"vision therapy" article from New York Times

SDN Members don't see this ad. (About Ads)

Found the article interesting, and I was wondering what some of the Ophthalmologists who browse here think. Don't forget to look at the comments. Most of the optometrists mentioned in the article start posting.

http://www.nytimes.com/2010/03/14/ma...4vision-t.html

Originally Posted by bungo

Found the article interesting, and I was wondering what some of the Ophthalmologists who browse here think. Don't forget to look at the comments. Most of the optometrists mentioned in the article start posting.

http://www.nytimes.com/2010/03/14/ma...4vision-t.html

Obviously this thread is likely to get contentious quickly but as an optometrist who does SOME vision threapy, I will say the following:

Vision therapy is kind of like chiropratic. 90% of it is totally legitimate, and 10% of it is pretty wacky. Unfortunately, it's often the 10% that gets all the attention. Much like there's chiros out there claiming to cure cancer and MS by spinal manipulation, there's some wacky VT guys out there claiming that they can cure your autistic kid by having them hop and down on a balance beam wearing different strength prisms.

So leaving out that wackiness, I believe that VT is an effective legitimate treatment for many things. Most optometrists have seen all kinds of kids benefit TREMENDOUSLY from VT after years of being told by educators, psychologists, pediatricians, teachers, special ed people, neuro-psych people et al that "there's nothing wrong with you." "You're just lazy."

I basically agree with Guyton on this statement:

Originally Posted by Guyton

At base, the dispute comes down to the fact that behavioral optometrists and pediatric ophthalmologists define what constitutes a diagnosable level of problems like convergence insufficiency differently. “The two professions can’t talk to each other because their basic definitions are so different,” Guyton says.

Guyton says that many of his colleagues in ophthalmology can be too categorical in condemning vision therapy, which he says can be of real value in helping patients overcome a number of eye problems. The trouble is, he says, behavioral optometrists overstate their claims, generalizing, for example, from the evidence that vision therapy works for convergence insufficiency to validate all that they do. “You really can’t validate by association,” Guyton says.

I've seen dozens of children with convergence insufficiency told by pediatricians ophthalmologists, even other optometrists "there's nothing wrong" or "they don't have CI."

And when you do one quick near point convergence test on them, yea, it might be normal. But try repeating it a couple of times. Or do a couple of tests that require sustained convergence at 16 inches on these children and it's a catastrophe. No small wonder they have "ADHD" or can't read. If I got transient diplopia or a headache after 30 seconds of sustained convergence, I'd probably avoid reading or start bugging the kid sitting to me too.

So does VT cure ADHD? Of course NOT. Does VT cure learning disabilities? Of course NOT. Do these things sometimes get misdiagnosed? Oh yea.

I've also seen all kinds of kids diagnosed with any one of a host of learning problems/ADHD who after years of intervention at school or occupational therapy or speech/language therapy, nothing has improved. After 6 weeks of VT, the improvement is incredible. Why?

Because these are often the children who had an "eye exam" at the school nurse or the pediatrician's office that went something like this:

Cover your right eye. Can you see? Yes?
Cover your left eye. Can you see? Yes?

There's nothing wrong with you.

But it should be fairly obvious to anyone that calling out letters on a chart from 20 feet away, monocularly, has essentially zero bearing on whether you can read words on a page, 16 inches from your face, with both eyes open, and keep your eyes continuously focused on the page, and keep them continuously pointing at the same point on the page, and move them across the page making a whole series of minute saccadic movements that we're not really designed for all the while trying to get all of that into your head.

Remedy that problem, (which is incredibly easy to remediate) and suddenly they LOVE reading. Suddenly they have NO PROBLEM sitting at their desk in the 3rd or 4th grade for most of the morning. Suddenly the 1/2 hour of homework takes 1/2 hour, instead of the previous nightly 2 1/2 hours of whining, complaining, nagging, avoiding, threatening, grounding, punishing, rebelling aggravating nightmare for kids and parents alike.

So is VT utopia? No. Of course not.

Is VT highly effective for the things it's effective for, and can it have a tremendous impact on people's lives? 100% for sure.

I will also say that in my office, I do NOT charge "thousands of dollars" for VT and I do NOT keep patients in therapy for 20, 30, 40 weeks at a time. We've all seen the patients going through these incredible therapy programs that have lasted years on end with minimal or marginal improvement in academic performance.

The vast majority of the patients that I take on get substantial remediation of their problems within 12 weeks. I get a fair amount of referrals for VT evaluations and I can honestly say that I actually refer MORE of those patients out for family counseling/therapy than I agree to do actual VT on. You can almost always tell within a 15-20 minute exam and discussion with mom and/or dad (preferably both) in the room that the family dynamic is TOTALLY dysfunctional.

Most of what I prescribe for the patients I DO take on involves 15-20 minutes of home therapy a day and a 1/2 hour office visit every week for the first four weeks and then alternating weeks for the remaining 8. Most major medical plans in my area will cover 4-6 office visits. So the most out of pocket expenses that the vast majority of my patients have comes out to 4 1/2 hour office visits which usually comes out to a few hundred bucks.

So I don't get the "thousands of dollars." I can only fantasize about that. lol

So here we go......let the great debate begin. Hopefully it can remain civil on both sides.

Thanks for the opinion KHE. Civility would be appreciated. There are enough inflammatory comments on both sides over at the nytimes website.

Originally Posted by KHE

So I don't get the "thousands of dollars." I can only fantasize about that. lol

An optometrist at Costco giving a free eye exam said that my 6 year might have eye-teaming issues, and recommended a vision therapist. We went to the therapist, and after an evaluation, they recommended a course of treatment involving 30-40 visits, at $100 each, none of which is covered by our insurance (Anthem).

Besides the fact that that is $3-4K, I was extremely surprised to see that recommendation (leaving entirely aside the fact that my son doesn't have problems with reading, paying attention, etc., beyond what is age appropriate). 30-40 visits? Not something like "come in for a few visits, and we'll check in and take it from there." I almost expected to be offered a discount for paying up front.

This is apparently a very busy office in my area.

Is it just me, or does this treatment plan give you concern as well?

thanks, Michael

Originally Posted by terekita

An optometrist at Costco giving a free eye exam said that my 6 year might have eye-teaming issues, and recommended a vision therapist. We went to the therapist, and after an evaluation, they recommended a course of treatment involving 30-40 visits, at $100 each, none of which is covered by our insurance (Anthem).

Besides the fact that that is $3-4K, I was extremely surprised to see that recommendation (leaving entirely aside the fact that my son doesn't have problems with reading, paying attention, etc., beyond what is age appropriate). 30-40 visits? Not something like "come in for a few visits, and we'll check in and take it from there." I almost expected to be offered a discount for paying up front.

This is apparently a very busy office in my area.

Is it just me, or does this treatment plan give you concern as well?

thanks, Michael

There are certainly issues out there that would warrant that kind of treatment schedule but it would be unlikely (at least, IMHO) to see something like that in an asymptomatic child who is on grade level.

The exception would be is that I have seen some patients who are doing well in school but they have these high strung, uber over achieving parents who are stressing out that the kids are getting A-s and not A+s in their elite boarding schools so they have seen these vision therapy "gurus" who do this kind of intense therapy to get the kid from that A- to the A+.

Most of us would regard that as unnecessary but I guess the best analogy would be like taking your local club pro, scratch golfer and turning them into a PGA tour powerhouse with intense practice and therapy techniques.

I don't do that type of thing. If the child is on grade level, and the school or the parents aren't stressed about the kids performance, then I generally do not intervene.

It's interesting that two separate doctors brought the issue up and the one at Costco would not seem to have anything personal to gain from making an unneeded referral so clearly they thought enough of it to refer.

In your mind, what is "age appropriate" with respect to your son's reading and attention ability and what did this therapist suggest was the cause and how did they expect the therapy to remedy the perceived issue?

During residency, I saw one 5 year old w/ a long history esotropia (and of course amblyopia) who was treated for several years with vision therapy before his parents finally brought him to see an ophthalmologist. Those cases are rare, but they leave a pretty bad taste in your mouth. This case was a bit strange though b/c both the kid's parents were optometrists.

Originally Posted by Mirror Form

During residency, I saw one 5 year old w/ a long history esotropia (and of course amblyopia) who was treated for several years with vision therapy before his parents finally brought him to see an ophthalmologist. Those cases are rare, but they leave a pretty bad taste in your mouth. This case was a bit strange though b/c both the kid's parents were optometrists.

What was strange about waiting? The kid was 5y/o, still within the age range to have his amblyopia "reverse." I would have postponed surgery also unless the ET was very high. Remember, surgery doesn't correct amblyopia...

The ophthalmologists that I have seen that are staunch against VT because they are not trained in the area (other than pencil-pushups) and therefore can not be considered an "expert" anymore; just my observation...

Originally Posted by Meibomian SxN

What was strange about waiting? The kid was 5y/o, still within the age range to have his amblyopia "reverse." I would have postponed surgery also unless the ET was very high. Remember, surgery doesn't correct amblyopia...

Amblyopia can be treated but not necessarily reversed. If you let a 2-3 year old kid go on for several years with an ET, he could easily have permanent damage done to his visual system. Patching at that point will help it but not reverse it.

As an extreme example, a lot of pediatric ophthalmologists are now recomending doing surgery for cataracts at 1 week if possible. Of course sensory deprivation amblyopia is much worse than strabismic amblyopia. But the point is that the amblyopia can do permanent "brain damage" if not treated promptly.

Originally Posted by Mirror Form

Amblyopia can be treated but not necessarily reversed. If you let a 2-3 year old kid go on for several years with an ET, he could easily have permanent damage done to his visual system. Patching at that point will help it but not reverse it.

As an extreme example, a lot of pediatric ophthalmologists are now recomending doing surgery for cataracts at 1 week if possible. Of course sensory deprivation amblyopia is much worse than strabismic amblyopia. But the point is that the amblyopia can do permanent "brain damage" if not treated promptly.

Surgery is more often a cosmetic solution to amblyopia. Unless the strabismus is high, simply correcting the refractive error and simple VT are gold standard. The "brain damage" done at the 2-3yo level is not as severe when coupled with a corrected refractive error and VT, as opposed to letting a myopic 2-3yo go years being uncorrected.

But now I have to agree, years with no resolution is crossing into the stubborn zone.

Originally Posted by terekita

An optometrist at Costco giving a free eye exam said that my 6 year might have eye-teaming issues, and recommended a vision therapist. We went to the therapist, and after an evaluation, they recommended a course of treatment involving 30-40 visits, at $100 each, none of which is covered by our insurance (Anthem).

Besides the fact that that is $3-4K, I was extremely surprised to see that recommendation (leaving entirely aside the fact that my son doesn't have problems with reading, paying attention, etc., beyond what is age appropriate). 30-40 visits? Not something like "come in for a few visits, and we'll check in and take it from there." I almost expected to be offered a discount for paying up front.

This is apparently a very busy office in my area.

Is it just me, or does this treatment plan give you concern as well?

thanks, Michael

Yes, this treatment plan would concern me; especially if the child had no complaints of anything other than a refractive error.

But that's no different than PCPs diagnosing HTN & diabetes on a first visit, or like when my dentist insisted I needed a filling for the smallest little cavity!

Originally Posted by KHE

In your mind, what is "age appropriate" with respect to your son's reading and attention ability and what did this therapist suggest was the cause and how did they expect the therapy to remedy the perceived issue?

Thanks for your thoughtful reply. The main issue with my son's reading, and it is an infrequent one, is that he sometimes loses the line that he's on. Many other six year olds that I've observed lose the line with similar frequency, so it's on that basis that I consider it "age-appropriate."

Incidentally, he enjoys reading very much, and in no way tries to avoid situations where reading is required.

The optometrist at Costs said he had convergence insufficiency, as did the therapist.

Now, my son has mentioned things like his vision going "pixelated," but it's hard to know exactly what he means. He also has an intensely active imaginative world. Based on other things that he has reported, we don't really know how to assess these self-reports.

I guess I'm left with this question: if a child doesn't have significant problems reading, and if there are no other symptoms beyond the self-reported and fairly nebulous statements, should we be wary of a practice that recommends such a treatment schedule?

First, I agree you shouldn't diagnosis HTN on one visit, DM yes you can, and the dentist thing well that is why they make more than we do.

Second, where are we getting the data that says VT is the gold standard??

Lastly surgery is part of the spectrum to "treat amblyopia", any good peds ophtho will always do glasses and patching first before considering surgery.

Oh did forget this part, VT probably has its place and I bet it actually does help but the many quacks (pay 100 visit for 40 visits for CI) give it a bad name. Just like the kiddo I heard of one time getting hyperbaric O2 for his ET

Originally Posted by terekita

Thanks for your thoughtful reply. The main issue with my son's reading, and it is an infrequent one, is that he sometimes loses the line that he's on. Many other six year olds that I've observed lose the line with similar frequency, so it's on that basis that I consider it "age-appropriate."

Incidentally, he enjoys reading very much, and in no way tries to avoid situations where reading is required.

The optometrist at Costs said he had convergence insufficiency, as did the therapist.

Now, my son has mentioned things like his vision going "pixelated," but it's hard to know exactly what he means. He also has an intensely active imaginative world. Based on other things that he has reported, we don't really know how to assess these self-reports.

I guess I'm left with this question: if a child doesn't have significant problems reading, and if there are no other symptoms beyond the self-reported and fairly nebulous statements, should we be wary of a practice that recommends such a treatment schedule?

I wouldn't use the term "wary." My experience with most intense VT practitioners is that they are not charlatans. They are true believers so I would bet that this practice/doc actually does feel that that is an appropriate course of action for your son.

That being said, the case sort of speaks for itself. In the absence of any significant reading issues or concerns from the school, I would not pursue that course of treatment for my son.

Convergence insufficiency certainly can cause a child to lose place while reading but so can a whole slew of things. If a 6 year old is supposed to be able to read for 10 minutes, and he loses his line with the same frequency after one minute of reading as he does after 8 or 9 minutes, and that loss of place rate is age appropriate, I wouldn't lose sleep. If it's substantially worse after 8 or 9 minutes as compared to one, then some intervention may be considered but usually not 40 sessions. For cases like that in my practice, I usually give about 10-15 minutes per day of home training for about 10-12 weeks with maybe one office based session a month.

Symptoms of CI in small children can often be remedied by just showing them and reminding them of proper reading posture. Kids (all kids) have a natural tendency when they read to put the book on the floor and then put their nose on the book. Whether you have CI or not, that's not ergonomically correct and for CI it's obviously a lot worse.

The self-reported symptoms can be from CI but again, can also be from an active imagination.

If that were my child, I would just monitor it closely. My experience has been that issues like CI and saccadic deficits tend to really manifest themselves around the 3rd grade when the reading material goes from picture books to chapter books, and when the schools seem to shift from "learning to read" to "reading to learn."

Once that happens, the reading demands go way up and that's when you start seeing the kids who are "smart" and "used to love reading" but now are "lazy." Reading that used to take 10 minutes now takes 1/2 hour and the amount of whining skyrockets. Usually these kids are very good at math because there isn't the same level of visual demand to attend to a work sheet of 3rd grade math problems than there is to attend to a 3rd grade chapter book.

These kids also tend to be tremendous auditory learners. If you tell them a story, they will have a college level discussion with you about it. If they READ the story themselves, they can't remember anything they read after they finished reading it.

Originally Posted by terekita

Now, my son has mentioned things like his vision going "pixelated," but it's hard to know exactly what he means. He also has an intensely active imaginative world. Based on other things that he has reported, we don't really know how to assess these self-reports.

maybe look into visual snow - http://en.wikipedia.org/wiki/Visual_snow

Originally Posted by Meibomian SxN

Surgery is more often a cosmetic solution to amblyopia.

Surgery for young children with strabismus is not cosmetic. It has been shown to improve visual outcome. The long standing gold standard is:
1. tx refractive error
2. tx ambylopia
3. then tx any signficant residual strabismus with surgery

KHE, thanks so much--that is extremely informative and helpful! And thanks, DrMassacre, for the visual snow tip.

Originally Posted by Meibomian SxN

Surgery is more often a cosmetic solution to amblyopia. Unless the strabismus is high, simply correcting the refractive error and simple VT are gold standard. The "brain damage" done at the 2-3yo level is not as severe when coupled with a corrected refractive error and VT, as opposed to letting a myopic 2-3yo go years being uncorrected.

Surgery for strabismus is certainly not cosmetic, especially in kids, and it is not the treatment for amblyopia, patching is. Observing for too long can certainly cause permanent visual damage, particularly when it comes to developing binocular vision. I'm not sure I would call VT the "gold standard" without the support of most pediatric ophthalmologists or clinical trials.

To echo previous posts, in the right patient and in the hands of the right practitioner, VT may work very well.

Originally Posted by Mirror Form

Surgery for young children with strabismus is not cosmetic. It has been shown to improve visual outcome. The long standing gold standard is:
1. tx refractive error
2. tx ambylopia
3. then tx any signficant residual strabismus with surgery

Exactly! So as you have kindly pointed out, surgery is always the last option. Surgery is a cosmetic fix, it allows alignment but not treatment of the amblyopia. If you were to correct an ET with just surgery, the eyes will be aligned but most likely the brain will choose the non-amblyopic eye for vision.

Originally Posted by MstaKing10

Surgery for strabismus is certainly not cosmetic, especially in kids, and it is not the treatment for amblyopia, patching is. Observing for too long can certainly cause permanent visual damage, particularly when it comes to developing binocular vision. I'm not sure I would call VT the "gold standard" without the support of most pediatric ophthalmologists or clinical trials.

To echo previous posts, in the right patient and in the hands of the right practitioner, VT may work very well.

Sorry, when I said VT as gold standard, I catergorize patching under VT therapy because it takes often many f/u's; so I'll take it out for this conversation.

It is better stated surgery is a treament for strabismus, not amblyopia.



Look up professor

Some of you seem to be talking about different things. Let's clarify terms here:

1. Amblyopia is improper development of the visual pathways of one or both eyes.
2. Strabismus is improper alignment of the eyes.
3. Stereopsis is 3-dimensional vision attained by cortical comparison of slightly disparate images from each eye.
4. Fusion is alignment of images from each eye (different from stereopsis).

Surgery can improve the latter 3 (see J Pediatr Ophthalmol Strabismus. 1995 Nov-Dec;32(6):353-7), but not amblyopia. Amblyopia can only be improved by patching or penalization, thereby forcing the visual pathways of the "lazy" eye to develop more properly. Of course, bringing the eyes into proper alignment with surgery may counter future suppression and worsening of amblyopia, once the amblyopic eye has improved.

Visionary, great post. You summarized it well and there is certainly some confusion in the prior posts. It is important to remember that monofixation syndrome (central suppression with peripheral fusion) is often the goal following strabismus surgery and is viewed as a successful outcome, even if there is a small angle residual tropia (< 8-10 PD). This results in a smaller suppression scotoma and better function than if you just let the eye remain deviated as suggested in some of the prior posts.

Originally Posted by Visionary

Some of you seem to be talking about different things. Let's clarify terms here:

1. Amblyopia is improper development of the visual pathways of one or both eyes.
2. Strabismus is improper alignment of the eyes.
3. Stereopsis is 3-dimensional vision attained by cortical comparison of slightly disparate images from each eye.
4. Fusion is alignment of images from each eye (different from stereopsis).

Surgery can improve the latter 3 (see J Pediatr Ophthalmol Strabismus. 1995 Nov-Dec;32(6):353-7), but not amblyopia. Amblyopia can only be improved by patching or penalization, thereby forcing the visual pathways of the "lazy" eye to develop more properly. Of course, bringing the eyes into proper alignment with surgery may counter future suppression and worsening of amblyopia, once the amblyopic eye has improved.

A significant amount of strabismus and lack of fusion can LEAD TO amblyopia. Therefore correcting strabismus is typically part of the gold standard treatment plan for amblyopia. I dont' know too many people who recommend long term patching of a young child with strabismus instead of surgical correction.

Originally Posted by Mirror Form

A significant amount of strabismus and lack of fusion can LEAD TO amblyopia. Therefore correcting strabismus is typically part of the gold standard treatment plan for amblyopia. I dont' know too many people who recommend long term patching of a young child with strabismus instead of surgical correction.

Perhaps it's the wording, but your post seems to suggest that surgery alone can actually treat amblyopia. That is clearly incorrect. Suppression, not strabismus, causes amblyopia (point of fact: alternating fixation). If it is going to occur, suppression and at least some degree of amblyopia are usually present by the time a strabismic child first presents to an eye care professional. Surgery is, therefore, never going to prevent amblyopia. Neither does it directly treat it. Surgical correction can improve stereopsis and fusion, which can counter suppression and, in turn, keep amblyopia from worsening. Patching or penalization is what is required to treat amblyopia. Though you may not want to, for cosmetic/social reasons, you can have strabismus without amblyopia. That said, I am a proponent of surgical correction. It can aid treatment, as described above, and, perhaps more importantly, it can remove the unfortunate social stigma associated with strabismus.

Originally Posted by Visionary

Perhaps it's the wording, but your post seems to suggest that surgery alone can actually treat amblyopia. That is clearly incorrect.

Sorry, I guess I take it for granted that people should know the basics of how to treat kids with strabismic amblyopia. If a patient has a signficant amount of strabismus that has lead to amblyopia, and it isn't corrected by glasses and patching, then surgery is indicated.

Originally Posted by Mirror Form

Sorry, I guess I take it for granted that people should know the basics of how to treat kids with strabismic amblyopia. If a patient has a signficant amount of strabismus that has lead to amblyopia, and it isn't corrected by glasses and patching, then surgery is indicated.

I give up. There is obviously no reasoning with you.