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THE INTERFACE BETWEEN
OPHTHALMOLOGY
OPTOMETRIC VISION THERAPY
                                                                                                 &
n Leonard J. Press, O.D.                        Introduction                                   Orthoptics had its heyday from early to




                                                T
                                                                                               mid-20th century, but was gradually
Abstract                                                           he impetus for this pa-     transformed from an active therapeutic
Considerable disparity lies between                                per stems in part from a    service into a marginal service. The num-
o p h th alm ologic impressions of                                 meeting that I attended     ber of certified orthoptists in the United
optometric vision therapy, and the reality                         on March 21, 2001, in       States dwindled, and those remaining pro-
of optometric vision therapy as practiced                          Orlando, Florida. Re-       gressively engaged in assisting with pre
in the United States. The viewpoint shared      viewed in a prior issue of this journal, the   and post strabismus surgical measure-
by ophthalmology in particular, and the         meeting entitled “Why Can’t EYE                ments and monitoring rather than in per-
medical field in general, is one that is fil-   Learn?” was jointly sponsored by Jeffer-       forming non-surgical therapeutic
tered through organizational policy state-      son Medical College and the Section on         services. The service itself was diluted
ments and the isolated experiences of           Ophthalmology of the American Acad-            from an active approach to amblyopia and
influential individual practitioners. This      emy of Pediatrics (AAP).1 The subtitle of      strabismus therapy to a passive approach
has resulted in a skewed portrayal of           this meeting was: “Learning Differences        for a handful of convergence problems.
optometric vision therapy. The purpose of       and Visual Perception from a Pediatric            This raises an obvious question. Why,
this paper is to present a balanced per-        Ophthalmology and Neuro-psychology             if orthoptics was efficacious for a broad
spective on this subject, and one that          Perspective.”                                  spectrum of binocular applications, was
should be of assistance in creating an in-         My participation during this meeting        the field virtually vacated by ophthalmol-
terface between ophthalmology and op-           was serendipitous. Dr. Harold Koller, who      ogy? The answer, to be succinct, is that
tometry that better serves the public.          I had known from my days in the Philadel-      orthoptics was more than most ophthal-
                                                phia area, was the Chair of the meeting.       mologists could manage. This belief is
                                                During his presentation, Dr. Koller made       supported by an authoritative textbook on
Editor’s note                                   several passing references to Optometry        Orthoptics from 1949 by Mary Everist
This article originally appeared in Binoc-      and vision therapy. Following his invita-      Kramer, supervisor of the Orthoptics De-
ular Vision & Strabismus Quarterly,             tion to me to give a short [impromptu] pre-    partment at the George Washington Uni-
2002; 17(1):6-11. We wish to thank editor,      sentation on the subject, I joined the group   versity Hospital in Washington, DC.3 The
Paul E. Romano, MD, MS for his permis-          on the podium for a panel discussion. The      text was edited by Ernest A. W. Shepard,
sion to reprint.                                questions to me from the audience              M.D., Professor of Ophthalmology at the
                                                touched on six areas of concern that I will    George Washington University School of
                                                address at the end of this paper.              Medicine. In the Preface, we find the fol-
                                                The evolution of optometric vision             lowing candid observation:
                                                therapy                                           “When ophthalmologists discuss or
                                                   To appreciate the science and substance     write about orthoptics, their views are
                                                of optometric vision therapy, it is insight-   generally based upon the work of an
                                                ful to consider vision therapy as an out-      orthoptic technician, the results of whose
                                                growth of orthoptics. This evolution has       work they have observed. Since few oph-
                                                been chronicled in detail elsewhere,2 and      thalmologists have had the opportunity to
                                                several points need to be elaborated. Al-      observe good orthoptists, there is a wide
                                                though ophthalmologists pioneered              variance of opinion regarding the role of
                                                orthoptics, it was neither cost-effective      orthoptics in the treatment of ocular im-
                                                nor time-effective in their hands.             balances.”


Journal of Behavioral Optometry                                                                            Volume 13/2002/Number 2/Page 37
Consider the following guidelines for          tance in the accomplishment of a rapid        tional ophthalmologic sources. This is not
successful orthoptic treatment as outlined        and lasting cure for her patients.            as much as oversight as it is evidence of
by Kramer and Shepard (pp. 154-169):               Ophthalmologic practice drifted from         the disinterest of ophthalmology in visual
· Necessitates frequent office visits at        the holistic attributes required for success    development from a behavioral perspec-
  first, with gradual reduction as the train-   as outlined by Kramer. As ophthalmology         tive.
  ing is carried out at home.                   was becoming an increasingly medical            Ophthalmolgic initiatives to dis-
· Approximate length of time of treatment       and surgical practice, optometry in             credit vision therapy
  is usually from two months to two years.      mid-century was rendering vision therapy           Nature abhors a vacuum and, as optom-
· If surgery is indicated the ophthalmolo-      services well-suited to these attributes for    etrists began to improve patient’s perfor-
  gist may prefer to give orthoptic training    orthoptic success. Another text published       mance through vision therapy programs,
  before surgery, or institute surgery be-      in 1949 is essential in understanding the       ophthalmologists found themselves hav-
  fore orthoptic training. The decision         pivotal role that Optometry was about to        ing to address inquiries about how a
  rests upon the type of case, the age, the     play. Entitled Vision: its Development in       child’s vision might be influencing behav-
  physical and mental development of the        Infant and Child, this text represented a       ior, development, or school performance.
  patient, the cooperation of the patient       fusion of Optometry, Ophthalmology,             In 1972, the American Academy of Pedi-
  and parents, and the ease or difficulty of    Orthoptics and Psychology.4                     atrics, the American Academy of Oph-
  making weekly visits to the doctor’s of-         Pediatric ophthalmologists should be         thalmology and Otolaryngology, and the
  fice.                                         conversant with the collaboration that          American Association of Ophthalmology
· The training must be intensive to be ef-      took place among these fields at the Yale       issued a policy statement entitled “The
  fective. Breaks in training should be         Clinic of Child Development. Arnold             Eye and Learning Disabilities”, which de-
  given when the child reaches a point of       Gesell, M.D., and Frances Ilg, M.D., were       nied any relationship between vision and
  saturation after intensive training.
                                                substantially aided by Vivienne Ilg, O.D.       learning. The inaccuracies in this policy
· More than treating “a pair of eyes”,          and Gerald Getman, O.D., in this effort.        statement were swiftly pointed out in an
  orthoptics consists of treating the person
                                                Their work was unparalleled in the field of     article in the Journal of the American
  as a whole, since much of the success of
  restoring normal binocular vision de-
                                                child development. The melding of               Optometric Association by Flax.5
                                                orthoptics with an optometric perspective          Despite Flax’s scholarly refutation of
  pends upon the personality, cooperation,
  and enthusiasm of the child.                  served to broaden the basis for optometric      the points raised in the 1972 paper, an ad
                                                vision therapy as practiced in the second       hoc working group of the American Asso-
· Training should be adapted to a child’s
  mental capacities as well as to his ocular    half of the 20th century. Permit me to          ciation for Pediatric Ophthalmology and
  skills. Some children learn faster than       quote from the preface of this text:            Strabismus, and the American Academy
  others, some retain knowledge better            The authors have attempted to achieve         of Ophthalmology, issued a policy state-
  than others, some have greater concen-          a closer acquaintance with the interre-       ment in 1981 entitled “Learning Disabil-
  tration ability than others, some are           lations of the visual system per se and       ities, Dyslexia, and Vision” offering
  more attentive than others.                     the total action system of the child.         conclusions similar to those in the 1972.
· Causes for failure in orthoptics include        This finally entailed the use of the          Again Flax, this time with two associates,
  inexperience or poor judgement on the           retinoscope and of analytic optometry         authored a scholarly rebuttal.6 Their arti-
  p a rt of the ophthalm ologist or               at early age levels where these techni-       cle unmasked the sweeping negative gen-
  orthoptist, and termination of orthoptic        cal procedures are ordinarily not ap-         eralizations aimed at optometry with no
  training before establishment of good           plied. The examinations of the visual         conclusive supporting documentation. It
  binocular stability.                            functions and of visual skills were re-       points out how the references offered are
· Success in administering orthoptics             ally conducted as behavior tests, not         misconstrued, nonapplicable, and grossly
  hinges on a personality profile of dignity      only to determine the refractive status       distorted.
  without arrogance, humility without             of the eyes, but also to determine the           Organized ophthalmology not only
  subservience, mental alertness without          reactions of the child as an organism         chose to ignore the legitimate critiques of
  perceptive tension, and necessary force-        to specific and total test situations.        its policy statement, but conscripted the
  fulness without aggressiveness.                  Although the Yale physicians antici-         American Academy of Pediatrics in its ef-
· The ability to impart knowledge is the        pated ophthalmologic interest in their          forts. As recently as 1998, a subject re-
  essence of orthoptic training, for in real-   work, that was not to be the case. The          view of this area chose to depict visual
  ity it is a course of instruction which the   Optometric Extension Program, and the           training as controversial, unscientific and
  orthoptist gives to the patient. A good       optometrist A.M. Skeffington in particu-        virtually irrelevant to learning.7 Pub-
  orthoptist possesses an artistic tempera-     lar, proved to be influential in post- gradu-   lished in the journal, Pediatrics, this joint
  ment and intelligence with all the vir-
                                                ate studies in vision development and           policy statement was the latest in an effort
  tues. She is teacher, nurse, friend,
                                                vision therapy. They are acknowledged           to ensure that as many parents as possible
  confidante, advisor, and healer to the pa-
                                                by Gesell et al in the preface to their text.   would be dissuaded from undertaking vi-
  tient. Her enthusiasm and genuine inter-
  est can make the difficult seem easy.         In contrast, one is hard- pressed to find       sion therapy. It is important to note that
  These qualities are the piece de resis-       reference to the work done at the Yale In-      the pediatric/ophthalmologic policy state-
                                                stitute of Child Development in tradi-          ments overlooked a landmark paper pub-

Volume 13/2002/Number 2/Page 38                                                                                 Journal of Behavioral Optometry
lished in the Journal of the American          ticle, “Is vision therapy quackery?”,             from firsthand experience devel-
Optometric Association on the efficacy of      speaks for itself.                                oped considerable skepticism about
optometric vision therapy, including over         Permit me to illustrate the sensational-       the scientific base of many things
200 references.8 More recently, a Joint        ism of this approach with an analogous ti-        done by physicians. Several years
Policy Statement was issued by the Amer-       tle for a prospective article: “Is                ago – which means things should
ican Academy of Optometry and the              Strabismus Surgery A Hoax?” In such an            have improved in the meantime – I
American Optometric Association, pin-          article I might point out that strabismus         served as an expert witness in a
pointing flaws in the criticisms of Oph-       surgery was accepted as a legitimate ap-          hearing involving the scientific va-
thalmology and Pediatrics against              proach in medicine without the benefit of         lidity of optometrists’ use of vision
optometric vision therapy.9                    controlled scientific studies, and that its       training to correct strabismus (mis-
   In one of the more candid discussions       outcome as other than a cosmetic cure re-         alignment of the eyes). Ophthalmol-
to appear in print on this subject, several    lies principally on anecdotal evidence.           ogi s t s had char ged t h a t t h e
pediatric ophthalmologists revealed their      Even if I were to present an even-handed          optometric research on vision train-
concern about the collective insouciance       analysis I have successfully cast asper-          ing did not prove that vision training
of their profession. Their remarks can be      sions by virtue of how the question of its        worked. They were right; some
found in a paper by Mazow et al on ac-         efficacy was couched.                             optometric literature on the subject
commodative and convergence insuffi-              The shallow intentions of the “Quack-          was scientifically flawed. However,
ciency, and its relationship to learning,      ery” article, and its willful or unintended       I also evaluated the research that
published in the Transactions of the           ignorance of studies that should have been        ophthalmologists used to defend
American Ophthalmological Society.10           evaluated, were exposed by one of the             their surgical approach to correct-
Consider the following (Dr. Leonard Apt,       foremost optometric researchers in ac-            ing strabismus. The literature on
p.171):                                        commodation and convergence, Dr.                  surgical correction was no more sci-
   My impression is that many ophthal-         Jeffrey Cooper.15 However, as has been            entifically valid than the compara-
   mologists handle this disorder              our experience in Optometry, no matter            ble studies on vision training.
   poorly. Too often they consider most        how thoughtful and scholarly our re-              Physicians who live in glass houses
   cases of asthenopia in young per-           sponses are to the Ophthalmologic asper-          should not throw stones.
   sons as instances of uncomplicated          sions cast on vision therapy, the negative        How does the public view the conflict-
   convergence insufficiency and treat         campaign continues.                            ing opinions of organized optometry and
   these patients with simple push-up          Fallacies inherent in                          ophthalmology? They’re likely reminded
   exercises. This unsophisticated ap-         ophthalmologic critiques of vision             of the classic New Yorker cartoon that
   proach ofttimes is not helpful and the      therapy                                        borrows a line from Gore Vidal. In the
   patient leaves dissatisfied. Many              The picture painted thus far does not       cartoon, two dogs wearing suit and tie are
   ophthalmologists do not fully appre-        seem to bode well for bridging the gap be-     seated at a bar sipping martinis. One looks
   ciate the role and function of the pro-     tween ophthalmologic and optometric            at the other and declares: “It’s not enough
   c e ss of accom modation and                viewpoints about vision therapy. How-          that we succeed. Cats must also fail.”
   convergence, their interrelation-           ever, several observations may serve oph-      Public savvy was the impetus leading to a
   ship, and how to study their                thalmologists and pediatricians well in        resolution by the National PTA, issued at
   dysfunctions. Thus proper treatment         their efforts to serve as informed patient     its national meeting in Oregon in 1999,
   is not given. Many of these patients        advocates. There is a common flaw that is      urging educators, other professionals and
   end up under the care of optome-            shared by the joint organizational policy      the public to become more conversant
   trists.                                     statements of Ophthalmology and Pediat-        with the role that vision plays in the learn-
   But Optometry has clearly demon-            rics, Koller’s quackery article, and the       ing process. Public savvy is a strong rea-
strated its body of knowledge in this area,    opinions of local ophthalmologists in-         son why The White House has issued a
with notable works that summarize its          clined to discredit optometric vision ther-    statement every year, for the past decade,
clinical relevance and validity.11-13 Oph-     apy and its practitioners. It is counter-      honoring August as Vision and Learning
thalmology has not undertaken Dr. Apt’s        intuitive that material taught in every Col-   Month.
challenge to develop a more sophisticated      lege of Optometry in the country, and for         All this begs an obvious question: If vi-
clinical approach to vision problems that      which there are definitive clinical practice   sion therapy is unsubstantiated and mis-
contribute to learning difficulties. Rather    guidelines issued by a national profes-        guided, how does it survive in the
than objectively evaluate ongoing              sional organization in existence for over      marketplace? Consider the following: Op-
optometric contributions to this field,        100 years, 16 has no basis. This was           tometrists are rarely, if ever, the first pro-
ophthalmology collectively continues to        brought to the surface by Jeffrey Bauer, a     fessionals consulted when parents find
take a simpler and less responsible ap-        Ph.D., Fulbright Scholar, and Kellogg          their children struggling to learn. Optom-
proach. The quintessential low road was        Foundation National Fellow, who noted:17       etrists who practice vision therapy are
taken in an article published in the Review       Regarding the related insinuation           therefore seeing a skewed population,
of Ophthalmology several years ago.14             that optometrists simply do not know        typically of children who are not perform-
Dripping with innuendo, the title of the ar-      as much as ophthalmologists, I have         ing to levels of realistic expectation in

Journal of Behavioral Optometry                                                                             Volume 13/2002/Number 2/Page 39
school. More than likely, they have been        QUESTION 1:                                     Academy of Optometry (AAO) has a
through a number of assessments and in-          Where is the scientific basis for              diplomate program in binocular vision
terventions prior to coming to our offices.      Optometric Vision Therapy?                     and perception as well as in pediatric
Physicians harbor the notion, evident in        ANSWER 1:                                       optometry.
the language of organizational policy            As mentioned, Dr. Cooper’s scholarly          QUESTION 5:
statements, that a proposed course of vi-        article provides references that clearly       Why is vision therapy so expensive?
sion therapy when indicated somehow de-          substantiate the scientific basis of vi-      ANSWER 5:
ters unsuspecting parents from pursuing          sion therapy. Clinical Practice Guide-         It is intriguing that physicians don’t ask
                                                 lines are available from the American          the same questions regarding the ex-
necessary and proven courses of action.
                                                 Optometric Association on the Care of          pense, scientific underpinnings, and
On the contrary, this fallacy is actually the
                                                 the Patient with Learning Related Vi-          pertinence to learning of occupational
basis for success of many patients in
                                                 sion Problems, Accommodative and               therapy, which they endorse far less
optometric vision therapy.                       Vergence Dysfunction, Amblyopia,               critically, despite the obvious parallels
   In many instances, optometric vision          and Strabismus. Each of these has ref-         between the two fields.19 To answer
therapy is successful in helping patients        erences incorporating scientific               the question directly, the fees for vision
precisely because they have had other in-        method. The research presented is              therapy services are commensurate
terventions which have ignored pertinent         commensurate with clinical research            with other therapy procedures involv-
visual abilities. In other instances visual      in fields such as occupational therapy,        ing similar bodies of knowledge and
problems trivialized by other profession-        and is equal to or better than research        time expended. Aside from the doc-
als, or the effective sensory integration of     traditionally presented for clinical           tor’s time in evaluating the patient,
visual abilities to facilitate motor planning    methods in pediatric ophthalmology.            there are often prior reports to read that
and multi-tasking, is lacking. If               QUESTION 2:                                     are pertinent to decisions about
optometric vision therapy were princi-           How do optometrists know which pa-             optometric intervention, time spent
pally “tender, loving care,”or a Haw-            tients might benefit from vision ther-         programming and sequencing activi-
thorne effect, then the prior interventions      apy?                                           ties to strike an effective balance be-
the child had would have already supplied       ANSWER 2:                                       tween office and home therapy, and
that effect. Why would vision therapy            The Four Clinical Practice Guidelines          time spent with therapists to discuss on-
supply more of a Hawthorne effect than           from the AOA mentioned above pro-              going progress.
occupational therapy, or remedial reading,       vide clear guidelines for differential di-    QUESTION 6:
                                                 agnoses. Textbooks referenced in this          Why does vision therapy work when it
or music lessons, or the myriad activities
                                                 article, in addition to others available,      does? Eye problems shouldn’t have
in which today’s parents engage their chil-
                                                 provide this as well.                          anything to do with LD or ADD since
dren? It is more likely that vision therapy
                                                QUESTION 3:                                     these are CNS or brain problems.
is helping the patient develop abilities that    Is it true that vision therapy patients are   ANSWER 6:
were a legitimate missing link in the learn-     “in for life?”                                 The retina is brain tissue. Dissociating
ing process. In acquiring improved visual       ANSWER 3:                                       the role of the eye in visual processing
processing abilities, the patient is in a        Nothing could be further from the truth.       from brain function is an artificial dis-
better position to benefit from traditional      The clinical practice guidelines above,        tinction. With regard to learning and
educational interventions.                       in addition to guidelines issued by the        attention systems, principles of cogni-
Improving the interface to better                College of Optometrists in Vision De-          tive neuroscience substantiate that in-
serve the public                                 velopment (COVD)18 based on ICD                terventions directed toward sensory
   Answers to the questions posed to me          codes for various conditions, are proof        and motor eye functions have a salutary
during the panel discussion of “Why              that this is not the case.                     and pervasive effect on central pro-
Can’t EYE Learn?” will not immediately          QUESTION 4:                                     cesses of the brain.
bridge the chasm between ophthal-                How might I judge if a patient is in need
                                                                                               References
mologic and optometric points of view,           of vision therapy, or if a person I am re-    1. Romano P. Report of the meeting of the Amer-
but are important steps in the right direc-      ferring the patient to is a credible pro-        ican Academy of Pediatrics Section on
                                                 vider?                                           Ophthalmology “Why Can’t EYE Learn?”
tion. Close inspection of these answers                                                           Bin Vis & Strab Quart 2001;18:217-21.
may influence ophthalmology and pediat-         ANSWER 4:                                      2. Press LJ. The evolution of vision therapy. In:
rics to channel its efforts in patient advo-     All optometrists receive graduate edu-           LJ Press, ed. Applied Concepts in Vision
                                                 cation in and are licensed to practice vi-       Therapy. St. Louis: Mosby, 1997:208.
cacy toward interventions that truly                                                           3. Kramer ME. Clinical Orthoptics: Diagnosis
                                                 sion t her apy. T he O pt om et r i c            and Treatment. St. Louis: C.V. Mosby, 1949.
warrant skepticism. Optometric vision                                                          4. Gesell A, Ilg FL, Bullis GE. Vision: Its Devel-
                                                 Extension Program (OEP) provides
therapy has stood the test of time and the                                                        opment in Infant and Child. New York:
                                                 post-graduate education in the areas             Harper and Row, 1949.
metric of clinical science to the point          encompassing vision therapy. The Col-         5. Flax N. The eye and learning disabilites. J Am
where the practice of deterring patients         lege of Optometrists in Vision Devel-            Optom Assoc 1972;43:612-17.
from seeking this service becomes ques-                                                        6. Flax N, Mozlin R, Solan HA. Discrediting the
                                                 opment (COVD) provides a board                   basis of the AAO policy: Learning disabilities,
tionable.                                        certification process, and has a national        dyslexia and vision. J Am Optom Assoc
                                                 directory of providers. The American             1984;55:399-403.



Volume 13/2002/Number 2/Page 40                                                                                  Journal of Behavioral Optometry
APPENDIX 1                                                         APPENDIX 2
   PRIMARY DIAGNOSTIC CONDITIONS                               SAMPLE METHODS FOR OPTOMETRIC VISION THERAPY
           AMENABLE TO                              AMBLYOPIA
    OPTOMETRIC VISION THERAPY*                      Sequence:    1. Appropriate Rx
                                                                 2. Occlusion therapy
 Diagnostic Condition              ICD-9-CM                      3. Eye-hand coordination
                                     CODE                        4. Ocular motor accuracy
 Accommodative excess                367.53                      5. Accommodative therapy
 Accommodative                       367.50                      6. Fusion enhancement
      insufficiency                                 Methodology: For 1) and 2) standard approaches
 Accommodative infacility             367.50                     For 3) letter tracking sheets; pointer-in-straw
 Amblyopia                            368.01                     For 4) Haidinger Brush device (foveal fixation)
 Convergence excess                   378.84                     For 5) loose lens accommodative rock
 Convergence insufficiency            378.83                     For 6) Polaroid vectrograms
 Divergence excess (DE)               378.24        ACCOMMODATION
 Divergence                           378.85        Sequence     1. Appropriate Rx
      insufficiency (DI)                                         2. Monocular accommodative stimulation
 Esotropia                            378.35                     3. Monocular accommodative relaxation
 Exotropia                            378.15                     4. Binocular accommodative stimulation
 Intermittent exotropia               378.23                     5. Binocular accommodative relaxation
      (DE or basic)                                 Methodology  For 1) standard approach including multifocal if indicated
 Intermittent esotropia               378.21                     For 2) through 5) loose lens and lens flippers
      (DI or basic)                                              For 2) through 5) letter charts of various sizes utilized at
 Vertical deviations                  378.43                     appropriate dioptric demand distances
 Visual processing deficit(s)         315.90        VERGENCE
                                                    Sequence     1. Appropriate Rx
 *The clinical practice guidelines delin-                        2. Monocular accommodative and ocular motor activities if
 eating these diagnoses can be found in                          evidence of inequality OD vs. OS
 the following monographs published by                           3. Bi-ocular phase of 2) if suppression evident
 the American Optometric Association                             4. Physiological diplopia therapy if spatial localization deficient
 (St. Louis):                                                    5. Expansion of fusional vergence ranges
 1. Care of the Patient with Strabismus:                         6. Integration of accommodative and fusional vergence ranges
    Esotropia and Exotropia (1995)                  Methodology  For 1) standard approach using prism if indicated
 2. Care of the Patient with Accommoda-                          For 2) amblyopia and accommodation above
    tive and Vergence Dysfunction (1998)                         For 3) septum or prism dissociation
 3. Care of the Patient with Learning Re-                        For 4) Brock string (beads)
    lated Vision Problems (2000)                                 For 5) Computerized random dot stereograms/adapted stereoscopes
                                                                 For 6) Stereoscopes; orthopic and chiascopic fusion/lens flippers
                                                    STRABISMUS
7 American Academy of Pediatrics (Committee         Sequence     1. Appropriate Rx
   on Children with Disabilities American Acad-
   emy of Pediatrics and American Academy of                     2. Monocular accommodative and ocular motor phase
   Ophthalmology, American Association for                       3. Monocular activities in a binocular field
   Pediatric Ophthalmology and Strabismus).                      4. Anti-surppresion; bi-ocularity
   Pediatrics 1998.102:1217-19.
8. Special report: The efficacy of optometric vi-                5. First, second, third degree fusion (select free space or
   s io n t h e r a p y. J Am O p to m A sso c                   instrument stimuli based on correspondence and depth
   1988;59:95-105.
9. American Academy of Optometry, American                       of suppression)
   Optometric Association. Vision, learning and                  6. Integration of fusion with vestibular-motor feedback
   dyslexia: A joint organizational policy state-                7. Integrate sensorimotor functions including accommodation
   ment. J Am Optom Assoc 1997;68:284-86.
10.Mazow ML, France, TD, Finkelman S, et al.                     (including AC/A and CA/C effects)
   Acute accommodative and convergence insuf-       Methodology  For 1) standard approach using multifocals and prism if indicated
   ficiency. Tr Am Ophth Soc 1989;87:158-173.                    For 2) anaglyphic or polaroid targets
11.Rosner J. Helping Children Overcome
   Learning Difficulties. 3rd ed. New York:                      For 4) anaglyphic, septum, or prismatic dissociation targets
   Walker and Company, 1993.                                     For 5) major amblyoscope; adapted mirror sterescopes;
12.Scheiman MM, Rouse MW. Optometric Man-                        computerized vergence stimuli
   agement of Learning-Related Vision Prob-
   lems. St. Louis: Mosby, 1994.                                 For 6) egocentric/oculocentric balance activities (may preceed
13.Griffin JR, Christenson GN, Wesson MD.                         anti-suppression when indicated by clinical assessment)
   Optometric Management of Reading Dys-
   function. Boston: Butterworth-Heinemann,                      For 7) orthopic and chiascopic free space fusion stimuli with lens
   1997.                                                         flippers and variable viewing distances and angles
14.Koller HP. Is vision therapy quackery? Re-
   view of Ophthalmology 1998;3:38-49.


Journal of Behavioral Optometry                                                                          Volume 13/2002/Number 2/Page 41
15.Cooper J. Deflating the rubber duck. J Behav
   Optom 1998;9:115-19.
16.Optometric clinical practice guideline: Care
   of the patient with learning related vision
   problems. St. Louis: American Optometric
   Association, 2000.
17.Bauer JC. Not What The Doctor Ordered. 2nd
   ed. Columbus, OH: McGraw-Hill, 1998.
18.College of Optometrists in Vision Develop-
   ment. , www.covd.org or 1-888-268-3770
19.Scheiman M. Understanding and Managing
   Vision Deficits: A Guide for Occupational
   Therapists. Thorofare, NJ: Slack, 1997.

Corresponding author:
Leonard J. Press, O.D., FCOVD, FAAO
Optometric Director
The Vision and Learning Center
Fair Lawn, NJ 07410

Journal of Behavioral Optometry
published by:
Optometric Extension Program Founda-
tion, Inc.
1921 East Carnegie Ave., Suite 3-L
Santa Ana, CA 92705
949-250-8070
www.oep.org




Volume 13/2002/Number 2/Page 42                   Journal of Behavioral Optometry

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Tv opthalmologist&optometrist

  • 1. THE INTERFACE BETWEEN OPHTHALMOLOGY OPTOMETRIC VISION THERAPY & n Leonard J. Press, O.D. Introduction Orthoptics had its heyday from early to T mid-20th century, but was gradually Abstract he impetus for this pa- transformed from an active therapeutic Considerable disparity lies between per stems in part from a service into a marginal service. The num- o p h th alm ologic impressions of meeting that I attended ber of certified orthoptists in the United optometric vision therapy, and the reality on March 21, 2001, in States dwindled, and those remaining pro- of optometric vision therapy as practiced Orlando, Florida. Re- gressively engaged in assisting with pre in the United States. The viewpoint shared viewed in a prior issue of this journal, the and post strabismus surgical measure- by ophthalmology in particular, and the meeting entitled “Why Can’t EYE ments and monitoring rather than in per- medical field in general, is one that is fil- Learn?” was jointly sponsored by Jeffer- forming non-surgical therapeutic tered through organizational policy state- son Medical College and the Section on services. The service itself was diluted ments and the isolated experiences of Ophthalmology of the American Acad- from an active approach to amblyopia and influential individual practitioners. This emy of Pediatrics (AAP).1 The subtitle of strabismus therapy to a passive approach has resulted in a skewed portrayal of this meeting was: “Learning Differences for a handful of convergence problems. optometric vision therapy. The purpose of and Visual Perception from a Pediatric This raises an obvious question. Why, this paper is to present a balanced per- Ophthalmology and Neuro-psychology if orthoptics was efficacious for a broad spective on this subject, and one that Perspective.” spectrum of binocular applications, was should be of assistance in creating an in- My participation during this meeting the field virtually vacated by ophthalmol- terface between ophthalmology and op- was serendipitous. Dr. Harold Koller, who ogy? The answer, to be succinct, is that tometry that better serves the public. I had known from my days in the Philadel- orthoptics was more than most ophthal- phia area, was the Chair of the meeting. mologists could manage. This belief is During his presentation, Dr. Koller made supported by an authoritative textbook on Editor’s note several passing references to Optometry Orthoptics from 1949 by Mary Everist This article originally appeared in Binoc- and vision therapy. Following his invita- Kramer, supervisor of the Orthoptics De- ular Vision & Strabismus Quarterly, tion to me to give a short [impromptu] pre- partment at the George Washington Uni- 2002; 17(1):6-11. We wish to thank editor, sentation on the subject, I joined the group versity Hospital in Washington, DC.3 The Paul E. Romano, MD, MS for his permis- on the podium for a panel discussion. The text was edited by Ernest A. W. Shepard, sion to reprint. questions to me from the audience M.D., Professor of Ophthalmology at the touched on six areas of concern that I will George Washington University School of address at the end of this paper. Medicine. In the Preface, we find the fol- The evolution of optometric vision lowing candid observation: therapy “When ophthalmologists discuss or To appreciate the science and substance write about orthoptics, their views are of optometric vision therapy, it is insight- generally based upon the work of an ful to consider vision therapy as an out- orthoptic technician, the results of whose growth of orthoptics. This evolution has work they have observed. Since few oph- been chronicled in detail elsewhere,2 and thalmologists have had the opportunity to several points need to be elaborated. Al- observe good orthoptists, there is a wide though ophthalmologists pioneered variance of opinion regarding the role of orthoptics, it was neither cost-effective orthoptics in the treatment of ocular im- nor time-effective in their hands. balances.” Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 37
  • 2. Consider the following guidelines for tance in the accomplishment of a rapid tional ophthalmologic sources. This is not successful orthoptic treatment as outlined and lasting cure for her patients. as much as oversight as it is evidence of by Kramer and Shepard (pp. 154-169): Ophthalmologic practice drifted from the disinterest of ophthalmology in visual · Necessitates frequent office visits at the holistic attributes required for success development from a behavioral perspec- first, with gradual reduction as the train- as outlined by Kramer. As ophthalmology tive. ing is carried out at home. was becoming an increasingly medical Ophthalmolgic initiatives to dis- · Approximate length of time of treatment and surgical practice, optometry in credit vision therapy is usually from two months to two years. mid-century was rendering vision therapy Nature abhors a vacuum and, as optom- · If surgery is indicated the ophthalmolo- services well-suited to these attributes for etrists began to improve patient’s perfor- gist may prefer to give orthoptic training orthoptic success. Another text published mance through vision therapy programs, before surgery, or institute surgery be- in 1949 is essential in understanding the ophthalmologists found themselves hav- fore orthoptic training. The decision pivotal role that Optometry was about to ing to address inquiries about how a rests upon the type of case, the age, the play. Entitled Vision: its Development in child’s vision might be influencing behav- physical and mental development of the Infant and Child, this text represented a ior, development, or school performance. patient, the cooperation of the patient fusion of Optometry, Ophthalmology, In 1972, the American Academy of Pedi- and parents, and the ease or difficulty of Orthoptics and Psychology.4 atrics, the American Academy of Oph- making weekly visits to the doctor’s of- Pediatric ophthalmologists should be thalmology and Otolaryngology, and the fice. conversant with the collaboration that American Association of Ophthalmology · The training must be intensive to be ef- took place among these fields at the Yale issued a policy statement entitled “The fective. Breaks in training should be Clinic of Child Development. Arnold Eye and Learning Disabilities”, which de- given when the child reaches a point of Gesell, M.D., and Frances Ilg, M.D., were nied any relationship between vision and saturation after intensive training. substantially aided by Vivienne Ilg, O.D. learning. The inaccuracies in this policy · More than treating “a pair of eyes”, and Gerald Getman, O.D., in this effort. statement were swiftly pointed out in an orthoptics consists of treating the person Their work was unparalleled in the field of article in the Journal of the American as a whole, since much of the success of restoring normal binocular vision de- child development. The melding of Optometric Association by Flax.5 orthoptics with an optometric perspective Despite Flax’s scholarly refutation of pends upon the personality, cooperation, and enthusiasm of the child. served to broaden the basis for optometric the points raised in the 1972 paper, an ad vision therapy as practiced in the second hoc working group of the American Asso- · Training should be adapted to a child’s mental capacities as well as to his ocular half of the 20th century. Permit me to ciation for Pediatric Ophthalmology and skills. Some children learn faster than quote from the preface of this text: Strabismus, and the American Academy others, some retain knowledge better The authors have attempted to achieve of Ophthalmology, issued a policy state- than others, some have greater concen- a closer acquaintance with the interre- ment in 1981 entitled “Learning Disabil- tration ability than others, some are lations of the visual system per se and ities, Dyslexia, and Vision” offering more attentive than others. the total action system of the child. conclusions similar to those in the 1972. · Causes for failure in orthoptics include This finally entailed the use of the Again Flax, this time with two associates, inexperience or poor judgement on the retinoscope and of analytic optometry authored a scholarly rebuttal.6 Their arti- p a rt of the ophthalm ologist or at early age levels where these techni- cle unmasked the sweeping negative gen- orthoptist, and termination of orthoptic cal procedures are ordinarily not ap- eralizations aimed at optometry with no training before establishment of good plied. The examinations of the visual conclusive supporting documentation. It binocular stability. functions and of visual skills were re- points out how the references offered are · Success in administering orthoptics ally conducted as behavior tests, not misconstrued, nonapplicable, and grossly hinges on a personality profile of dignity only to determine the refractive status distorted. without arrogance, humility without of the eyes, but also to determine the Organized ophthalmology not only subservience, mental alertness without reactions of the child as an organism chose to ignore the legitimate critiques of perceptive tension, and necessary force- to specific and total test situations. its policy statement, but conscripted the fulness without aggressiveness. Although the Yale physicians antici- American Academy of Pediatrics in its ef- · The ability to impart knowledge is the pated ophthalmologic interest in their forts. As recently as 1998, a subject re- essence of orthoptic training, for in real- work, that was not to be the case. The view of this area chose to depict visual ity it is a course of instruction which the Optometric Extension Program, and the training as controversial, unscientific and orthoptist gives to the patient. A good optometrist A.M. Skeffington in particu- virtually irrelevant to learning.7 Pub- orthoptist possesses an artistic tempera- lar, proved to be influential in post- gradu- lished in the journal, Pediatrics, this joint ment and intelligence with all the vir- ate studies in vision development and policy statement was the latest in an effort tues. She is teacher, nurse, friend, vision therapy. They are acknowledged to ensure that as many parents as possible confidante, advisor, and healer to the pa- by Gesell et al in the preface to their text. would be dissuaded from undertaking vi- tient. Her enthusiasm and genuine inter- est can make the difficult seem easy. In contrast, one is hard- pressed to find sion therapy. It is important to note that These qualities are the piece de resis- reference to the work done at the Yale In- the pediatric/ophthalmologic policy state- stitute of Child Development in tradi- ments overlooked a landmark paper pub- Volume 13/2002/Number 2/Page 38 Journal of Behavioral Optometry
  • 3. lished in the Journal of the American ticle, “Is vision therapy quackery?”, from firsthand experience devel- Optometric Association on the efficacy of speaks for itself. oped considerable skepticism about optometric vision therapy, including over Permit me to illustrate the sensational- the scientific base of many things 200 references.8 More recently, a Joint ism of this approach with an analogous ti- done by physicians. Several years Policy Statement was issued by the Amer- tle for a prospective article: “Is ago – which means things should ican Academy of Optometry and the Strabismus Surgery A Hoax?” In such an have improved in the meantime – I American Optometric Association, pin- article I might point out that strabismus served as an expert witness in a pointing flaws in the criticisms of Oph- surgery was accepted as a legitimate ap- hearing involving the scientific va- thalmology and Pediatrics against proach in medicine without the benefit of lidity of optometrists’ use of vision optometric vision therapy.9 controlled scientific studies, and that its training to correct strabismus (mis- In one of the more candid discussions outcome as other than a cosmetic cure re- alignment of the eyes). Ophthalmol- to appear in print on this subject, several lies principally on anecdotal evidence. ogi s t s had char ged t h a t t h e pediatric ophthalmologists revealed their Even if I were to present an even-handed optometric research on vision train- concern about the collective insouciance analysis I have successfully cast asper- ing did not prove that vision training of their profession. Their remarks can be sions by virtue of how the question of its worked. They were right; some found in a paper by Mazow et al on ac- efficacy was couched. optometric literature on the subject commodative and convergence insuffi- The shallow intentions of the “Quack- was scientifically flawed. However, ciency, and its relationship to learning, ery” article, and its willful or unintended I also evaluated the research that published in the Transactions of the ignorance of studies that should have been ophthalmologists used to defend American Ophthalmological Society.10 evaluated, were exposed by one of the their surgical approach to correct- Consider the following (Dr. Leonard Apt, foremost optometric researchers in ac- ing strabismus. The literature on p.171): commodation and convergence, Dr. surgical correction was no more sci- My impression is that many ophthal- Jeffrey Cooper.15 However, as has been entifically valid than the compara- mologists handle this disorder our experience in Optometry, no matter ble studies on vision training. poorly. Too often they consider most how thoughtful and scholarly our re- Physicians who live in glass houses cases of asthenopia in young per- sponses are to the Ophthalmologic asper- should not throw stones. sons as instances of uncomplicated sions cast on vision therapy, the negative How does the public view the conflict- convergence insufficiency and treat campaign continues. ing opinions of organized optometry and these patients with simple push-up Fallacies inherent in ophthalmology? They’re likely reminded exercises. This unsophisticated ap- ophthalmologic critiques of vision of the classic New Yorker cartoon that proach ofttimes is not helpful and the therapy borrows a line from Gore Vidal. In the patient leaves dissatisfied. Many The picture painted thus far does not cartoon, two dogs wearing suit and tie are ophthalmologists do not fully appre- seem to bode well for bridging the gap be- seated at a bar sipping martinis. One looks ciate the role and function of the pro- tween ophthalmologic and optometric at the other and declares: “It’s not enough c e ss of accom modation and viewpoints about vision therapy. How- that we succeed. Cats must also fail.” convergence, their interrelation- ever, several observations may serve oph- Public savvy was the impetus leading to a ship, and how to study their thalmologists and pediatricians well in resolution by the National PTA, issued at dysfunctions. Thus proper treatment their efforts to serve as informed patient its national meeting in Oregon in 1999, is not given. Many of these patients advocates. There is a common flaw that is urging educators, other professionals and end up under the care of optome- shared by the joint organizational policy the public to become more conversant trists. statements of Ophthalmology and Pediat- with the role that vision plays in the learn- But Optometry has clearly demon- rics, Koller’s quackery article, and the ing process. Public savvy is a strong rea- strated its body of knowledge in this area, opinions of local ophthalmologists in- son why The White House has issued a with notable works that summarize its clined to discredit optometric vision ther- statement every year, for the past decade, clinical relevance and validity.11-13 Oph- apy and its practitioners. It is counter- honoring August as Vision and Learning thalmology has not undertaken Dr. Apt’s intuitive that material taught in every Col- Month. challenge to develop a more sophisticated lege of Optometry in the country, and for All this begs an obvious question: If vi- clinical approach to vision problems that which there are definitive clinical practice sion therapy is unsubstantiated and mis- contribute to learning difficulties. Rather guidelines issued by a national profes- guided, how does it survive in the than objectively evaluate ongoing sional organization in existence for over marketplace? Consider the following: Op- optometric contributions to this field, 100 years, 16 has no basis. This was tometrists are rarely, if ever, the first pro- ophthalmology collectively continues to brought to the surface by Jeffrey Bauer, a fessionals consulted when parents find take a simpler and less responsible ap- Ph.D., Fulbright Scholar, and Kellogg their children struggling to learn. Optom- proach. The quintessential low road was Foundation National Fellow, who noted:17 etrists who practice vision therapy are taken in an article published in the Review Regarding the related insinuation therefore seeing a skewed population, of Ophthalmology several years ago.14 that optometrists simply do not know typically of children who are not perform- Dripping with innuendo, the title of the ar- as much as ophthalmologists, I have ing to levels of realistic expectation in Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 39
  • 4. school. More than likely, they have been QUESTION 1: Academy of Optometry (AAO) has a through a number of assessments and in- Where is the scientific basis for diplomate program in binocular vision terventions prior to coming to our offices. Optometric Vision Therapy? and perception as well as in pediatric Physicians harbor the notion, evident in ANSWER 1: optometry. the language of organizational policy As mentioned, Dr. Cooper’s scholarly QUESTION 5: statements, that a proposed course of vi- article provides references that clearly Why is vision therapy so expensive? sion therapy when indicated somehow de- substantiate the scientific basis of vi- ANSWER 5: ters unsuspecting parents from pursuing sion therapy. Clinical Practice Guide- It is intriguing that physicians don’t ask lines are available from the American the same questions regarding the ex- necessary and proven courses of action. Optometric Association on the Care of pense, scientific underpinnings, and On the contrary, this fallacy is actually the the Patient with Learning Related Vi- pertinence to learning of occupational basis for success of many patients in sion Problems, Accommodative and therapy, which they endorse far less optometric vision therapy. Vergence Dysfunction, Amblyopia, critically, despite the obvious parallels In many instances, optometric vision and Strabismus. Each of these has ref- between the two fields.19 To answer therapy is successful in helping patients erences incorporating scientific the question directly, the fees for vision precisely because they have had other in- method. The research presented is therapy services are commensurate terventions which have ignored pertinent commensurate with clinical research with other therapy procedures involv- visual abilities. In other instances visual in fields such as occupational therapy, ing similar bodies of knowledge and problems trivialized by other profession- and is equal to or better than research time expended. Aside from the doc- als, or the effective sensory integration of traditionally presented for clinical tor’s time in evaluating the patient, visual abilities to facilitate motor planning methods in pediatric ophthalmology. there are often prior reports to read that and multi-tasking, is lacking. If QUESTION 2: are pertinent to decisions about optometric vision therapy were princi- How do optometrists know which pa- optometric intervention, time spent pally “tender, loving care,”or a Haw- tients might benefit from vision ther- programming and sequencing activi- thorne effect, then the prior interventions apy? ties to strike an effective balance be- the child had would have already supplied ANSWER 2: tween office and home therapy, and that effect. Why would vision therapy The Four Clinical Practice Guidelines time spent with therapists to discuss on- supply more of a Hawthorne effect than from the AOA mentioned above pro- going progress. occupational therapy, or remedial reading, vide clear guidelines for differential di- QUESTION 6: agnoses. Textbooks referenced in this Why does vision therapy work when it or music lessons, or the myriad activities article, in addition to others available, does? Eye problems shouldn’t have in which today’s parents engage their chil- provide this as well. anything to do with LD or ADD since dren? It is more likely that vision therapy QUESTION 3: these are CNS or brain problems. is helping the patient develop abilities that Is it true that vision therapy patients are ANSWER 6: were a legitimate missing link in the learn- “in for life?” The retina is brain tissue. Dissociating ing process. In acquiring improved visual ANSWER 3: the role of the eye in visual processing processing abilities, the patient is in a Nothing could be further from the truth. from brain function is an artificial dis- better position to benefit from traditional The clinical practice guidelines above, tinction. With regard to learning and educational interventions. in addition to guidelines issued by the attention systems, principles of cogni- Improving the interface to better College of Optometrists in Vision De- tive neuroscience substantiate that in- serve the public velopment (COVD)18 based on ICD terventions directed toward sensory Answers to the questions posed to me codes for various conditions, are proof and motor eye functions have a salutary during the panel discussion of “Why that this is not the case. and pervasive effect on central pro- Can’t EYE Learn?” will not immediately QUESTION 4: cesses of the brain. bridge the chasm between ophthal- How might I judge if a patient is in need References mologic and optometric points of view, of vision therapy, or if a person I am re- 1. Romano P. Report of the meeting of the Amer- but are important steps in the right direc- ferring the patient to is a credible pro- ican Academy of Pediatrics Section on vider? Ophthalmology “Why Can’t EYE Learn?” tion. Close inspection of these answers Bin Vis & Strab Quart 2001;18:217-21. may influence ophthalmology and pediat- ANSWER 4: 2. Press LJ. The evolution of vision therapy. In: rics to channel its efforts in patient advo- All optometrists receive graduate edu- LJ Press, ed. Applied Concepts in Vision cation in and are licensed to practice vi- Therapy. St. Louis: Mosby, 1997:208. cacy toward interventions that truly 3. Kramer ME. Clinical Orthoptics: Diagnosis sion t her apy. T he O pt om et r i c and Treatment. St. Louis: C.V. Mosby, 1949. warrant skepticism. Optometric vision 4. Gesell A, Ilg FL, Bullis GE. Vision: Its Devel- Extension Program (OEP) provides therapy has stood the test of time and the opment in Infant and Child. New York: post-graduate education in the areas Harper and Row, 1949. metric of clinical science to the point encompassing vision therapy. The Col- 5. Flax N. The eye and learning disabilites. J Am where the practice of deterring patients lege of Optometrists in Vision Devel- Optom Assoc 1972;43:612-17. from seeking this service becomes ques- 6. Flax N, Mozlin R, Solan HA. Discrediting the opment (COVD) provides a board basis of the AAO policy: Learning disabilities, tionable. certification process, and has a national dyslexia and vision. J Am Optom Assoc directory of providers. The American 1984;55:399-403. Volume 13/2002/Number 2/Page 40 Journal of Behavioral Optometry
  • 5. APPENDIX 1 APPENDIX 2 PRIMARY DIAGNOSTIC CONDITIONS SAMPLE METHODS FOR OPTOMETRIC VISION THERAPY AMENABLE TO AMBLYOPIA OPTOMETRIC VISION THERAPY* Sequence: 1. Appropriate Rx 2. Occlusion therapy Diagnostic Condition ICD-9-CM 3. Eye-hand coordination CODE 4. Ocular motor accuracy Accommodative excess 367.53 5. Accommodative therapy Accommodative 367.50 6. Fusion enhancement insufficiency Methodology: For 1) and 2) standard approaches Accommodative infacility 367.50 For 3) letter tracking sheets; pointer-in-straw Amblyopia 368.01 For 4) Haidinger Brush device (foveal fixation) Convergence excess 378.84 For 5) loose lens accommodative rock Convergence insufficiency 378.83 For 6) Polaroid vectrograms Divergence excess (DE) 378.24 ACCOMMODATION Divergence 378.85 Sequence 1. Appropriate Rx insufficiency (DI) 2. Monocular accommodative stimulation Esotropia 378.35 3. Monocular accommodative relaxation Exotropia 378.15 4. Binocular accommodative stimulation Intermittent exotropia 378.23 5. Binocular accommodative relaxation (DE or basic) Methodology For 1) standard approach including multifocal if indicated Intermittent esotropia 378.21 For 2) through 5) loose lens and lens flippers (DI or basic) For 2) through 5) letter charts of various sizes utilized at Vertical deviations 378.43 appropriate dioptric demand distances Visual processing deficit(s) 315.90 VERGENCE Sequence 1. Appropriate Rx *The clinical practice guidelines delin- 2. Monocular accommodative and ocular motor activities if eating these diagnoses can be found in evidence of inequality OD vs. OS the following monographs published by 3. Bi-ocular phase of 2) if suppression evident the American Optometric Association 4. Physiological diplopia therapy if spatial localization deficient (St. Louis): 5. Expansion of fusional vergence ranges 1. Care of the Patient with Strabismus: 6. Integration of accommodative and fusional vergence ranges Esotropia and Exotropia (1995) Methodology For 1) standard approach using prism if indicated 2. Care of the Patient with Accommoda- For 2) amblyopia and accommodation above tive and Vergence Dysfunction (1998) For 3) septum or prism dissociation 3. Care of the Patient with Learning Re- For 4) Brock string (beads) lated Vision Problems (2000) For 5) Computerized random dot stereograms/adapted stereoscopes For 6) Stereoscopes; orthopic and chiascopic fusion/lens flippers STRABISMUS 7 American Academy of Pediatrics (Committee Sequence 1. Appropriate Rx on Children with Disabilities American Acad- emy of Pediatrics and American Academy of 2. Monocular accommodative and ocular motor phase Ophthalmology, American Association for 3. Monocular activities in a binocular field Pediatric Ophthalmology and Strabismus). 4. Anti-surppresion; bi-ocularity Pediatrics 1998.102:1217-19. 8. Special report: The efficacy of optometric vi- 5. First, second, third degree fusion (select free space or s io n t h e r a p y. J Am O p to m A sso c instrument stimuli based on correspondence and depth 1988;59:95-105. 9. American Academy of Optometry, American of suppression) Optometric Association. Vision, learning and 6. Integration of fusion with vestibular-motor feedback dyslexia: A joint organizational policy state- 7. Integrate sensorimotor functions including accommodation ment. J Am Optom Assoc 1997;68:284-86. 10.Mazow ML, France, TD, Finkelman S, et al. (including AC/A and CA/C effects) Acute accommodative and convergence insuf- Methodology For 1) standard approach using multifocals and prism if indicated ficiency. Tr Am Ophth Soc 1989;87:158-173. For 2) anaglyphic or polaroid targets 11.Rosner J. Helping Children Overcome Learning Difficulties. 3rd ed. New York: For 4) anaglyphic, septum, or prismatic dissociation targets Walker and Company, 1993. For 5) major amblyoscope; adapted mirror sterescopes; 12.Scheiman MM, Rouse MW. Optometric Man- computerized vergence stimuli agement of Learning-Related Vision Prob- lems. St. Louis: Mosby, 1994. For 6) egocentric/oculocentric balance activities (may preceed 13.Griffin JR, Christenson GN, Wesson MD. anti-suppression when indicated by clinical assessment) Optometric Management of Reading Dys- function. Boston: Butterworth-Heinemann, For 7) orthopic and chiascopic free space fusion stimuli with lens 1997. flippers and variable viewing distances and angles 14.Koller HP. Is vision therapy quackery? Re- view of Ophthalmology 1998;3:38-49. Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 41
  • 6. 15.Cooper J. Deflating the rubber duck. J Behav Optom 1998;9:115-19. 16.Optometric clinical practice guideline: Care of the patient with learning related vision problems. St. Louis: American Optometric Association, 2000. 17.Bauer JC. Not What The Doctor Ordered. 2nd ed. Columbus, OH: McGraw-Hill, 1998. 18.College of Optometrists in Vision Develop- ment. , www.covd.org or 1-888-268-3770 19.Scheiman M. Understanding and Managing Vision Deficits: A Guide for Occupational Therapists. Thorofare, NJ: Slack, 1997. Corresponding author: Leonard J. Press, O.D., FCOVD, FAAO Optometric Director The Vision and Learning Center Fair Lawn, NJ 07410 Journal of Behavioral Optometry published by: Optometric Extension Program Founda- tion, Inc. 1921 East Carnegie Ave., Suite 3-L Santa Ana, CA 92705 949-250-8070 www.oep.org Volume 13/2002/Number 2/Page 42 Journal of Behavioral Optometry