Who Knew? Bifocals Retard Myopia After All

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

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, 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.)

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,

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,

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.

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!!

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.

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!