Who Knew? Bifocals Retard Myopia After All
January 25, 2010
A good study in Archives demonstrates that executive bifocals (+1.50) do retard myopia in fast-progressing myopes among children. After 2 years, axial length was .62 and myopia about -.50 more in the single vision compared to bifocal group- statistically significant, and if true over several years, very important to public health. Time to re-think bifocals and apologize to the optometrists.
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Who knew ? Optometrists knew.I also know no one makes executive bifocals anymore. Those were discontinued several years ago. But, I routinely Rx round seg bifocals for youngsters that require it, as discovered during near testing and Hx of symptoms.
I would love to have the reference for this article. Thank you so very much for posting this.
For the folks at EyeDoc News Ophthalmology Online….Who knew?
Functional optometrists have known this since the 1930’s that’s who….some folks just never bothered to listen! I am thrilled that the research is finally catching up to the clinical insights of the pioneers of functional/developmental/behavioral optometry!
[...] news, and now even ophthalmology studies confirm that bifocals can slow down myopia progression. Eye Doc News reports that: A good study in Archives demonstrates that executive bifocals (+1.50) do retard [...]
well, i appreciate the fact that the optometrists had a good hunch. but i find it utterly frustrating that the optometric community did not conduct the kind of rigorous scientific study like we ophthalmologists did, to settle this issue. i am sure there are a bunch of studies in your literature, but nothing like the one in Archives- randomized, double-blind, placebo controlled blah blah. only those gold-standard studies can change doctors’ minds.
i have no beef with optometry. my beef is with the degree of rigorous science. you would truly be doing your profession and mine a great favor if you would conduct the same kind of scientific studies we do. ( here’s a suggestion!- do a study on “vision training” for learning disabilities, so optom’s will finally stop ruining the reputation of optometry by ripping people off with this nonsense. the academy does great research on new treatments/protocols, and publishes its opinion on its effectivenes and proof of efficacy- you guys need to do the same).
i write this with respect for your profession- please dont be offended!
Thanks for your blog information, Dr. Weitzner!! As ophthalmology doesn’t always read the latest “Journal of Behavioral Optometry”, I am not always up on “Archives”.
An interesting exchange has occurred due this article within an email list that I am involved with. The question is not whether the “plus” at near helped to slow the myopia progression but whether the tool to deliver the “plus” must be an executive bifocal? A study from the Univ of Houston comes to mind in which “plus” delivered in the form of a flat top bifocal did NOT slow the progression as much as the recent study. Alas, it would be very interesting to find out if the delivery vehicle of the “plus” made a difference. Which is best or is there a difference between an “executive”, “flat top 25″, “flat top 28″, “flat top 35″, “round seg” or progressive? What about the “height” of the bifocal – should it be at the lower limbus, lower pupil margin or in the center of the pupil? These are questions that need to be addressed in a followup study.
From another comment “you would truly be doing your profession and mine a great favor if you would conduct the same kind of scientific studies we do. ( here’s a suggestion!- do a study on “vision training” for learning disabilities, so optom’s will finally stop ruining the reputation of optometry by ripping people off with this nonsense.” I personally find this inflammatory. The CITT study was conducted by optometrists and ophthalmologists to determine if convergence related to various visual asthenopia and whether this condition could be best improved. As you know, office based vision therapy was concluded to be the best treatment. The next part of this study is to determine the relationships with learning difficulties. Rather than “rip” optometry, how about applaud the efforts by both professions to find answers? Afterall, where are the ophthalmological gold standard studies that indicate strabismus surgery is the treatment of choice for strabismus?
here’s what i want from you guys-
take 1,000 kids with learning disabilities, diagnosed by a third party.
divide them into 2 groups.
500 get vision therapy.
500 get pseudo-vision therapy.
the kids/parents do not know which their kid is getting.(blind)
after 2 years, have these 1000 kids evaluated by a third party (double blind), and see if there’s any difference.
thats the only way you can get to the bottom of this. otherwise, any study you cite is worthless. thats the kind of study we did with the bifocal. and my beef is, that is not the kind of study i hear about in your literature- and there’s no excuse, if you ask me.
the effectiveness of strabismus surgery vs. observation/glasses/exercise has been studied countless times and has been proven so many times in the literature, i cant begin to cite you the hundreds of articles. i am a little stunned you cite that as an example. its like asking if phaco has been proven to be better than couching.
a more interesting question is whether phaco is truly better than small incision extracap (popular in india)- and a good study came out about 2 years ago that showed that indeed, there was no difference! how did they prove it? they took 500 cases- 1 got phaco, one got the small incision. they measured pre-op and post-op k readings, va, and endothelial cell counts. they compared the 2 groups after 6 months. see what im getting at? do that for vision training, my friend.
You wrote: “i have no beef with optometry. my beef is with the degree of rigorous science. you would truly be doing your profession and mine a great favor if you would conduct the same kind of scientific studies we do. ” And also: “i find it utterly frustrating that the optometric community did not conduct the kind of rigorous scientific study like we ophthalmologists did, to settle this issue. i am sure there are a bunch of studies in your literature, but nothing like the one in Archives- randomized, double-blind, placebo controlled blah blah. only those gold-standard studies can change doctors’ minds.”
In reviewing the cited bifocal article, my friend, I noticed the principle investigator is an optometrist!! In fact, of the listed authors not one is an ophthalmologist. I am glad you don’t have “a beef with optometry” because this “gold standard” article is optometry driven. The authors: Desmond Cheng, OD, MSc, PhD; Katrina L. Schmid, PhD; George C. Woo, OD, MSc, PhD; Bjorn Drobe, MSc, PhD
CITT has been cited by optometry and ophthalmology as being good science. As I previously mentioned, the CITT is progressing into learning difficulties. Be patient, my friend, optometry and ophthalmology are forging forward with some wonderful work in these areas. Study foundation and progression is very complicated in these areas due to many variables. CITT brought scientifically based foundational knowledge. The future is indeed bright.
In conclusion, I would suggest a review of the bestseller, Fixing My Gaze by Susan R. Barry Ph.D., for updates regarding strabismus. This excellent book, by a neuroscientist, reviews hundreds of studies in great detail. I am sure you will find them very enlightening.
i think the fact these optom’s chose to publish in Archives and not an optometry journal just buttresses my case- namely, that optometry does not employ the same degree of scientific rigor as ophthal. i hope that can change- optometry can surely make a significant contribution to eyecare.
the vision-training thing is way, way overdue- the aao regularly comments on the scientific merit of current techniques/treatments. why is optom dragging its feet?- this vision training scam has been going on for many years. enough already- its an embarrassment to your profession. let’s see a well-designed study that makes the case once and for all, for or against. as i explained, it would be very easy to conduct a study. all you need is the will and a little money.
Kudos to Dr. Mayer for professionally addressing the disingenuous and baseless criticisms of vision therapy in this column. Consider the logic espoused here as self-serving circular reasoning at best:
1) Optometrists do not publish studies of credible scientific rigor in peer reviewed journals.
2) Oops, turns out they do; but the only reason gold standard studies are published in Archives of Ophthalmology is that optometric journals aren’t interested in studies of scientific rigor.
3) And what is the evidence for that statement? Let’s consider just one piece of evidence to the contrary, for example the seminal review paper in Optometry (Journal of the AOA) by Ciuffreda in December 2002 (73(12):735-761). What’s that you say? Don’t confuse me with the facts?
4) Let’s stick with the author’s last point. After all, if one claims that clinical interventions such as VT are a “scam” and “an embarrassment to our profession”, let’s give him the benefit of the doubt. He may simply be unaware of supportive literature. He may simply be unaware that the majority of authors in the gold standard CITT studies published in Archives are optometrists engaged in vision therapy. He may simply be unaware that optometrists engaged in vision therapy help drive the gold standard PEDIG studies published in Archives that have supported optometric clinical experiences regarding upper limits of visual neuroplasticity.
So let’s forgive the oversight. What about the AOA Clinical Practice Guidelines for Care of the Patient with Learning Related Vision Problems? Even though that is in the pubilc domain, the author is comfortable impugning an entire profession by claiming that what we do is a scam and an embarrassment.
Ah, I get it now. The author really does have the public interest at heart. Someone has to unmask these optometric infidels. After all, one wouldn’t impugn our practices unless everything done in the critic’s clinical camp has been subjected to the same degree of scientific rigor and well-designed study demanded of VT, correct?
Hmm …. let’s see. Adult strabismus surgery. Recall seeing any studies of scientific rigor before it being accepted as efficacious? Botulinum toxin as off label use of an injected poison to align eyes. Recall seeing any randomized studies? Punctal occlusion. Any prospective, double blind, randomized controlled trials before it was accepted clinically? And the list goes on.
Forgive me, but I don’t see any case being “buttressed” here.
allow me to clarify-
there is no good evidence that vision training helps in learning disabilities/dyslexia. i agree that there is some evidence that it can help in accomodative/convergence issues. the paper by ciuffreda that you cite deals ONLY with accomodative/convergence issues. since you picked this article in your rebuttal, i assume it’s your strongest proof, and i feel reassured that indeed, there is no gold standard evidence that vt helps in dyslexia/learning disabilities (in the absence of accomodative/convergence issues). if there were, you’d have to be nuts NOT to do it. i am especially disgusted by vt for learning disabilities, as i have personally seen parents go through financial hardship “to do everything for their child”, when it has not been shown to be of any use, and when eminent scientists in ophthalmology ridicule it as nonsense (and recall- we ophthalmologists have no financial incentive to discredit it, as we have nothing to offer ).
i’m not sure if dr. press is being specious or playing dumb (i say playing, as he certainly seems intelligent), but ill err on the side of specious–it is the height of speciousness, and only reinforces in my mind how weak dr. press’ argument is, to suggest that adopting vt prior to rigorous randomized studies is akin to adopting strabismus surgery or botulinum before clinical studies had been done. for crying out loud— botulinum rx, strabismus surgery, punctal occlusion- all of these things produce immediate, dramatic results. so of course they gained enormous following prior to standardized studies!! in fact, EVERY TREATMENT IN THE HISTORY OF MEDICINE HAS BEEN ADOPTED PRIOR TO STANDARDIZED STUDIES. that’s not the point, and dr. press knows it. the issue, is whether something of dubious/questionable value should be widely adopted prior to standardized studies. and here, ophthalmology has been very responsible- several treatments in recent years were not widely adopted when broached, despite the potential financial incentive- ie, laser to drusen to retard armd; macular translocation surgery; optic nerve fenestration for ischemic optic neuropathy etc. again- none of these things were widely adopted when first broached, as we had a high degree of skepticism, and the benefits did not seem dramatic. and when high quality studies confirmed that indeed, they were of no value, the matter was dropped. i wish optometry would exercise the same kind of healthy scientific skepticism.
vt has been going on for over a decade- what’s the excuse for not conducting a gold standard study to answer the question whether it is of any value for learning disability-type issues???? if you can show me a multi-center, randomized, double-blind, placebo controlled study published in a highly respected and well-known journal that proves that vt helps in learning disability/dyslexia, i would like to see it and eat my words.
I appreciate the reply, Dr. Weitzner. You wrote: “allow me to clarify – there is no good evidence that vision training helps in learning disabilities/dyslexia. i agree that there is some evidence that it can help in accomodative/convergence issues.”
Your statement, as I suspect you’re quite aware, is dogmatic. Look again at what I wrote. The document that I cited above, the AOA Clinical Practice Guidelines for Care of the Patient with Learning Related Vision Problems, addresses the role of vision therapy in learning related vision problems. Please read that CPG carefully, as the experts in Ophthalmology you mention failed to do so. We don’t posit that VT is a panacea, and we’re careful to note that it is but one dimension of a multi-faceted problem. It is available at http://aoa.org/x4816.xml. Select CPG 20, which has been revised as recently as 2008.
Equally important, much as optometrists publish in Ophthalmology journals, such as the one you cited at the outset, we publish in Learning Disabilities journals. And in that domain, the peer review process of learning specialists trumps whatever “eminent scientists in ophthalmology think”. After all, as you note below, ophthalmology doesn’t treat learning related vision problems. What then makes ophthalmologists arbiters of the efficacy of optometric vision therapy?
One of the most eminent and prolific researchers in the Learning Disabilities field is Dr. Harold Solan, an optometrist who also holds Master’s Degrees in several fields of education. Dr. Solan was head of the Learning Disabilities Unit at the SUNY College of Optometry for many years. He wrote an outstanding review paper of summarizing his scientific work in this area, the analog of the Ciuffreda paper you agree has substance. I commend that paper to you as well, and it is: Solan HA. Learning-related vision problems: How visual processing affects reading efficiency. Learning Disabilities 13(1):25-32; 2004. This is a multidisciplinary journal published by the Learning Disabilities Association of America.
The crux of your argument, Dr. Weitzner, is that you have personally seen parents go through financial hardship “to do everything for their child”, with apparently no return on investment. Isn’t that what we, in science refer to as anecdotal evidence?
Let’s be blunt. You see and hear from parents of children who, for whatever reasons, don’t have a positive outcome. In science we refer to that as being exposed to a skewed population. Much the same, we see patients who are ophthalmologic dropouts. Seeing patients with can’t wear their glasses doesn’t mean ophthalmologists can’t refract properly. Seeing a post-surgical strabismic who has had two, three, four surgeries and still can’t fuse doesn’t mean that strabismus surgery is a crap shoot. I know when they come to me it’s a skewed encounter. The difference is, I take the high road and don’t tell the patient they’ve been jobbed. Or have not been given informed consent as to how much of an art there is to strabismic surgery in addition to the science. I adopt a professional approach and that’s all we ask from Ophthalmology.
As an aside, though, I do find it paradoxical that you would characterize me as being specious. After all, it is your argument that is superficial, and I believe you’re quite aware of it — no matter how well you attempt to cloak it in a mantle of scientific concern. To wit, regarding clinical interventions by Ophthalmology not backed by scientific trials before being uncritically adopted, you write: “for crying out loud— botulinum rx, strabismus surgery, punctal occlusion- all of these things produce immediate, dramatic results. so of course they gained enormous following prior to standardized studies!!”
Not only is that poor science. It’s the height of hypocrisy. “We do it because we can tell right away it’s working”. Really, Dr. Weitzner? How long will each strabismus surgery hold? How many days of relief does punctal occlusion buy? How will we know when an off-label use of medication is efficacious? Something about glass houses and stones comes to mind. And it IS very much the point. Again, what is good enough for the ophthalmologic goose should be good enough for the optometric gander. Certainly there have been lucrative procedures in Ophthalmology that have been held to a high standard before being adopted and patients being charged outrageous sums of money.
But do you really want to go there? Let’s take a recent example more pertinent to vision therapy than what you cited. Consider so-called accommodating IOLs. Senior citizen on fixed income have to pay out of pocket, typically $5000 to the ophthalmologist for the two eyes, to have what gain from multifocal IOLs? How much accommodation can you predict, for a given patient that it will supply? Did this procedure go through the type of scientific trials you ask of VT? Is there a guaranteed outcome? Perhaps there are so many individualized cognitive factors, that doing such a study isn’t feasible. Why is it so expensive? Why doesn’t insurance cover it? Sound familiar?
The CITT gold standard study published in Archives of Ophthalmology, driven by Optometry, was 20 years in the making. Despite this, the editorial that accompanied the article tried to tone down the significance or application of the study. The CITT group will ultimately progress toward reading issues, as Dr. Mayer noted. Owing to the numerous variables in learning disability issues, the funding required to do it right is enormous. If it took CITT 20 years to get to the point where harsh critics now admit that office based therapy can offer something more than pencil push-ups, we anticipate that it will take at least another 10 or 20 years before we see the gold standard research that will presumably quell your animosity.
And when it comes, as it will, we shall equally look forward to seeing you eat your words.
1. you make a good point- that parents complaining about the lack of efficacy with their kids is anecdotal, and not science. my point, however, was not that these anecdotes “prove” anything, but rather that i have seen with my own eyes the pain of losing money to snake oil.
2. you still don’t answer why, after at least 10-15 years, the optometric community won’t run a gold standard study for vt rx of learning disabilities. we ophthalmologists have subjected far less controversial treatments to these gold standard studies, as i explained above.
3. accomodative and multi-focal iol’s have gone through brutally expensive and multi-year studies comparing them to standard iol’s, and have received fda approval based on those studies. i am stunned you don’t know that. HAH!! YOU’VE HOISTED YOURSELF ON YOUR OWN PETARD!! IF ONLY YOU WOULD SUBJECT VT FOR LEARNING DISABILITIES TO THE SAME REQUIREMENTS THAT THE FDA DEMANDED OF MULTIFOCAL/ACC IOL’S !!! THAT’S EXACTLY MY POINT!!!(man- i really nailed you on that one. sorry)
4. punctal occlusion offers immediate relief. good strabismus surgery straightens the eyes day 1 post-op; injection of avastin to the eye made neovascularization disappear in weeks; botulinum toxin to eom’s causes immediate resolution of paralytic strabismum—-what the devil are you talking about? these are all examples of therapies that gave immediate results, which is why they were adopted prior to gold standard studies being conducted. what is so difficult to understand here? these therapies cannot possibly be compared to vt for learning disabilities. yeesh.
5. what do i care if bad/incompetent/dishonest ophthal’s perform strabismus surgery that doesn’t help? that only proves that strabismus surgery by bad/dishonest/incompetent surgeons is inferior to glasses/orthoptics. SO WHAT? all i know is that excellent surgeons get remarkable results with strabismus surgery. my point here, is that vt for learning disabilities by the best friggin optometrist on planet earth is still a bunch of nonsense with no gold standard to back it up. trust me- strabismus surgery by the finest eye surgeons is undisputably the best thing a patient could ask for. so let’s not compare good orthoptics to bad strabismus surgery, ok?
6. we ophthal’s don’t have much experience treating learning disabilities with vt for a good reason – medical scientists with doctorates in neurology and vision have concluded it MAKES NO SENSE and doesn’t work!! therefore, we abandoned it. what’s your excuse?
i’m exhausted. i think any objective reader will see that my arguments are far stronger than yours. this will be my last post. i honestly wish you good luck- you seem like a well-meaning guy. just utterly unscientific.
I appreciate the left-handed compliments, Ari, as difficult as I imagine it is to acknowledge that I am making good points. You speculate that any objective reader will see that your arguments are far stronger than mine. Perhaps in a Lewis Carroll Wonderland, one can limit the public’s perception of facts by fiat. But in the real world, the marketplace will continue to support interventions that are efficacious.
Thank you for your assessment that I seem like a well-meaning guy. My patients and colleague seem to share your assessment, for which I am grateful. I honestly wish you good luck as well, though I am perplexed by the tenacity with which you’re hung up on labeling what we do as unscientific. So in the spirit of sticking to facts rather than sensationalism, let’s once again look at the substance of the arguments in your final post point by point.
1. “you make a good point- that parents complaining about the lack of efficacy with their kids is anecdotal, and not science. my point, however, was not that these anecdotes “prove” anything, but rather that i have seen with my own eyes the pain of losing money to snake oil.”
AND I HAVE SEEN THE PAIN OF PARENTS WHO, AFTER THEIR CHILD HAS EMERGED FROM STRUGGLING TO ACHIEVE, ARE PAINED that they were dissuaded from considering optometric vision therapy. The cost to the child, to the familiy, and to the system of leaving problems that could be ameliorated through VT as unresovled is immense. And bear in mind that the high majority of children that we see have already been through significant other therapies. So if what we do is merely a placebo effect, the child would have already responded to the attention that they have received from others. Snake oil, Dr. Weitzner? Please.
2. “you still don’t answer why, after at least 10-15 years, the optometric community won’t run a gold standard study for vt rx of learning disabilities. we ophthalmologists have subjected far less controversial treatments to these gold standard studies, as i explained above.”
WHAT AND WHERE ARE YOUR GOLD STANDARD STUDIES? YOU FAIL TO PROVIDE ANY GOLD STANDARD STUDIES TO SUPPORT YOUR POSITION, OR TO NEGATE MY POSITIONAs has been pointed out, the gold standard studies by CITT and PEDIG were comprised of significant optometric input. You conveniently overlook that. I will further point out that THE definitive gold standard study on CI to date, published in Archives of Ophthamlology in October 2008, began in the early 1990s as CIRS — the Convergence Insufficiency and Reading Study. But the NEI said you can’t prove that ameliorating CI has a salient effect on reading until your first prove:
a) you can measure CI
b) you can associate CI with symptoms
c) how to best treat CI
There were bio-statisticians involved from SUNY who met with me and Dr. Solan at SUNY, as well as colleagues from around the country. We went through many iterations to get the study off the ground, and CIRS was renamed CITT so that we could proceed.
3. accomodative and multi-focal iol’s have gone through brutally expensive and multi-year studies comparing them to standard iol’s, and have received fda approval based on those studies. i am stunned you don’t know that. HAH!! YOU’VE HOISTED YOURSELF ON YOUR OWN PETARD!! IF ONLY YOU WOULD SUBJECT VT FOR LEARNING DISABILITIES TO THE SAME REQUIREMENTS THAT THE FDA DEMANDED OF MULTIFOCAL/ACC IOL’S !!! THAT’S EXACTLY MY POINT!!!(man- i really nailed you on that one. sorry)
4. punctal occlusion offers immediate relief. good strabismus surgery straightens the eyes day 1 post-op; injection of avastin to the eye made neovascularization disappear in weeks; botulinum toxin to eom’s causes immediate resolution of paralytic strabismum—-what the devil are you talking about? these are all examples of therapies that gave immediate results, which is why they were adopted prior to gold standard studies being conducted. what is so difficult to understand here? these therapies cannot possibly be compared to vt for learning disabilities. yeesh.
5. what do i care if bad/incompetent/dishonest ophthal’s perform strabismus surgery that doesn’t help? that only proves that strabismus surgery by bad/dishonest/incompetent surgeons is inferior to glasses/orthoptics. SO WHAT? all i know is that excellent surgeons get remarkable results with strabismus surgery. my point here, is that vt for learning disabilities by the best friggin optometrist on planet earth is still a bunch of nonsense with no gold standard to back it up. trust me- strabismus surgery by the finest eye surgeons is undisputably the best thing a patient could ask for. so let’s not compare good orthoptics to bad strabismus surgery, ok?
6. we ophthal’s don’t have much experience treating learning disabilities with vt for a good reason – medical scientists with doctorates in neurology and vision have concluded it MAKES NO SENSE and doesn’t work!! therefore, we abandoned it. what’s your excuse?
i’m exhausted. i think any objective reader will see that my arguments are far stronger than yours. this will be my last post. i honestly wish you good luck- you seem like a well-meaning guy. just utterly unscientific.
An errant finger resulted in my last post being truncated, so I’ll continue on (something almost poetic about an errant finger here).
So to finish addressing your point #2, there were bio-statisticians involved from one of the SUNY Medical Centers with whom we met , as well as colleagues from around the country, to go through the many iterations needed to get the study off the ground, and CIRS was renamed CITT so that we could proceed. Your position that we should simply do scientific research on VT and Learning Disabilities that you would find acceptable is utterly naive. (And the public is skilled at detecting when self-proclaimed emperors have no clothes.)
3. “accomodative and multi-focal iol’s have gone through brutally expensive and multi-year studies comparing them to standard iol’s, and have received fda approval based on those studies. i am stunned you don’t know that.”
I AM STUNNED THAT YOU WOULD EQUATE FDA APPROVAL WITH GOLD STANDARD STUDIES. Are you not aware that FDA approval means only that the device is proven to be safe? FDA approval has nothing to do with the device being efficacious for specific applications.
4. “punctal occlusion offers immediate relief. good strabismus surgery straightens the eyes day 1 post-op; injection of avastin to the eye made neovascularization disappear in weeks; botulinum toxin to eom’s causes immediate resolution of paralytic strabismum—-what the devil are you talking about? these are all examples of therapies that gave immediate results, which is why they were adopted prior to gold standard studies being conducted. what is so difficult to understand here? these therapies cannot possibly be compared to vt for learning disabilities. yeesh.”
They cannot possibly be compared in YOUR mind. That doesn’t mean they cannot possibly be compared. You make a convenient demarcation between
5. what do i care if bad/incompetent/dishonest ophthal’s perform strabismus surgery that doesn’t help? that only proves that strabismus surgery by bad/dishonest/incompetent surgeons is inferior to glasses/orthoptics. SO WHAT? all i know is that excellent surgeons get remarkable results with strabismus surgery. my point here, is that vt for learning disabilities by the best friggin optometrist on planet earth is still a bunch of nonsense with no gold standard to back it up. trust me- strabismus surgery by the finest eye surgeons is undisputably the best thing a patient could ask for. so let’s not compare good orthoptics to bad strabismus surgery, ok?
6. we ophthal’s don’t have much experience treating learning disabilities with vt for a good reason – medical scientists with doctorates in neurology and vision have concluded it MAKES NO SENSE and doesn’t work!! therefore, we abandoned it. what’s your excuse?
i’m exhausted. i think any objective reader will see that my arguments are far stronger than yours. this will be my last post. i honestly wish you good luck- you seem like a well-meaning guy. just utterly unscientific.
i am too exhausted to answer all your points, most of which are utterly non-responsive.
you are ignorant of the fda’s workings- the fda demands that a medicine be proven to be safe, effective and better than current treatments/placebo in ordder to get final approval. a new expensive antibiotic that is no better than sulfa will not be approved. a new antibiotic that improves infection 10%, which is about how much placebos typically do, will not be approved. the fda typically demands gold-standard type studies for final approval (maybe you are confused– the fda only demands that it be proven safe for the first phase, not for final aproval). your vt for learning disabilities would never pass fda muster. not even close.
that is the crux of the matter, really. you talk a good game about how scientific optometry is about vt, but you guys never got around to conducting the kind of study that would pass fda approval.
ALSO, IF YOU THINK THE IMMEDIATE EFFECT OF STRABISMUS SURGERY, BOTULINUM OR PUNCTAL OCCLUSION IS IN ALL IN MY MIND AND CANNOT BE INDEPENDENTLY CONFIRMED, AND THUS NO BETTER THAN VT FOR LEARNING DISABILITY, WE REALLY OUGHT TO STOP THIS BACK AND FORTH.
lastly- i am not talking about ci or other orthoptic issues. jesus. i am talking about dyslexia/learning disabilities. and there are no gold standard studies on that. ophthalmology is full of gold standard studies for every important treatment we do- laser for diabetes(etdrs), avastin for srn(sailor,pronto..); iop lowering for glaucoma(agis, cigts…), iop lowering for ocular hypertension(ohts) jesus!! what the hell are you talking about? you don’t know that we ophthalmologists conduct these expensive multi-year gold standard studies for our treatments??
anyway- this will truly truly be my last post.
Ah, the errant finger strikes again.
As I was saying, they cannot possibly be compared in YOUR mind. That doesn’t mean they cannot possibly be compared. YOU MAKE A CONVENIENT DEMARCATION BETWEEN CONVERGENCE PROBLEMS AND LEARNING PROBLEMS THAT DOESN’T EXIST IN THE REAL WORLD. For example, the child with CI who struggles with learning, and reading in particular, because the print is unstable or doubles or fatigues easily, but can effectively grasp what someone else is reading, can often be helped rapidly and dramatically through optometric vision therapy. Just because you personally haven’t witnessed it doesn’t mean it doesn’t exist. It simply doesn’t exist to you because you haven’t seen it. One misses more by not looking than by not seeing.
5. “what do i care if bad/incompetent/dishonest ophthal’s perform strabismus surgery that doesn’t help? that only proves that strabismus surgery by bad/dishonest/incompetent surgeons is inferior to glasses/orthoptics. SO WHAT? all i know is that excellent surgeons get remarkable results with strabismus surgery. my point here, is that vt for learning disabilities by the best friggin optometrist on planet earth is still a bunch of nonsense with no gold standard to back it up. trust me- strabismus surgery by the finest eye surgeons is undisputably the best thing a patient could ask for. so let’s not compare good orthoptics to bad strabismus surgery, ok?”
NOT OK. ALL I KNOW IS THAT EXCELLENT DEVELOPMENTAL OPTOMETRISTS GET REMARKABLE RESULTS WITH OPTOMETRIC THERAPY.
Again, not your world, and not your field. Sticking to the strabismus analogy, you would serve the public well by being the expert on motor aspects of strabismus, and we’ll stick to being experts on the sensory aspects of strabismus. After all, it IS the public welfare we have at heart, isn’t it?
6. “we ophthal’s don’t have much experience treating learning disabilities with vt for a good reason – medical scientists with doctorates in neurology and vision have concluded it MAKES NO SENSE and doesn’t work!! therefore, we abandoned it. what’s your excuse?”
THIS WILL CHANGE EVERYTHING. That’s the title of a wonderful new paperback I commend to you, edited by John Brockman, and includes a number of authors who are adept in neurology and vision. In it, (p. 56), Nassim Nicholas Taleb writes that many doctors are driven by the beastly illusion of control. Taleb writes that one of the most difficult things for doctors to admit is that it is okay to decide on a course of action based on an incomplete understanding to the human body. To say, “this is the limit where my body of knowledge stops”.
From my personal experience, Ari, I can tell you that increasingly parents are tuning out ophthalmologists who carry on about VT as snake oil, and jump up and down about it being bogus, or “all they want is your money”. In fact, your lack of objectivity is having precisely the opposite effect intended. The more unreasonable your approach is, the more people suspect that you’re being irrational.
Dr. Mayer commended the book to you by Susan Barry, called Fixing My Gaze. I echo that suggestion. In the third chapter, “School Crossings”, Sue writes passionately and wisely about her struggles with learning. With incredible effort on the part of her mother to virtually home school her, she ultimately attained a Ph.D. from Princeton. She writes eloquently there, and elsewhere, about being patronized by opthhalmologists who reassured her about her visual capabilities despite three early strabismus surgeries.
Sue Barry, PhD, is the new wave, Ari. Her husband is an MD, PhD, and a retired astronaut. She knows as much about neurology and vision as any expert you would cite to supposedly prove your points. You would find it difficult to patronize her as merely another gullible consumer of VT. Read her book and the science behind it, Ari. Who knows? It might even fix your gaze.
Wow, you’re a prolific talker, Ari. Just when it appears that you’ve expended your last bullets, more blanks keep firing. Good thing I block off early morning early evening for administrative tasks. And there’s little that I find more important than dispelling errant notions of what we do. We owe that to our patients who have placed trust in our judgments.
You last wrote:
“you are ignorant of the fda’s workings- the fda demands that a medicine be proven to be safe, effective and better than current treatments/placebo in ordder to get final approval. a new expensive antibiotic that is no better than sulfa will not be approved. a new antibiotic that improves infection 10%, which is about how much placebos typically do, will not be approved. the fda typically demands gold-standard type studies for final approval (maybe you are confused– the fda only demands that it be proven safe for the first phase, not for final aproval). your vt for learning disabilities would never pass fda muster. not even close.”
MISPLACED ACCUSATION HERE. I am well aware of the FDAs workings. Let’s take the issue of LEARNING as it relates to something you may understand, which is amblyopia.
All leading researchers, Dr. Weitzner, now define amblyopia as a developmental disorder of spatial vision. The idea of improving amblyopia, even beyond what was thought to be a critical period, hinges upon understanding how the patient processes visual information. There are FDA approved devices for amblyopia therapy that prove to be nonsense. Your drug examples have much less to do with VT for learning disabilities than do device examples for amblyopia therapy. FDA approval is irrelevant when it comes to improving visual processing, presciely because there are complex, multfactorial, cognitive issues involved. Ophthalmology is re-discovering that the eye is connected to the brain. Who knows? You may decide to revisit what you’ve abdicated to Optometry.
Let me give you another pertinent example, since you dredged up the issue of drugs. Off label use of atropine penalization for amblyopia therapy. Ophthalmologists have been doing it for a hundred years. It would be easy enough to do a gold standard study for this application. Why was it not done until a few years ago? Would have been easy enough to do.
YOUR OWN COLLEAGUES ADMIT THAT YOU HIDE BEHIND A THIN VEIL OF SCIENTISM. On what basis do I say that?
PEDIG. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123:437-447. Look at the editorial that accompanied that study, and the NEI background:
“As physicians we pride ourselves in our use of scientific method to give the best care to our patients. Yet many of our daily decisions reveal us more as apprentices than scientists. We choose a particular treatment not because a clinical trial determined that it worked better, but because that is the way our mentors did it.”
Enough said.
Dr. Weitzner says:
“here’s what i want from you guys-
take 1,000 kids with learning disabilities, diagnosed by a third party.
divide them into 2 groups.
500 get vision therapy.
500 get pseudo-vision therapy.
the kids/parents do not know which their kid is getting.(blind)
after 2 years, have these 1000 kids evaluated by a third party (double blind), and see if there’s any difference.
thats the only way you can get to the bottom of this. otherwise, any study you cite is worthless.”
I am among the biggest advocates of quality optometric vision research. I agree with you that more and better research needs to be undertaken. Fortunately it is being done and will continue to to improve the quality of patient care.
However, the research you propose above will never occur and your statement clearly indicates that you have very little understanding about how optometrists approach this type of research.
Optometrist do not arbitrarily prescribe vision therapy for patients with learning disabilities. Rather, we use the best tools available to us to diagnose visual deficits, whether they be related to ocular health, refractive error, binocular vision dysfunction, or visual information processing deficits. We then make recommendations that will result in improvement or compensation of the visual problem.
This is a far cry from what you propose: truly randomly providing 2 years of vision therapy to the learning disabled. Why would we do this? What would we be treating? What would be the goals of such treatment? I suggest that your study would be unethical in that it would subject both the control and study group to treatment likely to be inappropriate for that patient.
If you’d like to propose a legitimate study design, we could consider it.
Dr. Weitzner,
You have described the upset of parents who have had unsuccessful vision therapy interventions. I’ve seen parents who were disgusted by unsuccessful strabismus surgery. I have never seen a parent who died during strabismus surgery I wonder how upset they would be if they knew that there might have been a nonsurgical alternative to the surgery and it was never mentioned to them. Children don’t die when we are unsuccessful with VT. They do die from ophthalmological care. The need for studies increases when you are killing as well as curing. As for your comments about strabismus surgery aligning eyes on the day after surgery, the real question is how many of these eyes are straight five years later. It is currous that ophthalmology largely abandoned eye exercise and went to multiple strabismus surgeries about the time that major medical insurance became readily available to pay for the surgeries. A coincidence? What is they say about casting the first stone?
Best,
David Cook, O.D.
I am an Optometrist with a Masters Degree in Psychology and in 1977 I co-authored a study (literature review) in the American Journal of Physiological Optics and Optometry (previous name) which conclusively showed that (according to studies performed by Ophthalmology) there was no foundation to the then known fact that Amblyopia could not be treated after age 6. We even traced the origin of this “knowledge” back to an offhanded statement by Chavasse in the 1880’s. It had never been proven in any research. My study was totally ignored by Ophthalmology (it was referenced in numerous textbooks in Optometry) which has recently “discovered” that amblyopia can be treated at almost any age.
So when you talk about “scientists” take a hard look in the mirror and see if you can find one there.
dr. koslowe- it is meaningless to discuss whether ophthalmology was or is guilty of non-scientific acts. no one is perfect. but at least we typically own up to it when confronted. what’s the excuse with vt for learning disability?
dr. cook.
i will not discuss conspiracy theories about 9/11 or strabismus surgery. it’s beyond ridiculous. in my own experience, i find that those who undergo strabismus surgery by reputable surgeons do very well in the long term. the strab surgeons i know are earnest, ethical doctors and could never subject a pt. to surgery if they knew or suspected that it was inappropriate, and that exercise would be just as good. it’s a pathetic argument.
dr. warford-
i remain puzzled. simply take 1,000 kids with a learning disability who in your expert opinion would benefit from vt, and then randomly assign them to some other non-vt rx and real vt. it’s simple. and trust me!- no one thinks for a second that the evidence of vt for learning disability is so compelling, that it would be unethical to deny these poor souls the beauty and majesty of vt!
“dr. warford-
i remain puzzled.”
Agreed.
“simply take 1,000 kids with a learning disability who in your expert opinion”
Of course, as an optometrist, I cannot diagnose learning disabilities. It is not within my scope of practice and I do not have any additional training outside of optometry to allow me to do this. If I did, I would be accused of malpractice.
“would benefit from vt”
This is part of the problem. Everyone can benefit from VT. It is like saying select 1000 people who could benefit from a fitness program with a personal trainer. Anyone could improve their health and fitness this way but only a percentage choose to do so. It is the same with VT. The question is not “could they benefit” but do they have a visual problem or unmet need that makes sense to take the time and effort to undergo VT. So you’ll have to be much more clear in exactly who you want in this study.
“it’s simple.”
I disagree with you on that point. But, simple or not, I am happy that vision research is progressing to help us make clinical decisions. I think you and I ultimately want the same thing – more and better optometric research – but your limited understanding of the subject results in completely unrealistic expectations.
c’mon. please dont play dumb- its aggravating.
find an expert in learning disabilities and explain to this expert which patients with learning disabilities you think will benefit from vt.
take a 1000 (make it 500- 1000 is too expensive)of those and randomize them to vt and phony vt.
dont make me laugh and imply that vt helps everybody, and so you cant randomize. i mean, c’mon. it took decades to prove that antibx don’t help ear infections- you’re telling me that vt’s effect is incontrovertible? gimme a break. trust me- when you tell ethics review board you want to withhold vt for these kids, they wont bat an eyelash.
did you know that patients were randomized to acupuncture and phony acupuncture (random needles). guess what?-no difference. yet the acupuncture people wont shut up and keep explaining how acupuncture works, and stimulates the liver and blah blah blah. and some of these acupuncture guys are serious people who are very knowledgeable in health/nutrition etc. they just are so fixated, they wont listen to reason. you guys are almost as bad with the vt for learning disabilities. stop whining, please, and do the study. you’re a smart guy!- its not that hard. and be ready to abandon it when vt is proven to be no better than placebo (remember- placebo improves everything by 10% typically- good luck beating that!) thanks!
Ari,
You’ve misunderstood most of what I’m trying to say. I’m not making excuses why the research can’t be done. I think it SHOULD be done. Other ODs are sick of hearing me advocate for more and better VT research. I’ll happily abandon any line of the therapy that doesn’t hold up to rigorous scrutiny because that will improve its overall efficacy. Heck, there are areas of VT I wish has been disprooven long ago.
My point here is that you are making yourself out to be the expert in how to design VT studies, yet with each and every post you reveal how little you know about VT and how ODs approach these problems.
Frankly, I am tired of you and MDs like you asking us prove something that we don’t claim! We don’t claim to treat learning disabilities! We claim to treat vision problems! It is very convenient for MDs to claim that VT is ineffective for learning disability cases and is therefor entirely voodoo. It allows them to do things like perform strab surgery on intermittent exotropes, in the processing turning mildly symptomatic patients into extremely symptomatic consecutive esotropes. We see this all the time and it breaks our hearts.
Ari, have you ever shadowed in a VT clinic for any length of time? I mean really taken the time to understand what VT is? I recommend it. It might give you a better perspective on what we are trying achieve with VT and why the research you request, and I agree is needed, is more difficult to produce than you claim.
Dr. Weitzner,
You don’t seem to realize that Vision Therapy is not recommended based on someone having a diagnosis of a Learning Disability. We treat patients who have diagnosable deficits in their visual skills or visual processing. No developmental optometrist I have ever met would tell you that Vision Therapy should be done on all learning disabled children.
You really owe it to your patients and to our professions to properly educate yourself as to what it is we do. As Dr. Press pointed out so well, when we see patients unhappy with the care they received by an MD, we chose the high road. We recognize that there is a place for your approach and knowledge, but that you can’t help everyone. We don’t bash you or blanketly say that strab surgery is a sham because is didn’t work for one patient. One approach cannot help everyone. We know that, it is time you began to realize that as well.
i see i need an attorney when i write here…
ok-
what i mean, is that i dont think there is any scientific evidence that vt can help any patient with a learning disability which the either you or the learning disability expert believes has a vision component.
so,
again-
team up with a learning disability professional and find 500 patients who you both believe has a learning disability due to a vision issue (except conv/acc- that i agree can be helped), that in your experience, think can be helped with vt. half get the vt, half get phoney vt. becha million dollars no difference. your other colleague makes believe this kind of study is impossible. its enough to drive a man to drink
Let me pose a question to you. Do you think double vision could in any way effect someone’s ability to learn? What about instability in the visual system that makes things move all the time? Blurry, unsteady vision? What about a child who can’t hold fixation or track a moving target? Could these problems impact learning?
Many of the children I see for Vision Training are having difficulty learning related to their deficient visual skills. THEY DO NOT HAVE A LEARNING DISABILITY that would be diagnosable by a psychologist. Many of them have been tested and DO NOT HAVE A LEARNING DISABILITY!! Many test boarder line on many tests but don’t fit into a category that lends to an LD diagnosis. We properly diagnose the root of the learning problem, fix it and learning becomes much more efficient. In children who do have a diagnosable learning disability, we need to see evidence of deficient visual skills in order to justify vision training. It is not an arbitrary decision.
It is very sad to routinely see patients who have been struggling for a long time with difficulties that are so easily addressed through vision therapy. Denying vision therapy as a very important part of your patient care recommendations is malpractice. Gathering information about what we actually do would allow you to have a discussion on these issues without the need of an attorney or a drink!!
oh my god. for the love of mike.
take 500 kids who YOU think can benefit from vt, presumably, those who have difficulty learning from a vision issue (besides conv/acc). randomize them to vt and phony vt and have a 3rd party determine any difference. enough already. its not rocket science for gods sake. jesus i need a drink!!
Dr. Weitzner,
We got it. We hear your repeated invitation to do a study. As Drs. Mayer and Press wrote several days ago, the study is already in the works.
In the meantime, you have an invitation to observe optometric vision therapy. There are many ODs around the country and the world who welcome interested professionals to observe evaluations and treatment. There’s probably somebody not too far from your home who would be happy to have you as a guest.
Personally, I would be honored to show you what we do and answer any questions you may have about why we do it. So if you choose to visit Charlotte, I’ll buy the first round.
Just curious ari. Optometrists go and watch surgeons do surgery on eyes, cataracts, lasik, etc… Have you ever gone and watched vision therapy, have you ever talked to parents who were seeing dramatic results?? You talk about snake oil (which is a bit of a stretch) but it sounds like the only problems that you discuss are the ones that come into your office.
I dare you to better yourself and your (lack of) knowledge of Vision Therapy and its affects on vision and learning and go see what the “snake oil” is all about. You may actually learn something:) I challenge you to actually talk to some parents who are in therapy and seeing the results. You want to talk about unfair studies, how about the fact that you obviously have not discussed Vision therapy with anybody who has been successful. I have a list of parents that you can call if you want to hear real life stories about how vision therapy change their childs life. Of course, you have to be willing to swallow your VERY LARGE pride.
Sincerely
Ryan
Dr. Weitzner,
Learning is a thing that requires comparison between what is expected and what is observed…and also requires, as a precondition, tacit acceptance of the possibility that what is expected may contain errors. It is difficult to see, from your comments, that you are ready to learn from this conversation.
You have repeatedly made comments to the effect that we should study vision therapy which does not treat vergence or accommodation. Please, enlighten me and my fellow readers… when, in your experience or thinking, does vision not involve vergence or accommodation?
I agree that a greater volume of scientific research could be beneficial in helping us improve the types of care provided to patients.
More germane to this conversation, though, I also find it sad that so many, still, masquerade as “ethical” and “rigorous” scientists. If you will dig into your past in the educational world to some time before the practice of medicine became synonymous with the practice of science, you will likely recall that the scientific method was not invented to serve western medicine, nor has medicine even been its primary practitioner. You may, after enough digging, recall that the first step in an ethical and rigorous practice of the scientific method, doctor, is to make an observation. The second step is to then observe the phenomenon with discipline, seeking to categorize, characterize, gather context, and generally gather as much information about the phenomenon as physically possible. The third step is to ask a good question. Only then can a scientist begin to formulate a useful and meaningful experiment.
Before you choose to engage in further vitriol, I respectfully, but firmly, suggest you take advantage of the offers you’ve been given during this discussion. Make some careful observation. Read. Visit the care offered in places where others do see success happening. After you’ve been considerate enough to make good observations, then, please, think of a good question.
After you’ve demonstrated that you, personally, are willing to practice science (since you’ve been clear by your comments that you are willing to practice blanket criticism of that which you don’t understand), then we’ll talk more about research that might help you, and others, learn.
I will finish by apologizing for anything I’ve said here that is unduly unkind or discourteous to you. I generally would leave unsaid comments like those I’ve made, but your comments are part of the public record and your degree suggests to the public that you speak as a scientist. Though the potential for harm may be small, I don’t think it right to allow you to portray your previous comments as being based on a love of science.
Should you feel a need to better understand what I’ve written for you, I will try to offer what help I can.
Dr. Weitzner,
I can’t tell from your posts if your interest in studies are based on scientific concerns or turf. Let’s settle this once and for all. Home many patients have you referred for in-office vision therapy since the gold standard study came out a year ago? If your haven’t referred any, then obviously this is a turf battle under the guise of an interest in studies. You may have excellent subjective, anectodal reasons for not referring, but those reasons are obviously not based on the best study on the topic performed to date. Indeed the followup survey on the amblyopia studies showed that very few ophthalmologists changed anything they were doing based on those prospective amblyopia study. It seems we are talking turf here, not science.
Incredible. I’ll give you credit where credit is due, Ari. You’re like the pinata at the party who keeps pouring out candy no matter how many intellectual beatings you take. And your best comeback appears to be the claim that we’re playing dumb, which is peculiar in light of your rhetoric.
In any event, I’m back with another set of observations. (Would have followed up sooner, but I’ve been too occupied the past couple of days helping children with vision-based learning problems.)
I particularly enjoyed your line:
“oh my god. for the love of mike.
take 500 kids who YOU think can benefit from vt, presumably, those who have difficulty learning from a vision issue (besides conv/acc). randomize them to vt and phony vt and have a 3rd party determine any difference. enough already. its not rocket science for gods sake. jesus i need a drink!!”
So I’ll give the argument one more good post-graduate try. Designing a non-drug, non-surgical study in which patients are randomized to two treatment groups, one being a placebo group, is incredibly challenging. While it may not be rocket science, it flies at a much higher altitude than you’re willing to admit. Take the CITT study, for example, since you profess to already know that conv/acc is acceptable therapy. It was incredibly difficult for this gold standard study to design, implement and maintain a true placebo group that received sham therapy.
It’s evident from your objections that you’ve not looked too deeply into the experimental or placebo designs for the CITT study, which would be a good homework assignment. Aside from the challenges of shamming the activities themselves, there’s the problem of masking the experimenters delivering the treatment. Easy enough to tell if a lens has no power in it. Easy enough to tell if you’re presenting a target to a patient over time that has no change in vergence demand.
So the only way the CITT study could approach “double blind” was to take experimenters who had no idea what they were doing. And there’s no assurance that was done, but the best way to approach that it is to take an experimenter who is new on the job, and therefore has no bias in being able to tell that a lens has no power, or a vergence demand isn’t changing because the stimuli aren’t disparating.
Now, let’s apply that principle to “learning disability” from your vantage point. We know how to design a zero sum lens or prism or disparity target. But how would you go about designing a placebo visual attention task that has no attention demand? How would you design a visual cognitive demand that has no cognition? How would you design a visual memory task that has no memory involved? Moreover, even if you masked the subjects in these experiments, how would you mask the experimenters?
For any therapist working in the vision-based learning problems field, the mark of success is the ability to adapt the procedure to the patient. To not use a naive experimenter. To help the patient develop problem solving strategies. To arrange conditions for them to internalize change. In other words, the better one is at not standardizing or shoe-horning the patient into a procedure, the more likely one is to have success. That is the antithesis of a strict protocol, where every subject gets the same treatment, and subjects who can’t understand the instructional set are dismissed from the study.
(By the way, occupational therapy, which parallels some of our procedures in this area, has had the same challenges. For years they were demeaned by pediatricians and other physicians who said their body of work wasn’t scientific enough. Their track record and ultimate acceptance hasn’t come from gold standard studies. It has largely come from helping patients. Not coincidentally, there are many synergistic relationships between OTs and developmental ODs, in part because we share common ground of having overcome objections to our interventions by self-annointed pseudo-arbiters of sound science. And yet, despite this, our optometric colleagues in CITT [and PEDIG] have excelled in bringing gold standard to the field. We’re like the Jews of Egypt in the days of old, Ari. The harder you try to oppress us, the more we produce.)
My colleagues and our patients recognize the close-mindedness and biases behind allegations that we are “ripping off people with this nonsense”. A final thought, Ari. In 2001, I had the pleasure of attending the first and only session held by the Section on Ophthalmology of the American Academy of Pediatrics. The session was entitled “Why Can’t EYE Learn” and was chaired by Harold Koller. I suspect you know, or know of Harold and the infamous yellow journalism in Review of Ophthalmology in the ’90s, featuring a rubber duck on its cover, begging the question: “Is Vision Therapy Quackery”.
During the break, I introduced myself to him (re-introduced, as we had crossed paths years before), and he was very gracious. He mentioned that Craig Hoyt was stuck in an airport in CA and couldn’t make the session. He invited me to the podium to make a presentation about optometric vision therapy. I detailed this experience subsequently in Paul Romano’s Binocular Vision quarterly ophthalmology journal. During the panel discussion at the end, and for a period of time after the meeting, I was deluged by questions such as the ones you’re asking. And I gave very similar answers. It was the first time most of these ophthalmologists ever interacted with an optometrist directly, and fleshed out the issues in collegial fashion. A number of them said privately, afterward, that I had made very good points which they acknowledged to be true “off the record”. They admitted being so entrenched in the inherited wisdom of VT as snake oil, or the skewed population they saw, that they had to wonder if I were an aberration.
A few months after that meeting, I received a plaque that I proudly display on the wall of my consulting office. Here’s a perverse thought for you: It’s the same consulting office in which I prescribe optometric vision therapy for children with vision-based learning problems. The plaque reads:
The American Academy of Pediatrics
Section on Ophthalmology
Presents This
Certificate of Appreciation
To
Leonard J. Press, O.D.
For outstanding presentation at the “Why Can’t EYE Learn” session
Gary T. Denslow, MD, MPH
Chair, Section on Ophthalmology
American Academy of Pediatrics
March 21, 2001
Orlando, Florida
Evidently they didn’t think I was playing dumb.
It may be far for you to visit Dr. Cook in GA, or Dr. Bonilla-Warford in FL, or Dr. Mayer in CA, or Dr. Bugaiski in NC, or Dr. Maino in IL, or Dr. Koslowe in Israel, or even Dr. Lane down the Jersey Shore. But I’m almost in your back yard. Take a field trip to my office after hours and we’ll have a drink, smash a pinata, and maybe even agree to disagree about vision therapy. Is it any wonder some of my best friends are ophthalmologists?
Dr.Weitzner,
Just to set the record straight on Amblyopia, Ophthalmology did not “own up to its mistakes” it simply “discovered” (as was reported at ARVO) what had “never been known before” that amblyopia can be treated at any age, including adults in their 50’s. Intellectual honesty would have predicated an apology to Optometry for ridiculing this position for years (you can’t teach an old dog new tricks to quote a famous Ophthalmology in the ’70s when explaining why amblyopia cannot be treated after age 6).
As far as research is concerned, I am sure that you must be familiar with my recent paper in the American Journal of Occupational Therapy showing the significance of a number of binocular skills as causative factors in learning problems. Of course I am not really surprised that you don’t know of it, but most of the ODs who have been answering you are aware of it. I am sure there are many aspects of medical eye treatment that I am not totally up to date on since they are not a vital part of my practice, however, I do not ridicule such treatment before carefully bringing myself up to date (as in CXL for keratoconus).
Dr. Koslowe
ari, you are to be commended for hanging in with this discussion.
Dr. Press’ comments about the problem of research design in this area is quite valid and much better than I was contemplating. Reread his points.
Let me introduce myself. I am a private practitioner, I have no great academic credentials, but I am pretty well published. I have been deceiving (oops, training) visually-related learning disabilities for 40 years with appropriate visual therapy and a Pitt-researched perceptual-motor program that has been buried in the public domain literature since 1972.
My source of referrals are school teachers, school psychologists, guidance counselors, college reading resouce specialists, clinical psychologists, neuropsychologists, rehab center psychologists (a LOT of referrals from that source, lately), occupational therapists, physical therapists, a rare ophthalmologist who now chairs a seat at Jules Stein, and most importantly, parents.
Why do they refer? Because of OUTCOMES.
Isn’t that what it all boils down to until the research is in? Outcomes?
These professional refer patients because of our outcomes. There’s something there, don’t you see? Otherwise, why refer?
Your bias has been influenced by your misplaced trust in people who were more motivated by professional *hubris* than science. E.g., there have now been four position papers published since 1972 by the AAO/AAP/AAPOS coalition. There have been three rebuttals published, with very GRAVE concerens about the honesty and scholarship of the white papers.
I am the author of the third rebuttal. It is available here: http://www.oepf.org/Reference/learning_disabilities.pdf. The paper calls for the retraction of the 1998 position paper. Since there is now a fourth white paper (which like each of its predecessors, “corrects” errors pointed out in each of the rebuttal pieces without acknowledging their existence, a point I mention in my Critique), I am planning another rebuttal paper, but problably a general piece, addressing the topic historically, highlighting the historical dishonesty of ophthalmology and pediatrics, with the working title, “Whither Integity?” I report a modest literature review that shows 329 references to support teh optometric position and in a section, show over 200 specific papers that relate to visual function and academics:
****
*The literature available at the time of the writing of the 1998 paper and that has been published since affirms a positive relationship between the following:
1. Saccadic skills and learning.15,68,70,111-120
2. C o n vergence insufficiency and learning. 0,96,98,128,132,134,177-193
3. Use of prisms and spectacle lenses and learning.98,130,191,193,194
4. Suppression and learning.109,110,195,196
5. Binocular vision and learning.2 0 , 8 0 , 8 6 , 9 3 , 9 7 , 9 9 , 1 0 9 – 1 1 1 , 1 2 3 , 1 9 7 – 2 1 2
6. Visual motor skills and learning.68-70,81,84, 86,111,113,116,124,144,204,213-222
7. Auditory perception and learning.7 6 , 7 7 , 8 2 , 2 1 2 , 2 2 3 – 2 2 8
8. Hyperopia and learning.7 4 , 9 6 , 1 0 2 , 1 0 3 , 1 0 6 , 2 2 9 , 2 3 0
9. Amblyopia and learning.105,196,211
10. Visual processing and learning.6,24,27,29,68, 88,95,118,144,154,224,231-271*
***
The Eugene Helveston argument in my Critique is especially damning. (There is NO data in his paper “Visual Function and Academic Performance” to support the very first sentence of the abstract, that ***”Evaluation of 1,910 first-, second-,
and third-grade students indicated that visual function and academic performance as measured by reading were not positively related.”***
Nada.
Your team’s critics need to do better than that, sir.
Your concern is real, ari, but you’e been misled. Your trust is misplaced. You’re welcome to visit my office, I’ll have some V-8 for you…..
(BTW: were you aware that national tutoring runs $6000/subject/year? I get lots of patients who’ve given up on those sinking holes in disgust. Check out the “Leaky Tub” analogy on my website.)
Ari,
Thank you for interest. You are truly committed to your position, but it does not sound like you want to totally discount vision therapy, in fact you sound to me like if you were presented with credible science to support vision therapy, you would be a supporter and an advocate of vision therapy. Is that true?
Dear Ari,
I am confused by your statements regarding vision therapy and learning disabilities. You obviously have a hidden agenda which can not be changed by any argument or reasonable perspective. There is no one cause of learning problems. Vision and visual function is but one potential interference factor which can impact a child’s performance in an academic environment. If this problem is eliminated, it can improve the child’s potential for success.
Some questions for you to answer
What is a learning disability? You make it sound simple? Is it a child with a reading problem, a spelling problem, a math problem, a writing problem, or a language problem? Is it a child with one of these problems or with two of these problems or is their another undiagnosed problem? How old is this child who has this learning problem? What specific intervention(s) have already been unsuccessfully explored? In other word, it is difficult to find 1000 or 500 or any amount of children who qualify simply as learning disabled.
You focus on not including children who have accommodative and convergence dysfunction in your proposed study. In my 34 years of experience, most of the children who are helped by the utilization of appropriate optometric vision therapy have these specific dysfunctions. In other words, we are treating the child with a convergence insufficiency and it has educational implications. We are not treating the educational problem because it requires a different group of professionals with different expertise.
You also focus on the lack of information in the literature regarding vision and learning. Dr David Granet in an article which appeared in the Journal Strabismus, 13:163-168, 2005 entitled “The Relationship between Convergence Insufficiency and ADHD” notes a seeming three-fold greater incidence of CI in the ADHD population.
We could argue that ADHD and /or ADD is not really a learning disability or maybe it is another variant of a learning disability. There is alot of disagreement regarding these terms. We also know the pros and cons of pharmacological intervention in these children. For a child failing in school, it is important to determine and remediate the obvious causes of their failure.
So I would suggest a quantum leap in our thinking regarding this topic. I would propose that there are children who have both visual problems such as convergence insufficiency and also have learning problems/ADHD/ADD. The CITT study has shown the success of vision therapy in the treatment of this dysfunction. The elimination of eyestain/fatigue, blurred vision, double vision, headaches and loss of place will have a positive influence on a child’s ability to maintain focus in a classroom environment. This change in performance will allow the teachers to be better able to teach/reach this child. The clinical insights already exist that vision therapy can be helpful for a child with problems in learning. It is not a panacea but a valuable adjunctive intervention. It will not help every child but it will help many children.
Your comments that vision therapy is a rip off and smells of snake oil is counter productive. It shows a professional attitude which is not about patient care or the healing process but about ego and control. Hopefully, we can deal with our differences on a patient to patient basis and not draw inappropriate conclusions from misleading information. The treatment of learning disabilities requires a interdisciplinary approach and/or mind set. It is narrow minded to eliminate vision as a factor in school performance.
Richard C. Laudon, O.D.
Ari,
Since you have made your son part of this thread, I feel it is OK to pursue this.
I can understand and expect what I feel to be MD hubris guiding your selective replies to the many excellent points that have been made. But I am simply stunned that even you say you have “a son who gets this special ed crap.” You seem to have spent almost now time thinking about the nature of of his problem, whatever it is. Have you though much about the nature of learning, the causation and complexities of learning problems, and the effect that they have on the quality of life of not only the affected child, but the entire family. Besides “special ed crap”, what avenues have you explored to assist him?
Can I assume that if you treat your own son with such insensitivity on a public forum, that you treat your patients similarly? Do we, as Optometrists who dedicate our career to improving the lives of our patients, simply expect more of you than is realistic? Do you simply not care? Are you in denial, as parents sometimes are? Do you agree with Michael Savage that “A fraud, a racket. … In 99 percent of the cases, it’s a brat who hasn’t been told to cut the act out” http://bit.ly/dvPWkl
Your wife obviously feels your son has some type of problem and has chosen one course. So, Ari, tell us. What course do YOU recommend for your son? Nothing? More discipline? More homework? That he simply suck it up and be a man?
Genuinely curious,
Nate
Dr. Weitz,
Your arguements are starting to really go off the deep end. I do not know how old you are but I am nearly 62 and was active in education and optometry 30 years ago. Special ed “crap” (and Medically approved Ritalin) were both available and in use way back then (when dinosaurs ruled the earth). About the same 30% of students did not “get through school okay” and did not do well on standardized testing. It is also probably true that without all this fancy “medicine crap” most people did not get cancer 30 years ago among with other illnesses. While I feel nothing was gained by changing the 1970’s MBD to the 1990’s ADD, the problems still exist and better therapies are available today than were available then.
Kennth Koslowe OD MS FCOVD-A
Ari,
Until you cite some double-blind, placebo controlled studies to back up your wild, tin-foil hat diatribes, I’ll consider it anecdotal and dismiss it.
Fair?
And of course, your offer, “i’l make it easy for you – forget double-blind.” is a total farce and you know it. After all the raving about double-blind, the minute we produce the new, more lenient study, you’ll revert to your old standard and retain your current mindset that we are scammers and snake oil salespeople. Yes, we are doing our research for the inherent value in it, but not because we think it will convince people like you. we are more realistic than that.
And finally, what beef do you have against the English language? The common belief is that a cultural change due to texting and tweeting is ruining the English language amongst the youth. Yet here you are, a doctor, authoring what purports to be a medical blog that is not spell-checked or proofread or even has a single capital letter written by you in the comments that I can find. Man, society really is in trouble if even MDs can’t write.
-Nate
MDs are immune to trends in health care? Say it ain’t so?
Need I remind anyone of RK, where the fervor reached such a height that patients were flying to Russia to be treated on a conveyor belt by Dr. Svyatoslav Fyodorov?
You mean NO ONE suspected that cutting thru 90% of a patient’s corneae MIGHT have been a bad idea, such that today we feel compelled to warn these patients that their eye might rupture due to airbag deployment, etc? We ALL know many of these patients are referred to behind their backs by doctors as “wrecks”?
Dare I mention the ‘revolution’ of treating with frontal lobotomies, which have devastated many a patient? Never mind these were performed as recently as 1980’s? Wow, couching for the brain: hate to sound sarcastic, but you’ve come a long way, baby!
Granted, I suppose a moment’s thought might come up with more contemporary examples (ritalin kids, anyone?), but these two should suffice.
I’m Not suggesting ODs are to be excused for doing the same with VT, but it certainly seems MDs have much dirty laundry hidden in THEIR closet. Glass house anyone?
this thread has veered wildly off topic, and we are just yelling past each other at this point, so the editor has deleted some of the thread, and i will no longer comment on this thread, as i personally find it frustratingly non-responsive ( as i’m sure you do as well!), and i regret losing my temper at my colleagues, or if i wrote anything offensive. im sure we will have opportunity to debate on future topics!
although i am the medical editor of eyedocnews, this blog is not “mine” but is run by another party. there are no official rules here- just common sense, and so if the postings veer off too much from the debate, especially if they degenerate into ad hominem attacks and goading, then those posts are simply deleted. the last several posts were deleted for this reason.
i take some responsibility for the breakdown of decorum here- some, but certainly not all! i can be very opinionated, and perhaps in a forum like this, i should choose my words a little more carefully. i have never, ever been accused of being politically correct. i detest political correctness, and prefer to be utterly blunt, but on this blog, it looks like i have to practice some.
i don’t back down from the substance of my remarks- sorry nate! certainly, some good valid points were made by defenders of vt, but overall, i disagree strongly. but as a scientist, i never assume i cant be proven wrong, and just as i started this thread apologizing to the optometrists for their good hunch about bifocals, i am happy, as a scientist, to eat my words about vt if it is ever proven (to my satisfaction- which is part of the problem, actually) to be of any use in those with learning disabilities (the definition of which is frustratingly vague in my opinion).
so, again- considering that i started this thread apologizing to the optometrists for belittling bifocals all these years, i hope i will be granted the benefit of the doubt that despite the unfortunate breakdown in decorum, that my intentions are honorable and serve only to promote the art and science of eye care.
i got the last word- i know that’s not fair, but it’s a small privilege when one is the medical editor! thus endeth this thread!
how about this- it might be interesting to have some of you optometrists contribute to this blog and start your own threads. we ophthalmologists are pretty weak in optics, contact lenses etc., and i think it would be great if optometrists contribute to this blog along with the ophthalmologists and ophthalmology consultants we have now. if interested, let me know, and i will speak with my partner who runs this blog.
Ari,
I do appreciate the offer to join the blogging team. Seriously. I have passed the offer along to my colleagues. Normally, I would love to blog under the Eye Doc News banner. I have been blogging for about five years and would like the challenge and diverse readership.
However, after witnessing how unprofessionally this blog is edited and moderated, specifically in the LACK of rules or guidelines, I would not consider it. I hope some other OD does.
Good luck, Ari.
-Nate
“so, again- considering that i started this thread apologizing to the optometrists for belittling bifocals all these years, i hope i will be granted the benefit of the doubt that despite the unfortunate breakdown in decorum, that my intentions are honorable and serve only to promote the art and science of eye care.”
See, I don’t see why you feel the need to apologize for “belittling BF all these years” (unless you did it in such an unprofessional manner that you simply demeaned yourself and your profession). As long as you presented a perspective based on uncertainty (i.e. lack of clinical data), you committed no crime.
As far as losing one’s objectivity, I think back to the poo-poohing MDs delivered to those who advocated vitamin/anti-oxidant supplementation (you know, the “expensive pee” line). Was THAT balanced? Was THAT justified? I think we all know the answer.
It’s not about being wrong or right, it’s about EXPLAINING what is known and not known, and providing proper information so the patient can give their informed consent. In the end, it’s not MY decision, or YOUR decision, but the patient’s: as long as we provide a balanced perspective upon which the patient can make a proper decision, then we’ve done our job.
As you point out, the best approach is simply to say that in lieu of clinical data to support any therapy or methodology, the best approach is to remain judgment-free, and admit that there are some answers which we just don’t have. I know, it’s hard for most ‘experts’ to utter the phrase, “I don’t know”, but sometimes it IS the truth.
So aside from sticking to known basic principles (”all things in moderation”, “the dose makes the poison”, “we don’t know how these substances interact with your Rx meds”, etc), perhaps it’s best to acknowledge the fact we don’t know it all (even in the year 2010!), and should avoid rhetoric so we don’t need to supplement our OWN diets with ‘crow’ in the future.