Gigerenzer, director of the Max Planck Institute for Human Development in Germany.  The fundamental issue, and the challenge to both Optometry and Ophthalmology, is how we help guide patients toward making good decisions.  There is one inescapable conclusion: the evidence bias against the cost and time involved in doing office-based therapy is outweighed by the value judgement of the doctor that it simply isn’t worth it.  A frank double standard.  While it was fine for Frank Sinatra to boast that he did things “My Way”, that simply isn’t good enough for eye doctors cloaking themselves in mantles of scientific concern.

 

gerd 2But let’s go beyond the obvious evidence-base for CI about which there is absolute certainty.  How do eye care practitioners typically handle other conditions such as strabismus and amblyopia about which there may be less certainty?  Gigerenzer offers insights about such heuristics from his Edge conversation: “Still, medical societies, individual doctors, and individual patients either produce the illusion of certainty or want it. Everyone knows Benjamin Franklin’s adage that there is nothing certain in this world except death and taxes, but the doctors I interviewed tell me something different. They say, “If I would tell my patients what we don’t know, they would get very nervous, so it’s better not to tell them.”

Take for example a recent case in our office involving refractive amblyopia.  The parents of a child came to us, referred by other parents in their neighborhood, regarding management of their son’s amblyopia.  He had previously seen a pediatric ophthalmologist who prescribed glasses for him having two significantly different powers between the eyes, accompanied by a patching regimen but no therapeutic activities.  I reviewed my findings with his parents at a separate conference during which I laid out the treatment approach of moving beyond patching and into MFBF techniques to bridge binocular integration, and then onto binocular activities to maximize outcome including depth perception.  The child’s parents seemed to grasp the difference in the optometric approach from the ophthalmologic, and proceeded to schedule vision therapy.

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At the first vision therapy session the child’s father seemed conflicted.  After our conference he went back to the pediatric ophthalmologist who said that his son was making fine progress with patching and that no other treatment was necessary.  For good measure, she increased the power in the lens of the amblyopic eye, further exaggerating the difference between the two eyes, though the family didn’t feel it was important at the time to mention it.  The father asked: “Do you really think my son needs vision therapy?  I want to do what’s best for him, but it’s very expensive and I want to make sure you feel he needs it because Dr. X said he didn’t.”

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This child’s first progress evaluation seemed to turn into a debate over whether this young boy was making progress demonstrable by “empirical evidence”.  Matters devolved from there into his parents becoming passive aggressive toward our staff, and I was left to wonder how much the pediatric ophthalmologist’s voice was in their head.  Can we graph out data and spend considerable time at each progress evaluation, or in this case even toward the end of a therapy session?  Of course, yet there has to be a happy medium between no evidence and smart clinical heuristics, in Gigerenzer’s terms.  I would love to have been a fly on the wall in the ophthalmologist’s office when she presented the data to the parents that they were demanding of us.  Did she review the PEDIG trials to establish the optimal number of hours for patching?  Was she conversant with the rich body of literature in ophthalmology journals over the past several years showing functional deficits in amblyopia that arise when visual acuity is used as the sole index of visual function, and its implications for therapy beyond patching?  Did she review the application of computerized methodologies for amblyopia therapy as pioneered by Dr. Jeffrey Cooper?  Where was the empirical evidence that the ophthalmologist’s approach was doing anything that would alter the Rx required to attain optimal outcome?  Was she conversant with the rationale that we were pursuing regarding reverse engineering hyperopic anisometropic amblyopia, as I have documented in the ophthalmic literature?

Presumably the ophthalmologist presented some sort of evidence to the parents, but exactly what it was we’ll never know.

 

 

 

 

The Interface Between Optometric Vision Therapy and Ophthalmology – Part 5

Much has changed since my serendipitous appearance on a panel organized by the Section on Ophthalmology of the American Academy of Pediatrics in 2001 detailed in Part 1.  The CITT and PEDIG studies are prime examples of movement in a positive direction regarding the interface between optometric vision therapy and ophthalmology.  More important, however, is what has not changed.  Neither the AAP nor AAPOS has had a conference similar to the one held in 2001 and were they to have one, it is highly unlikely that they would invite an optometrist to participate.  AAP and AAPOS have continued to publish policy statements intended to discredit optometric vision therapy.  And as much as these organizations claim that they support vision therapy for convergence insufficiency (CI), it has not changed the practice of ophthalmology which still relies primarily on home-based therapy reinforcing the double standard in their call for evidence-based medicine regarding optometric vision therapy for anything other than CI.

irony

One could take an optimistic view and hold open the possibility that at some point ophthalmologists and pediatricians will publicly endorse the merits of optometric vision therapy.  There are signs that this may be the case, as promoted by COVD here, and as we’ve blogged about previously here.  Yet at every turn in the literature there is irony, and the short chapter by Poonyathalang et al regarding eye exercises to accelerate recovery from ocular motor nerve palsy is simply another example.  From their discussion:

Cavin“In our study, there were 5 patients in the non-exercise group for which the recovery time was more than six months; all of them occluded their paralytic eye most of the time either with an eye patch or by squeezing their eyelids shut.  Even though these patients eventually regained almost full range of eye movement, they had persistent difficulty adjusting to the spatial environment … A few patients reported that their double vision persisted in the paralytic direction, causing difficulties especially when driving, even though their eye movements range was near complete. In those patients we found that the speed of the paralytic muscle was slower than of the conjugate muscle.  Since single vision was present in central gaze, we advised using larger head movements, in conjunction with a larger car mirror, to permit driving.  The binocular fusion mechanism normally makes it possible to point both eyes at the same visual target.  Our exercises provide visual, somatosensory, and efference copy signals so that the brain can adapt to the peripheral motor weakness and induce ‘spread of con-comitance’.  Thus, our eye exercises may have sped up the spread of con-comitance, which is part of the natural course of recovery from ocular motor nerve palsy.”

bridgemanNow the irony.  Let’s presume that following one’s finger toward the field of action of a nerve palsy or paretic muscle can help improve range of motion.  There may be visual and somatosensory feedback, but there isn’t much in the way of efference copy.  An article by Bruce Bridgeman calls that theory into serious question.  Does the name ring a bell?  You may have come across Dr. Bridgeman’s story before – he is a vision scientist who had an epiphany similar to what Stereo Sue experienced.  In Bridgeman’s case however the recovery of stereopsis was serendipity, brought about while immersed in a graduated stereoscopic 3D movie environment.  So Poonyathalang et al are on the right track, as was our pediatric ophthalmologist who suggested that a patient do repeated eye stretches.  But why not be more proactive about developing the fusion mechanism?

hertlerichardmd2010Richard W. Hertle, M.D., co-authored a chapter EOM surgery in the same text on Infantile Nystagmus as Poonyathalang et al.  You may have heard of Dr. Hertle before, as he is the ophthalmologic Vice-Chair of the CITT study.  Hertle’s chapter concludes with the following: “At any moment in time (the fourth dimension) the ocular-motor system abnormality of INS is clinically and electrophysiologically variably expressed.  The variability of the oscillation is due in part to a combination of complex visual system and developmental-neurological modifiers. The eye movement abnormality is not present in isolation; it continuously interacts with other ocular motor, vestibular, afferent-visual system, and cognitive factors on a minute-to-minute — as well as a year-to-year — basis.  The dynamic nature of this abnormality requires that clinicians and scientists evaluated and study this disease in that fourth dimension of time.  This conceptual approach will result in a more profound understanding of the disease and how our therapy changes the visual system of these patients.”

So where do you think we are, at the Interface Between Optometric Vision Therapy and Ophthalmology?  At the cusp of breakthrough, at the cusp of catastrophe, or mired somewhere in between?

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The Deliberate Deception

aapos-logoLast year our colleague, Dr. Dan Fortenbacher and I blogged about the egregious treatment of convergence insufficiency and optometric vision therapy on the website of the American Association for Pediatric Ophthalmology and Strabismus.  You’d figure that by now, one  year hence, these physicians would have taken the time to get it right.  After all, this website is ostensibly used as a portal to deliver credible information to the public.  If you go to the public information section (“Info for Patients”) and click on Vision Therapy, you’ll find that the aapos double standard regarding binocular vision still persists.  Could this merely be an oversight, or is it a deliberate attempt to deceive the public?  After all, as influential as our blogs may be, perhaps not enough ophthalmologists who have influence in aapos are taking the facts to heart.  You decide.

From the aapos website:

1. On the topic of What is Vision Therapy

“Orthoptic eye exercises are used by pediatric ophthalmologists and orthoptists, while optometrists call it orthoptic vision therapy. When pediatric ophthalmologists and orthoptists prescribe orthoptic eye exercises the exercises are taught in the office and carried out at home.”

2. Does Behavioral Vision Therapy Work?  “Behavioral vision therapy is considered to be scientifically unproven.”

3. On the topic of Why Might a Teacher Recommend Vision Therapy

“Children with dyslexia often lose their place while reading because they struggle to decode a letter or word combination and/or because of lack of comprehension, not because of a ‘tracking abnormality’.”

4. On the topic of What Should I Do if Vision Therapy Has Been Prescribed

“Seek a second opinion from an ophthalmologist who has the experience in the care of children recommended by your pediatrician or primary care provider.”

5. Where Can I Learn More About Learning and Reading Disabilities?  “Your best source is your pediatrician or primary care provider.”

After you digest this (or get indigestion), scroll down to compare your thoughts on these 5 points with mine:

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1. Stating in the year 2013 that pediatric ophthalmologists prescribe orthoptic eye exercises taught in the office and carried out at home is a deliberate deception.  I don’t know of a single pediatric ophthalmologist in the country who conducts in-office vision therapy the way in which it was done in the gold standard CITT.  The weight of scientific evidence is therefore that what pediatric ophthalmologists pass off as vision therapy is tantamount to placebo therapy.  Not to say that placebo therapy doesn’t have its place in medicine, but be honest with the public.

2. Behavioral vision therapy is scientifically unproven?  See #1.

3. Is “dyslexia” the major reason why a teacher would suspect a child has a vision problem that can benefit from vision therapy?  Unlikely.  That’s merely the dead horse that aapos has beaten for the past 40 years with recycled Joint Policy Statements that have been thoroughly discredited.  A teacher may be concerned that a child is fatiguing with sustained visual tasks, losing concentration, or any of the 15 signs in the CI Symptom Survey, for example.  They may be on the front lines of noting signs and symptoms of convergence insufficiency.  Why should a teacher or school nurse suggest a child visit a pediatric ophthalmologist whose opinion can be given over the phone irrespective of what the examination shows?  After all, according to aapos and most of its members, vision has nothing to do with learning unless blur is sufficient due to the need for glasses, or the child is seeing double from CI and placebo therapy will be prescribed.

4. Should you seek a second opinion about optometric vision therapy from a pediatric ophthalmologist not trained in our field?  See #3.

5. The best source to learn more about learning and reading disabilities is your pediatrician or primary care provider?  Really?  I would have thought a knowledgable educator, OT, or SLP might be the best source.  Why would MDs position themselves as authorities on learning and reading disabilities, superior to developmental optometrists yet alone other professionals who interact with these ODs?  The answer in part comes from “the halo effect”, and in this case is a deliberate deception served up with the side salad illusion.

Side Salad Illusion

Here’s how it works.  Which meal seems healthier, the one with the fast-food hamburger alone, or the one with the hamburger and the side salad?  Many people will say the one with the side salad, because the salad confers a halo effect on the burger.  But the burger is still unhealthy, and the salad won’t undo the damage from the burger.  Yet somehow you feel better about swallowing it.  The burger is the aapos spin on VT, and the side salad is the pediatrician or primary care provider.

Should you happen to be a pediatric ophthalmologist reading this, we would welcome your partnership in setting the record straight.  If you’re a pediatrician or primary care provider, we would welcome your input about being positioned as an authority on these issues. If you are an allied professional or patient reading the aapos website information about VT, caveat emptor.

An Inconvenient Truth

The phrase, An Inconvenient Truth, was popularized by Al Gore regarding the environment, but could just as readily apply to new information on the website of the American Academy of Pediatric Ophthalmology and Strabismus (AAPOS).  My colleague Dr. Fortenbacher and I have have previously exposed the inadequacies in the eyecare field regarding treatment of convergence insufficiency.  One might have been optimistic to think that organized Ophthalmology would catch up with evidence based medicine about this important condition.  Apparently this is an inconvenient truth that our medical colleagues are unable to deal with.

The perfect opportunity to do so presented itself last month, when AAPOS updated its website information on Convergence Insufficiency.  Suffice it to say that when you read this information it is considerably out of step with the series of research studies published by the CITT.  We anticipated that even though the results of the CITT should be presented to patients in terms of office-based therapy giving the greatest chance of success, ophthalmologists would still try to downplay the outcome research because most are not trained or equipped to do office based therapy in the manner in which it was conducted by the CITT.

A review by the Cochrane Data Base, the agency that for years has been used by insurance companies to deny claims for optometric vision therapy, makes it very clear that office-based therapy is the treatment of choice for CI.  Evidently AAPOS feels that only Optometry has to answer to a higher authority.  But CI is not a frankfurter, and patients who are told to make the best of things when guidance tantamount to placebo therapy is dispensed deserve better.  It is time for pediatric ophthalmologists to collectively practice what they preach, and follow the guidelines of evidence-based medicine. Given what controlled studies have proven, this notion of making value judgments based on what patients can likely afford is a blatant double standard bordering on deception when it comes to how CI is to be treated effectively.  At the very least, it ignores the inconvenient truth.

– Leonard J. Press, O.D., FCOVD, FAAO

 

 

Why Isn’t There Synergry Between Optometry & Ophthalmology in Strabismus Surgery?

Another great seminar crowd on Friday, this time in Blue Ash/Cincinnati, Ohio.  Only ventured there because it was a good opportunity to have an extended weekend with our daughter, son-in-law and our beautiful trio of granddaughters who live there.  I met a therapist, Melanie, who has coordinated seminars for our colleague Dr. Hillier along with Mary Kawar, and a number of the attendees had previously been to seminars with Dr. Scheiman or Dr. Appelbaum.  There is a real thirst in sharing knowledge about vision and collaborating on cases.  It was also great because we have colleagues in the immediate area such as Drs. Greg Kitchener and Marie Bodack, and those within traveling distance such as Drs. Carole Burns and Brenda Montecalvo, who were well-known to many of the attendees.

One of the points that we touch upon during the seminar, which resonates particularly for the PTs, is why there isn’t better synergy between Optometry and Ophthalmology in the field of strabismus.

For those not young enough to remember, back in the day when physicians wore bow ties, there were serious schisms between orthopedic surgeons and physical therapists.  If you went to an M.D. for an opinion about an injury such as a muscle tear or broken bone, you would essentially be told you either needed surgery or you didn’t.  Doing physical therapy was a waste of time and money, and there wasn’t sufficient research to support it.  If you consulted a physical therapist you would be given advice on a non-surgical approach to rehabilitation, and be cautioned about the invasiveness and lack of predictable outcomes of surgery.

Ultimately the two fields got together in the best interests of the patient, and now it is commonplace to do physical therapy prior to surgery to strengthen compensatory muscles that will be relied on more heavily, and to stabilize surgical outcomes with post-surgical therapy.  The orthopedic/PT community figured this out.  Why haven’t we?

I realize the analogy may not hold tightly for various reasons, but T. Keith Lyle, M.D., a highly respected strabismologist in his day in the U.K., well understood the utility of the question.  In a seminal paper authored in a 1973 issue of Documenta Ophthalmologica, entitled Value of Orthoptics in Pre- and Post-Surgical Management of Strabismus, Dr. Lyle wrote:  “Orthoptics as far as treatment is concerned is strictly limited to certain types of cases, although in some of these it is of the most profound importance.”

Dr. Lyle gives several case reports, and emphasizes the importance of post-operative follow up including “hand-eye exercises”, and how crucial it is to insure that the child develops good use of both eyes together in addition to the advantages of cosmetically aligned eyes.

I’ve mentioned Dr. Dominick Maino a number of times in our blogs, and in particular his wonderful editorial calling on ophthalmologists to end the double standard they have in uncritically accepting surgery as primary treatment for strabismus, having essentially discarded orthoptics yet alone any understanding of optometric vision therapy.  Adding to that is his most recent blog post on MainosMemos.  After citing a research article showing failure rate of eye muscle surgery surgery in isolation, Dr. Maino writes: “As I always state when I am reporting on research dealing with strabismus surgery, I have and will continue to refer patients to have strabismus surgery when appropriate, but I usually recommend that the patient have pre and post surgical intervention vision therapy.  We need clinical trials that show the benefit of having the patient participate in a program of optometric vision therapy both before and after surgical intervention….and that when this occurs the surgery success rates actually increase.”

We couldn’t agree more.  And it makes perfect sense to OTs, PTs, and SLPs — and the orthopedic surgeons and ENTs in their fields who grasp the natural synergy between surgery and therapy in appropriate cases.  Now let’s see if we can find some pediatric ophthalmologists with the resolve to come out of the dark ages.

– Leonard J. Press, O.D., FCOVD, FAAO

 

 

 

 

 

 

An Open Letter to Dr. X

Dear Dr. X:

I’m using just one of the letters of your last name so that we can keep your identity anonymous, if you wish.  A close colleague of mine, who practices developmental optometry and vision therapy, forwarded your letter which was shared with him by a one of the local doctors to whom you wrote your open letter dated December 1, 2011.  The letter is very familiar – I’ve seen similar versions from pediatric ophthalmologists seeking to discredit optometric vision therapy and purposely confound the public.  It can be summarized quite simply by the following graphic:

Since 1972, that’s nearly 40 years now, the professional organizations to which you belong have been like a dog on a bone in this crusade to ostensibly protect the public from misinformation about vision, learning and dyslexia.  As my colleague, Dr. Dominick Maino has referenced, this is a campaign that is transparent in its hypocrisy, duplicity, and double standards.  Your letter is a perfect case in point.  You write:  “There is no scientific evidence that dyslexia is a visual disorder or that eye training or vision therapy alleviates this disorder.  Time consuming and costly vision therapy gives parents and educators false expectations for improvement.  Its high cost is unsupportable at any time, but particularly so in these difficult financial times.  I have 9 years of training in medicine and ophthalmology … I would be delighted to provide vision training for my patients if scientific evidence supported its use.  Vision therapy is extremely lucrative for those who practice it.  On occasion, children will present with convergence insufficiency, or the decreased ability to keep their eyes in the convergent position when reading.  Presenting symptoms include fatigue and blur with prolonged close work … I evaluate each child for this condition and can prescribe convergence exercises, including computer software where appropriate.”

So here we have the crux of the issue.  You resent that Doctors of Optometry are able to render lucrative vision therapy services.  After all, if there were scientific support that satisfied you, you would render the services yourself.  The fact that you have no training in optometric vision therapy is immaterial.  After all, a buck is a buck, correct?  But wait a moment.  In these economic times, as you note, parents and educators need to be safeguarded against professionals who appear to be taking advantage of the public.  I couldn’t agree more.  Parading one’s credentials in medicine and ophthalmology is not a substitute for living up to the standard of one’s own literature.  Something about the Emperor having no clothes comes to mind.  You can gain a deeper understanding of this here.  As you will note, even the approach in your letter toward treating convergence insufficiency is not supported by current research.

Permit me to share with you the perspective of an M.D. who does not have an axe to grind.  This M.D. is the mother of a child who underwent vision therapy.  She wrote the following letter to a colleague of mine who wrote a book about children who struggle with undetected or untreated vision based learning problems.  Again, I have removed the names to keep this generic:

“I just finished your book last night.  It was what I had been looking for:  a general explanation of the different types of vision problems that vision therapy helps.  Now I am better prepared to explain to parents why they should take their kid to a certain optometrist even though they had a normal vision exam at another eye doctor’s office.  Since XXXX started vision therapy and I have observed firsthand the wonderful changes that have occurred, I have lost track of how many patients I have referred to Dr.  YYYY  and two other developmental optometrists who live in our area.  I have a new purpose in life:  I will do everything within my power to educate others about vision and how vision therapy can help, including parents, teachers, and especially other pediatricians.  Someday, I hope that all doctors will have learned about the topics covered in your book and that even the ophthalmologists will refer their patients to vision therapy.  I hope the American Academies of Pediatrics and Ophthalmology rescind their joint statement against vision therapy. Thank you again for the work you have done in this area.  I know you have changed the lives of many.”

You opened your letter, Dr. X, by stating that you are frequently asked to evaluate children who are having difficulty learning to read.  That thought should be of concern to all parents who would learn by reading your letter that dyslexia simply reflects a deficiency in phonemic awareness.  If a child is struggling with reading, the answer lies in heaping more phonics.  Vision cannot possibly be a contributing factor.

Consider this.  I participate in an online professional forum through LinkedIn.  It is oriented toward Reading Teachers & Tutors involved in dyslexia.  Here, again, are the words of a mother who would find your position on dyslexia naive and uninformed:

“I have to say I am finding this thread fascinating! As the mum to a daughter with dyslexia, I can only say that for her, phonics was a failure. At the age of 11 her spelling is still appalling and her reading level is still 2 years behind her peers. Her school was teaching the Spalding method focusing on all the sounds that the letters make. This was done daily from kindy through to year 4 yet even now she still gets confused. If she tries to sound out words for her spelling, there are always elusive strange “g’s” or extra “e’s” added and as hard as she tries she just doesn’t get it. We have tried speech therapy, tutors, Fast Forword, Multi lit, and spent THOUSANDS. I am still at a loss, but have to wonder if in her kindy years she had been confronted with more of a whole word approach, would this have had any benefits at all for her?? To be completely honest, what I think would help my daughter more than anything in her struggle with this learning difficulty, is an education department who is actually willing to help her. She was exhausted from her regular homework and tutoring homework and all the other extra work that she needs to do just to keep up.”

As you can see, Dr. X., the answer to dyslexia is not always “more phonics”.  Nor is it necessarily vision therapy, as you well know from reading our policy statements.  In reality the condition is sufficiently complex to defy any singular intervention.  Your letter ends with the invitation for the recipient to contact you with any questions regarding dyslexia or vision screening.  Perhaps the most important question is why your representation of the issues are conveniently selective, and why your letter omits peer-reviewed research on the role of vision in reading.

Sincerely,

Leonard J. Press, O.D., FCOVD, FAAO

More Pediatric Ophthlamo-Spin

Dr. John Abbondanza is someone we’ve blogged about before. He is an esteemed colleague who does great work within our profession.  The CBS affiliate in Boston ran a generally nice piece about the work that Dr. Abbondanza is doing through optometric vision therapy, and we posted it on our Facebook site this morning.

The title of the piece seems a bit odd: Unusual Therapy Helps Kids Struggling In School.  It reminded me of the New York Times Sunday Magazine piece last year that painted vision therapy as controversial, citing the opinion of pediatric ophthalmologists who characteristically qualified vision therapy as “unproven”.  This position is a willful or unintended ignorance, based on a very selective review of available data.  Even if one were not aware of the science at hand, absence of evidence is not evidence of absence.  Lord knows pediatric ophthalmology has relied on this principle in advocating its own interventions, a double standard that Dr. Dominick Maino exposes in a recent editorial.

Sure enough, into the body of the story, comes this obligatory spin, from the local so-called expert compelled to question the science behind the therapy:

 “Vision therapy, in the vast majority of children, does not play a role in helping a child read,” said Dr. Melanie Kazlas, a pediatric ophthalmologist at Massachusetts Eye and Ear Infirmary and Children’s Hospital. Kazlas recommends traditional interventions like working with a reading specialist. “There is no harm in such treatments yet we don’t want the child to have a delay in having more effective treatment,” she said.  

In my experience, and that of many of my colleagues, there are two kinds of pediatric ophthalmologists who pass judgment on optometric vision therapy in the guise of expertise.  One is the ophthalmo-agnostic, the disbeliever who doesn’t know what she doesn’t know.   The other is the ophthalmo-atheist, the disbeliever who discounts any benefit to vision therapy because it has no fundamental redeeming value.  There would be no harm in these opinions if they did not delay the child from receiving more effective treatment.

This is reminiscent of an earlier post in which I cited one of my favorite New Yorker cartoons.  Two dogs handsomely dressed in a bar raise martini glasses to each other in a toast and declare:

It is not enough that dogs succeed; cats must also fail.”

It’s actually an adaptation of a quote from Gore Vidal who quipped that it is not enough to succeed, but others must fail.  Think about it for a moment.   Here we have the mother of a child who is also a student in her second grade class.  She is clearly more of an expert in education than a pediatric ophthalmologist.  Yet this teacher’s son already began to show signs of not keeping up in first grade.  If traditional educational intervention had helped, his mother wouldn’t have sought the optometrist who was ultimately able to help him thrive.

This is true of the majority of children with vision based learning problems that we see.  Their parents have been told by pediatric ophthalmologists that “everything is fine”.  They have 20/20 sight and their eyes are healthy.  They’ve already had “traditional interventions like working with a reading specialist”, as Dr. Kazlas suggests.  Yet they continue to struggle.  Even then, most pediatric ophthalmologists cannot bring themselves to admit that optometric vision therapy might be beneficial.

Yet despite the determination of “experts” like Dr. Kazlas to discount the benefits of optometric vision therapy, patients like Jacob Snoeyink find their way to doctors like John Abbondonza because parents like Marah Shoeyink can see through the thin veil of concern.

Now for another touch of irony.  The same institution (Mass Eye & Ear) housing the “expert” interviewed for this article publishes a newsletter that, three years ago, carried a front page article about a gentleman who had severe balance disorders.   He was diagnosed as having Meniere’s Disease, underwent rehabilitation therapy at the hospital and engaged in activities that help to develop his balance, such as becoming a student of T’ai Chi and Chi
Gung energy arts.  As you read the article in the newsletter you’ll gain the sense that the institution’s thinking regarding the ear is much broader than its thinking about the eye.  Perhaps there will be similar enlightenment for pediatric ophthalmology down the road, and a good place to begin would be to read the Clinical Practice Guidelines on Care of the Patient with Learning Related Vision Problems (CPG #20).  Then we’ll talk more.


– Leonard J. Press, O.D., FCOVD, FAAO