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Researchers: Pediatrics/ Ophthalmology statement on vision therapy outdated, flawed

July 29, 2009

TuckerIra2A “Joint Policy Statement” published online in the Journal Pediatrics on July 27 appears to cobble together outdated research and vision science, such as the controversial Irlen lens, in an attempt to discredit optometric vision therapy, according to prominent optometrists.
          
The policy statement, developed by the American Academy of Pediatrics, Section on Ophthalmology; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus;  and American Association of Certified Orthoptists, sheds doubt on the claim that vision therapy treats dyslexia – a claim that vision researchers and clinicians have not made for decades.

It also ignores the evidence of the proven benefits of vision therapy, such as in well-designed studies, most notably the Convergence Insufficiency Treatment Trial (CITT), which was funded by the National Eye Institute. This study showed that vision therapy administered in an eye care provider’s office is the best course of treatment for that condition.

“This publication pretends to be a review of the literature, but instead is a straw man argument,” noted Leonard Press, O.D., chair of the AOA’s Pediatrics and Binocular Vision Committee and prominent member of the College of Optometrists in Vision Development (COVD).  “The references at the end, for example, include outdated research literature, and are padded with 23 references to the Irlen lens concept.  None of the positive studies on vision therapy from optometric literature is included.”

The timing of the “joint policy statement” seems curious as well, noted Dr. Press, with recent studies showing positive results from vision therapy and with prominent individuals from the academic and scientific communities supporting vision therapy. 

  • In May, Susan R. Barry, Ph.D., professor of neurobiology in the Department of Biological Sciences at Mount Holyoke College, published a book, Fixing My Gaze, about her long struggle with vision problems and the ultimate success of vision therapy treatment.
  • More currently, there is the well-publicized success of former vision therapy patient Larry Fitzgerald as a wide receiver for the Super Bowl-contending Arizona Cardinals earlier this year.  Fitzgerald credits his grandfather’s vision therapy treatments as a key to his success in catching the football.  Just last month, Fitzgerald started working with COVD as a spokesperson.
  • And now, as children and parents ready for the school year, and the AOA is engaged in a media campaign to raise awareness of the importance of having vision examinations before school, there appears to be a campaign to discredit vision therapy.

 Dr. Press said there has been a regular pattern of such publications.

 “What the policy statements have consistently done is link vision therapy treatment to unrelated conditions and then show the treatment is not successful,” he noted.

He prepared a detailed refutation of the “joint policy paper” (see here) and told AOA News that he was grateful, in a way, for its publication because the paper provides another opportunity to cite relevant research, recount the success stories and raise awareness of the role of optometric vision therapy in treating vision conditions that inhibit learning.

Other prominent optometrists and educators also took issue with the “joint policy paper.”

“It should also be noted that every school and college of optometry teach courses in and provides clinical experiences for students in the area of vision therapy and that the procedures used in vision therapy have been codified within text books published by major publishers throughout the United States and the international community,” said Dominick M. Maino, O.D., M.Ed., professor of Pediatrics/Binocular Vision at the Illinois College of Optometry and editor of Optometry & Vision Development.

“Optometric vision therapy is a scientifically sound series of therapeutic procedures used successfully for a number of vision disorders from amblyopia to learning-related vision problems,” Dr. Maino said.

“In this era of evidence-based medicine it is disheartening to read this panel of ‘experts’ purposefully misleading the reader by disregarding recently published randomized clinical trials and the only quality research about the effectiveness of treatments for convergence insufficiency,” said Mitchell Scheiman, O.D., chief of the Pediatric/Binocular Vision Service and a professor at Salus University.  Dr. Scheiman was the study chair for the year-long CITT study, which had clinic sites in nine states and included 208 children. 

The authors of the joint policy statement falsely note that “symptomatic convergence insufficiency can be treated with near-point exercises, prism convergence exercises, or computer-based convergence exercises. Most of these exercises can be performed at home, and extensive in-office vision therapy is usually not required. Alternatively, for other patients, reading glasses with base-in prism or minus lenses can be used as treatment,” Dr. Scheiman said.

“The references they use to support these statements are not research studies, but are editorial responses to the CITT studies published in Archives of Ophthalmology.  The authors of these editorials base their opinions about the effectiveness of home-based therapy on their “clinical experience” and fail to present any quality data from randomized clinical trials.  The authors also conveniently chose not to reference the only randomized clinical trial of base-in prism for the treatment of convergence insufficiency. That study, in fact, found that base-in prism was no more effective than placebo reading glasses.”

7 comments

  1. [...] but rather the tactics that were used to arrive that the policy statement. This is from the American Optometric Associatio Newsblog: The policy statement …  sheds doubt on the claim that vision therapy treats dyslexia – a [...]


  2. This is a perfect example of the type of information the AOSA leadership should be distributing to its membership.

    The AOA’s headlong dash to mandating residencies and subspecialization should not proceed at the expense of other specialties beyond ocular disease.

    We should take every opportunity to support every leg of the profession lest it fall over. It is very gratifying to see support for all constituencies within the profession. It is good for the students to see balance.

    Daniel G. Fuller, O.D.


  3. Well written. Thank you for defending the very important work that we do for our patients.


  4. [...] Statement on vision therapy outdated, flawed. [...]


  5. Paragraph 2 above says, “The policy statement… sheds doubt on the claim that vision therapy treats dyslexia – a claim that vision researchers and clinicians have not made for decades.”

    This statement seems to directly contradict claims made on the following website belonging to a well-known vision therapist:
    http://www.optometrists.org/Bethesda/index.html

    First paragraph of the home page says, “…offers a full range of family vision care services, specializing in the treatment of children and adults with behavioral, sensorimotor or learning-related vision problems — such as those previously diagnosed with add-adhd, dyslexia, and/or avoidance of reading.”

    Futher down on the home page under Optometry Services, Typical Difficulties, bullet 5 lists, “Learning-related visual problems, Dyslexia, Learning Disabilities, Attention Deficit Disorder.”

    When you click on the hyperlink for Dyslexia in bullet 5, you are taken to the Vision Therapy section which right at the top says, “Who Benefits? – Learning -Dyslexia -ADHD -Lazy Eye -Stress -Special Needs -Sports”.

    Does vision therapy treat dyslexia or not?


  6. Regarding the comment above by “Chi”, I see no contradiction. To resolve the issue, go to the AOA website: http://aoa.org/x4816.xml. The last CPG on the list, CPG 20, is on the Care of Learning Related Vision Problems. You’ll note that there is a whole section toward the end on assessment which includes the Dyslexia Determination Test. We don’t determine if someone has Dyslexia just out of curiosity. We do so because vision therapy helps treat visual deficits associated with dyslexia.

    But, if you pose the veiled question: “Does VT treat dyslexia?”, we’d qualify the answer by saying “not directly”. What you cited from Dr. Appelbaum’s site states that people diagnosed with Dyslexia benefit from VT. That isn’t synonymous with claiming that VT treats Dyslexia.

    On the contrary, to take the more generalized view, Dr. Appelbaum is part of a group, to which I belong, that maintains a website http://www.visionhelp.com. On that website we make this issue very clear. See: http://www.visionhelp.com/dyslexia.htm. We do not make the claim that VT treats dyslexia. Our collective statements are consistent with our AOA/AAO Joint Policy Statement, posted on the AOA Website and in the Appendix of the CPG above.

    The problem with critics of optometric VT is that they claim we have no relevance in the multidisciplinary approach to learning disablities, of which dyslexia is a form. Framing a question such as “Does VT treat dyslexia” mirrors the approach by the JOPS of the AAP and its collaborators. It invites the conclusion that since optometric VT doesn’t directly treat dyslexia, it is tangential at best. More egregiously, it infers that if VT is useless for children with dyslexia, it is therefore a waste of time and money in general. Quite a leap, don’t you think?

    I made the statement years ago that although critics of VT for learning problems in general cloak themselves in a mantle of scientific concern or patient advocacy, most of them — and I’m careful not to overgeneralize this — but most of them have a thinly veiled agenda. I am curious what prompts Chi to pose the question above.

    Let’s accept the description by Shaywitz that Dyslexia represents the far end of a continuum of reading disabilities. Now look at Table 1 (p. 14) of the AOA CPG on Learning Related Vision Problems. Note the Signs and Symptoms of Ocular Motility Disorders which include these 7 factors:

    * Moving head excessively when reading
    * Skipping lines when reading
    * Omitting words and transposing words when reading
    * Losing place when reading
    * Requiring finger or marker to keep place when reading
    * Experiencing confusion during the return sweep phase of reading
    * Experiencing illusory text movement

    Even if we just limit VT to treating ocular motility disorders (and it does much more – read the CPG to see all the factors related to Reading Disability through deficits in Visual Information Processing), we can derive the answer to the question about VT treating persons with dyslexia:

    Do the 7 factors above impair reading ability?
    - Yes.

    Does optometric VT treat ocular motility dysfunction?
    - Yes.

    Does optometric VT improve reading ability?
    - To the extent that he 7 factors above influence reading — yes.

    If optometric VT improves reading ability, does it help persons with Dyslexia?
    - To the extent that Dyslexia involves reading ability and fluidity — yes.


  7. When the editors of the Archives of Ophthalmology opined anecdotally that their home-based treatments for CI were indeed effective, contrary to the findings of the randomized, double-blind CITT study that was published in the same issue of their journal, they undermined the very credibility for which their journal, and their profession, stands. Such irony is not lost on me!



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