Vision therapy Qs

[siliso]

Looking for some insight as an ignorant MD - a patient was recommended for an “in depth vision assessment” and evaluation for vision therapy due to deficits noted on neuropsych testing in visual attention and visuospatial components of an IQ battery. Per standard eye exam by local OD, their visual acuity is perfect and no sign of ocular disease, but apparently that’s not the question. Who would one refer to and what kind of testing/treatment might be recommended in such a case? Any resources you could point me to for learning more about this?

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[hnines]

You are looking for a functional or developmental optometrist. In the exam, they do more than check eye health and acuity - they look at focusing abilities, eye teaming, and tracking. They can also do visual perceptual testing (which it sounds like your patient needs) to examine how a person is processing visual information. You can find functional ODs on www.covd.org with a zip code search. I'm a vision therapist currently, so feel free to ask other questions if you want more info!

 

[Snakedoctor1]

The above response is absolutely correct. I'm an Optometrist and I work at a vision therapy practice. Please let me know if you have further questions. Developmental Optometrists are ODs who choose to specialize in vision therapy. As with most areas within Optometry, there is no official "specialization" although many have completed residencies in binocular vision clinics, and some are fellows of the College of Optometrists in Vision Development.

 

[backrow]

Looking for some insight as an ignorant MD - a patient was recommended for an “in depth vision assessment” and evaluation for vision therapy due to deficits noted on neuropsych testing in visual attention and visuospatial components of an IQ battery. Per standard eye exam by local OD, their visual acuity is perfect and no sign of ocular disease, but apparently that’s not the question. Who would one refer to and what kind of testing/treatment might be recommended in such a case? Any resources you could point me to for learning more about this?

Please save your patient from paying thousands of dollars out of pocket and refer them to a pediatric ophthalmologist (even if they are an adult) which will be covered by their insurance.

 

[siliso]

Thanks for the advice. I’m having trouble figuring out whether even the theoretical backbone of vision therapy is evidence based in terms of functional outcomes. If it is, why would insurance, medical or visual, exclude it? I’m concerned to refer to a vision-therapy profit center suspecting that a costly and uninsured treatment plan may be recommended to anyone who presents. Would be helpful to know what fraction of persons presenting they evaluate as normal and not in need of treatment.

 

[Dusn]

Vision therapy is quackery. As an ophthalmologist, I applaud your local OD for telling the patient that their vision and eyes were perfect and not trying to scam money out of an overly anxious patient.

 

[KHE]

Vision therapy is quackery. As an ophthalmologist, I applaud your local OD for telling the patient that their vision and eyes were perfect and not trying to scam money out of an overly anxious patient.

95% of vision therapy is completely legitimate and effective.

The problem is, the 5% that is goofy is what gets all the attention.

 

[Dusn]

95% of vision therapy is completely legitimate and effective.

The problem is, the 5% that is goofy is what gets all the attention.

Please feel free to provide a link to some randomized, non-anecdotal studies demonstrating the effectiveness of vision therapy for anything but convergence insufficiency (and even there the patient can do simple pencil pushups on their own without having to pay money for vision therapy). Siliso, please feel free to ask about this on the ophthalmology board. Unfortunately asking the question here is the equivalent of me going to the chiropractic message board and asking how spinal manipulation treats diabetes.

This is a pretty good explanation of the lack of science involved in vision therapy:

https://sciencebasedmedicine.org/vision-therapy-quackery/

 

[KHE]

Please feel free to provide a link to some randomized, non-anecdotal studies demonstrating the effectiveness of vision therapy for anything but convergence insufficiency (and even there the patient can do simple pencil pushups on their own without having to pay money for vision therapy). Siliso, please feel free to ask about this on the ophthalmology board. Unfortunately asking the question here is the equivalent of me going to the chiropractic message board and asking how spinal manipulation treats diabetes.

This is a pretty good explanation of the lack of science involved in vision therapy:

https://sciencebasedmedicine.org/vision-therapy-quackery/

You are equating vision therapy, which is completely legitimate with "behavioral optometry" which is more dubious.

 

[siliso]

Tell me more about completely legit vision therapy? Any links to studies or evidence based guidelines? What are the indications?

 

[Snakedoctor1]

Vision therapy is used to treat anything under the umbrella of binocular vision dysfunction. Convergence insufficiency is the most studied and most common of these conditions. Accommodative dysfunction and oculomotor dysfunction are also very common, and very treatable. These conditions almost invariably go hand in hand. Many cases of strabismus and amblyopia can also be improved with vision therapy. This is common Optometry school curriculum, and is taught to every graduating OD in the country, and is therefore within the purview of Optometry.

Indications for a binocular vision evaluation include: headaches/eye strain/double vision during visually demanding activities, lack of depth perception, cosmetic misalignment of the eyes, reduced visual acuity etc. An Optometrist should be more than capable of differentiating between cases which may be helped by vision therapy, or whether a different course of action is indicated such as a surgical referral, patching, change in glasses Rx, or whether the cause is pathological.

Visual perceptual difficulties are less easily measured, and not as well understood. I see no harm in attempting to improve these areas with currently available resources, as long as the patient understands what is being treated, and what isn't.

The article posted above about vision therapy quackery assumes false premises, so let me make them clear: There is no evidence that vision therapy treats learning disabilities, ADD, ADHD, Autism Spectrum Disorder, or any other behavioral problem, and those who make these claims are misrepresenting a relatively well-understood aspect of Optometry.

Optometrists who practice vision therapy are often referred to as developmental, or behavioral Optometrists. This can be a bit misleading, because we are not treating "behavioral issues" as most people understand them. We are using techniques which improve visual coordination in order to treat conditions such as the ones I've already listed.

More research is definitely needed. For those who condemn vision therapy because of the lack of gold standard studies, I would ask how much of commonly practiced medicine is actually backed by a randomized controlled trial. I think you'll find that if we were to eliminate all aspects of healthcare which are not backed by gold-standard research, there wouldn't be much left.

In the mean time, I will use the knowledge I have to treat the conditions I know how to treat. As an eye doctor, that is my responsibility. My patients will continue to benefit from my services, and I will continue to eliminate diplopia, visually-induced headaches, eye strain and fatigue, visual suppression, ocular motility/alignment, etc.

Without a good understanding of binocular dysfunction, a person is unlikely to understand the purpose and potential benefits of vision therapy. It's easy to dismiss a thing we know next to nothing about. So I challenge detractors to come up with an argument other than "not enough research, therefore quackery" and "you can't treat autism with vision therapy."

You may find this link to be somewhat helpful: https://www.add-adhd.org/pdfs/03_sum_vt_research_Cooper.pdf

 

[siliso]

The assessment from PsyD was the kid has ADHD -but- should have a specialized vision assessment from a specifically named provider to...I guess make sure it wasn’t an eye problem making them inattentive and distractible? If a pt had no visual/headache/eyestrain complaint and a normal standard vision screening/optometric exam would you agree further eval not needed @Snakedoctor1 ?

 

[Snakedoctor1]

The assessment from PsyD was the kid has ADHD -but- should have a specialized vision assessment from a specifically named provider to...I guess make sure it wasn’t an eye problem making them inattentive and distractible? If a pt had no visual/headache/eyestrain complaint and a normal standard vision screening/optometric exam would you agree further eval not needed @Snakedoctor1 ?

If the PsyD is worried about visual-perceptual problems, and the specifically named provider was planning on testing further to determine whether or not these deficits show up on other testing, or whether there is a concurrent binocular vision issue, then I don't see the harm. However, if the patient is under the impression that the treatment of these visual-perceptual difficulties may somehow treat the underlying ADHD, or that the ADHD has been mistakenly diagnosed, then I think they would be getting evaluated for the wrong thing.

I have treated many patients with various binocular vision problems who also have ADHD, as well as other behavioral and neurological issues. There is no evidence for a causal relationship that I am aware of, and we are careful to educate our patients about what we can treat, and what we can't. If a patient has a measurable vision problem that may be treated with therapy, then that is another barrier removed for that patient. If that vision barrier happens to be a major detriment to their school performance, then the improvement in reading/school performance may be significant. This doesn't mean the behavioral/neurological issue was fixed, or even improved with vision therapy. It just means vision may have been a part of the puzzle.

Without any obvious visual symptoms, it may not be worth the time and money to go through the various testing batteries, since it will be hard to determine whether or not treatment will result in anything tangible for the patient. It really depends on the patient, what tests have been done, and what testing the named provider intends to do.