FAQ's - Frequently Asked Questions
The following is an interview with Leonard J. Press, O.D., FCOVD, FAAO.
Dr. Press is the author of the textbook Applied Concepts in Vision Therapy. The interview is conducted by Rachel Cooper, founder of Optometrists Network.
In this FAQ interview, Dr. Press examines current questions and opinions concerning vision therapy and refers the reader to relevant medical literature and web pages. He also discusses the many applications of vision therapy to a wide range of visual and learning difficulties.
What is vision therapy?
You can think of vision therapy as physical therapy for the eyes and the brain. The neurological aspect is very important because the eyes are direct physical extensions of the brain. We see with our brains and minds, not just our eyes. There are plenty of web pages which give accurate definitions of vision therapy. Let's move on to some frequently asked questions which aren't covered on lots of other pages.
Are "orthoptics" and "vision therapy" the same thing?
Orthoptics, which literally means "straightening of the eyes", dates back to the 1850s and is limited in scope to eye-muscle training and the cosmetic straightening of eyes. Vision therapy includes orthoptics, but has advanced far beyond it to include training and rehabilitation of the eye-brain connections involved in vision. Clinical and research developments in vision therapy are closely allied with developments in neuroscience.
What is the difference between an optometrist and an ophthalmologist?
In the United States, there are two different types of licensed vision care professionals: the optometrist and the ophthalmologist. The optometrist is a doctor of optometry (O.D.) who diagnoses and treats visual health problems as dictated by state law. Some optometrists specialize in vision therapy. The ophthalmologist is a doctor of medicine (M.D.) who specializes in surgery and diseases of the eye. A small number of ophthalmologists work with or refer to vision therapists or orthoptists. To read some special educators' statements regarding differences between optometrists and ophthalmologists, see Choosing an Eye Doctor.
What should patients or parents keep in mind while researching vision therapy on the Internet?
As with any subject matter, the public must be careful to consider the source. Vision therapy is a well established field within the optometric profession. I would, therefore, recommend that the reader place most credence in information acquired from optometric web sites or from patient or parent advocate sites which look at the subject objectively. Readers need to be aware that some web pages are misrepresenting vision therapy.
Can you be more specific?
Let's say you were seeking information on the Web about treatment of a hip problem. If you had a question about physical therapy, you would look to a physical therapist (P.T.). For information on surgery, you would rely on an orthopedist (M.D.). In this particular example, you could get accurate information about either treatment options from both professionals. That's because orthopedic surgeons and physical therapists have learned to work together in the best interests of the patient. Unfortunately, this is not the case in vision care where optometrists and ophthalmologists don't always agree on vision therapy. Some ophthalmologists have even taken it upon themselves to post unjustifiably negative information on vision therapy on the Internet.
Why would some ophthalmologists and their organizations claim that vision therapy doesn't work?
In 1993, Paul Romano, MD, the editor of Eye Muscle Surgery Quarterly, conducted a worldwide survey of eye muscle surgeons. He asked surgeons to indicate whether they would favor a surgical or non-surgical approach to the treatment of intermittent exotropia (a form of strabismus). 85% of the international group recommended non surgical approaches, as compared with only 52% of the American surgeons. Dr. Romano postulated three important reasons why this might be so:
- Insurance companies and single-payer systems outside of the U.S. have stricter medical standards in regards to approving payment of eye muscle surgery. Also, they do not pay as well for eye muscle surgery as insurance companies in the U.S.
- Non surgical therapy isn't as economically rewarding for the surgeon in the U.S. due to the personnel and fees involved.
- Due to his lack of training in this area, the surgeon is reluctant to acknowledge the benefits of non surgical therapy for fear of losing patients.
Does the public assume that ophthalmologists (M.D.s) are the ultimate authorities about everything in eyecare, including vision therapy?
The public needs to be aware that ophthalmologists are not the ultimate authorities in all areas of visual health. Ophthalmologists are wonderful surgeons and excellent authorities about eye disease, but as a rule they're under informed about subject areas such as, visual processing, convergence, accommodation and vision therapy. Some ophthalmologists concede this. In the medical journal, Transactions of the American Ophthalmological Society, eye muscle surgeon and researcher David Guyton, M.D., states: "We [ophthalmologists] have probably abdicated the study of accommodation and convergence to the optometric profession. A perusal of the literature will reveal that most of the advances in this area are being made in the optometric institutions by vision scientists who use definitions and terms with which we are not even familiar."
So, if an ophthalmologist says, "Vision therapy doesn't work", remember that this is an opinion from a professional who has little knowledge of the subject. Many of the M.D.s who criticize vision therapy have not done their homework. As I said before, it is important to consider the source of information. Optometrists who specialize in vision therapy are the authorities regarding developmental vision and vision therapy.
Can you give an example of a case where the outcome depended on whether the parent relied on the opinion of an optometrist or an ophthalmologist?
Yes. This is just one example among many. Lauren, a nineteen year-old, was referred to me by an occupational therapist. Lauren had initially been prescribed glasses and patching for a lazy eye. When she reached age nine, an ophthalmologist assured her mother that Lauren no longer needed glasses and that her lazy eye would not worsen further.
To make a long story short, Lauren had multiple problems throughout the years. Reading fatigued her. As she read, print jumped around, words went uncontrollably in and out of focus and she skipped lines. Her mother observed that Lauren's lazy eye would turn inward when she was tired. Each year, her mother took Lauren back to the ophthalmologist, only to be told that everything was fine.
Because the ophthalmologist said that everything was fine, Lauren's avoidance of reading was determined by the school to be due to laziness. Her aversion to reading was so strong that the school suggested to the family that she was dyslexic, and needed large print books and taped material.
Lauren's mother finally decided to seek a second opinion from a vision specialist. I tested Lauren on the Visagraph, a standardized computer which records and analyzes eye movements while the patient is reading. Results showed that Lauren, age nineteen, was reading at a 4th grade level. At this point, I tested her eyesight with eyedrops in place and discovered that Lauren did not really have a lazy eye! Lauren's so-called lazy eye could see 20/20 with the proper prescription lens. I prescribed glasses for reading, and a vision therapy program and Lauren has made great improvements. It is unfortunate that Lauren went so many years without proper treatment. In a perfect world, the ophthalmologist might have said: "Although I do not find any eye health problems or the need for glasses or medication, Lauren has significant problems and does not seem to be psychosomatic. Therefore, I will refer her to a vision specialist for more extensive testing."
Can vision therapy help with learning problems?
Vision problems often can and do interfere with reading and learning. Optometrists do not claim that vision therapy is a direct treatment for learning disabilities, such as LD, dyslexia or ADD. Vision therapy is directed toward resolving visual problems which interfere with educational instruction. The statement on vision therapy and learning disabilities by the American Optometric Association and the American Academy of Optometry makes it clear that a multidisciplinary approach to learning disabilities is recommended, and that vision is but one aspect of the overall picture. Statements to the effect that vision therapy has no place in the treatment of learning disabilities are inaccurate and misleading.
Vision therapy can improve visual function so the patient/student is better equipped to benefit from educational instruction. In 1991, Firmon Hardenbergh, M.D., the Chief of Ophthalmology at Harvard University Health Services, had this to say regarding a double-blind scientific study of children with reading disability and convergence difficulty:
- "The application of orthoptics [included in vision therapy] to all learning/reading disabled or deficient children who manifest convergence insufficiency should be the first line of therapy."
- Regarding visual processing and learning disabilities, Corinne Smith, Ph.D., Associate Dean of Education at Syracuse University, noted in her 1997 text on Learning Disabilities, that students with visual perception disabilities have trouble making sense out of what they see.
- "The problem is not with their eyesight, but with the way their brains process visual information."
Is there scientific evidence that vision therapy works?
In a word, yes. Studies on vision therapy are on a par with the published literature in parallel rehabilitative interventions such as physical therapy and occupational therapy. Furthermore, the data which supports vision therapy is considerably more impressive than the data which has substantiated other forms of visual intervention before these were put into public use by eyecare practitioners. The same profession (ophthalmology) which calls for "more scientific" studies of vision therapy had no qualms about recommending elective procedures such as eye muscle surgery or refractive surgery prior to any scientific study whatsoever.
The most concise source of information regarding scientific studies on vision therapy can be found on the website of the College of Optometrists in Vision Development. See Vision Therapy References for other publications.
What's the position of educators regarding vision therapy?
According to law in many states, if a child is classified as having a specific learning disability, the school is required to either provide the necessary therapy, or to pay for the parents to obtain the necessary help not provided by the school. This puts educators in a tight spot. Funds are limited, so schools understandably try to minimize expenditures. Regarding perceptual impairment or visual processing disorders, educators are sometimes faced with two basic choices:
- Have someone already on staff provide the therapy necessary or
- Deny that the therapy has anything to do with the child's learning problems.
Some school systems try to adopt the latter approach, which leaves more money in the pot for services which are provided within the school system.
In the case of the former, the school might assign the child to a staff Occupational Therapist. OTs are highly skilled in helping children with developmental, gross motor, and fine motor activities particularly handwriting, but they are not trained or licensed in vision therapy. Specifically, occupational therapists can not administer important vision therapy procedures which involve lenses, prisms, and devices which insure that both eyes work together as a synchronous team.
Fortunately, we are seeing an increase in schools which recommend that parents of children with visual problems seek evaluation and treatment with a licensed optometric vision therapist.
I've heard a lot about special lenses or filters which can improve reading. Can that be done instead of vision therapy?
You're probably referring to Irlen Tinted Lenses and no, they're not a substitute for vision therapy. Experiments continue to try to look for passive means such as filters to improve vision and reading. What sources tend to overlook is Irlen's caution when she introduced the concept of SSS, or Scotopic Sensitivity Syndrome, as a possible basis for reading difficulty with some dyslexics. Many of the symptoms of SSS overlap with visual dysfunction such as instability of print, loss of place when reading, and difficulty concentrating when reading. This prompted Irlen, in her 1991 book: "Reading by the Colors", to write that individuals interested in being screened for SSS should first see a vision specialist for a complete visual examination.
Irlen, an educational psychologist, recognized the difference between routine eye examinations and a vision therapy evaluation. She noted:
"When individuals take a routine eye examination, the vision specialist normally assesses acuity, refractive status, and binocular function. When the exam is more than routine, additional tests will analyze the visual system in greater detail and will also evaluate focusing ability and tracking skills. The doctor will also check for the presence of eye diseases. For SSS treatment to be successful, existing visual problems need to be treated first. Perceptual skills are based on a solid visual foundation. It is essential for individuals to eliminate all visual problems prior to getting treatment for perception or other learning difficulties."
Does insurance pay for vision therapy?
In this era of insurance cost cutting measures, it can be difficult to receive adequate insurance coverage. Patients are much more effective in getting reimbursement when they pursue their claims directly, armed with knowledge and facts from the doctor's office. There are national optometric guidelines formulated for covered conditions and length of treatment. The College of Optometrists in Vision Development (888-268-3770) has an insurance committee that offers to conduct peer review of claims when it becomes obvious that the individual or individuals reviewing the claim are not optometrists. Ultimately the patient must consider the following:
- What problems or concerns are you having with your vision or performance?
- What options have you tried other than vision therapy, and what has been the result? If you have not had success pursuing other interventions, and the doctor's diagnosis and treatment proposal make sense, what value would you place on improvement?
Vision therapy is rarely the first form of help that patients discover. If the patient or family is struggling, and other suggestions have not borne fruit, investing in vision therapy makes sense. Insurance reimbursement is helpful, but not all our decisions about our welfare, or our children's future, are made based on someone else paying for it.
Is it true that there are certain conditions, like lazy eye, where the patient is too old, or it's too late to intervene with vision therapy?
First, let's define the terms. What the public knows as "lazy eye" is technically amblyopia. A diagnosis of amblyopia means that one eye doesn't see as clearly as the other eye even with proper glasses or contact lenses. Amblyopia can occur with or without strabismus, which is a crossing or turning of the eyes. Strabismus is sometimes attributed to one or more weak eye muscles, however the problem is more often due to a defective neurological signal to the involved muscle(s) rather than to an actual muscular abnormality.
Secondly, allow me to emphasize that, in regards to amblyopia and strabismus, the eye muscle training benefits of vision therapy are medically proven. There is no controversy there. Where eye doctors do not always agree is in regards to this question you have asked. There are eye surgeons who promote the idea that if a child has an eye turn, you must operate by age two to get meaningful results, and if there is amblyopia, or lazy eye, intervention of any kind is only meaningful before age 6 or 7. There are many scientific articles in optometric journals which prove that it's never too late to treat a lazy eye, but I'd like to refer to an study by an eye surgeon.
In the American Journal of Ophthalmology, von Noorden, a well-known strabismus surgeon and researcher reviewed the records of 408 patients who had eye turns shortly after birth, and divided their surgical outcomes based on age at the time of surgery:
|4 month - 2 years||Optimal||24%|
|2 years - 4 years||Optimal||15%|
|Older than 4 years||Optimal||16%|
Re: surgical treatment, the data above shows that useful results can be obtained by intervening after age 2. The data also shows that there should be no rush to go to surgery after the age of 2, because the outcomes don't differ that much after that age. By the way, the positive outcomes measured above include cosmetic improvement ONLY. Vision therapy aims to do more than simply straighten the appearance of the crossed or turned eyes. It aims to help patients develop useful binocular (two-eyed) vision.
You can learn more about eye muscle surgery as a treatment for lazy eye or eye turns, etc. by visiting the web site of Dr. Jeffrey Cooper.
Re: vision therapy treatment, you'll always get the best results if you intervene at a young age, IF you can get a child's cooperation. But, children have little motivation to cooperate. It's been proven that a motivated adult with strabismus and/or amblyopia who works diligently at vision therapy can obtain meaningful improvement in visual function. As my patients are fond of saying: "I'm not looking for perfection; I'm looking for you to help me make it better". It's important that eye doctors don't make sweeping value judgments for patients. Rather than saying "nothing can be done", the proper advice would be: "You won't have as much improvement as you would have had at a younger age; but I'll refer you to a vision specialist who can help you if you're motivated."
Any concluding thoughts?
With the advent of computers in the work environment, we're seeing more adults with eye strain-related vision problems which can be improved through vision therapy. Also, there are special needs patients with developmental or head injury problems which neuro-optometric diagnosis and vision therapy treatment can uniquely help. Still, the majority of my patients continue to be children with learning or reading problems who have been through all kinds of interventions. These children have been told that their eyes are healthy and that glasses aren't necessary, but they continue to struggle with visual processing. Their visual processing problems or developmental vision problems can't be detected unless the eye doctor specifically tests for them. I'd like to sum up with a quote from the web site of one of the world's leading vision companies, Ciba Vision:
"Because reading problems usually have multiple causes, treatment must often be multidisciplinary. Educators, psychologists, eye care practitioners and other professionals often must work together to meet each person's needs. The eye practitioner's role is to help overcome any vision problems interfering with the ability to read. Once those are addressed the student is better prepared to respond to special reading education efforts." (www.cibavision.com, 1999)
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