Who Knew? Bifocals Retard Myopia After All

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.

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.

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.

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.

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.

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.

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.

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?

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!

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.