Discussion between ophthalmologist and optometrist!

If your child has amblyopia and/or strabismus, you’re going to want to check this out: “Do You See With Your Eyes Or With Your Brain and … What Difference Does It Make?” on The VisionHelp Blog.

I know about it thanks to Stella’s developmental optometrist, who emails relevant vision-related news and helpful educational opportunities and resources to her patients and colleagues. Tonight she shared a link to an engaging discussion between Dr. Press, a developmental optometrist and Board Certified Fellow of the College of Optometrists in Vision Development (COVD) who contributes to The VisionHelp Blog, and Dr. Granet, a prominent ophthalmologist. Really! They communicated with each other! And did a wonderful job of it, too. Though some of their chat is very expert-level, and therefore hard to follow, I was able to glean interesting points and find references to studies worth checking out. Hope it’s helpful to someone out there!

Dr. Press’ review (on The VisionHelp Blog) of Dr. Granet’s appearance on TV’s “The Doctors sparked this online dialog. Dr. Granet should be applauded for taking the time to respond to the (relatively mild) critique of his comments on amblyopia treatment, along with the optometrists who continued to engage him diplomatically yet honestly. You may’ve seen the video segment from the show, in which Dr. Granet tests a young toddler  for vision problems due to a family history of amblyopia. I really felt for the mom and dad, who found out in front of a live audience that their child likely does struggle with her vision. I remember that moment hitting me hard in the privacy of a small exam room. But as pointed out by “The Doctors,” early detection is something to be thankful for, and they’ve got it on their side.

In the comment section you’ll find an interesting conversation in which the disconnect between ophthalmologists and optometrists is taken on directly and in a very civil fashion. I couldn’t help but chime in (possibly coming across like a hysterical idiot parent, but hey, I tried!) and I hope you will, too. After all, it’s been talked about here on Little Four Eyes frequently. The lack of clarity many of us face in making decisions about our children’s care would be alleviated greatly if the two fields could find a way to collaborate or at least communicate. This comment section interaction seems like a step in the right direction. Stella’s doctor thought it was great and I agree.

One last time, here’s the link to the post and ensuing discussion:

Do You See With Your Eyes Or With Your Brain and … What Difference Does It Make?

(P.S. The video seems worth sharing, if only to convince other parents that eye exams are a great idea for all little ones and to show them how accurate testing can be even on babies as young as six months.)

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30 responses to “Discussion between ophthalmologist and optometrist!

  1. Thanks! I’d seen the original post, but hadn’t seen the discussion. It’s a very interesting read. (And on a pretty unrelated note, as a science librarian, I love seeing how professionals in the field use and refer to their literature).

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  2. You’re being needlessly harsh on yourself – you didn’t come across like “a hysterical idiot parent” at all. You spoke from the heart, with clarity, and that is more valuable than dogma any day of the week. As I’m fond of saying, every dogma has its day, and increasing numbers of parents will insist that ophthalmologists stop saying white because we say black. Thanks for referencing the site and the discussion, and we would love to continue to hear from parents who have felt that they were given no option other than surgery, patching or glasses, or worse — were told that vision therapy is unproven, unscientific, quackery or the like. My educated hunch is that there are many more parents in that boat than parents whose children have been “dis-serviced” by VT. In the final analysis, truth will prevail.

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  3. I’m a parent of a son who had vision therapy about 2.5 to 3 years ago, and I’m still a huge fan. Just posted on my blog “Simply Stated” this morning about vision therapy and its value at http://kellysnedden.wordpress.com/. I think parents need to enter this discussion because, despite all of the medical terms, reasoning and research, we see the results at home and on the grade card. I liken vision therapy to other therapies – perhaps not everyone can benefit from it. Does every patient benefit from acupuncture? I suppose not, but for those it helps it can be a godsend. Thank you to all who continue to push for the advancement of vision therapy. Perhaps not everyone can benefit, but for those lives it does improve – wow! I know, there are many out there who have benefited.

    The huge factor in this is the child’s self-esteem I think. For those who DON’T get treatment and therefore believe they are “less than” their classroom counterparts, is a huge concern to me. How many troubled teens have given up on learning and their desired future to settle perhaps for drugs and rap sheets? When, with vision therapy, their eyes and brain could sync and a future could be revealed to them that they had long ago written off? We cannot sit back and wonder.

    I personally think vision therapy screening should be a standard part of the 20/20 vision screening children receive in schools, etc. I also believe those studying elementary and secondary education should receive a background on vision therapy and what to look for in the classroom. There are simple, quick things that can be detected. I’m a mother of a child who was struggling with reading and now reads above his grade level and has scored exemplary in reading on the state assessment. Is Vision Therapy real? You bet and Seeing is Believing!

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  4. I recently received this e-mail from a parent of a child whom I recently saw in my Annapolis, Maryland office: “As I learn more about about vision problems that cause reading problems, I want to help more children. I was very upset to find out that even though my son had an eye exam, the eye doctor did not test his “vision.” More parents and teachers need to be aware of these problems. Already after just a few weeks of vision therapy, he is picking up more books and there is much less resistance to homework. I never heard of this until just a few months ago, and I wish I knew sooner. Just because your child has 20/20 eyesight, it doesn’t mean his vision is normal. It just means he can see clearly 20 feet away. The Snellen eye chart (the one with the big E at the top) does not check for eye movement, focusing, eye teaming (moving together), depth perception, visual memory, etc. which are needed to read, write, hit a baseball, spell, and other near activities.

    Some symptoms my son had: excessive blinking or eye rubbing, headaches, blocking one eye when reading, tilting head when reading, letter reversals after first grade, poor reading comprehension, slow reading, poor sports performance, looses place when reading, skips letters, numbers and words, tantrums during homework, labled add/adhd, lazy, behavioral problem.

    For more info see http://www.VisionHelp.com http://www.pavevision.org http://www.covd.org

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  5. Dear amberhj,
    Your comment on the Vision Help blog was truly insightful, and it led me to your beautifully written posts about Stella. I am so glad you found VT for Stella, and she is making such great progress. It’s obvious you’re a wonderful mom.
    Sue Barry

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    • Wow! It’s YOU! Hello and thank you very much, Sue. I can’t tell you how thrilled I was to see your comment and how much your kind words mean to me. You and your book (including the anecdotes you share about YOUR mom, by the way, which I just LOVED) have been such a spark for me, such a source of hope and inspiration and information. Thank you so much for sharing your amazing story. I tell everyone who will listen about “Fixing My Gaze” and I have no doubt that you’ve made a huge difference in not only my little Stella’s life, but many, many children and adults. You have my utmost respect and appreciation.

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      • Dear amberhj,
        I wrote my book with parents like you in mind and in the hopes that, once others learned more about binocular vision and the effectiveness of VT, they would pass on the information. You are doing just that in a beautifully written blog that is full of keen observations and insights. Thank you for your contributions.
        Sue Barry
        PS I’m glad you liked the stories about my mother who was a remarkable parent and teacher. I knew from the time I wrote the first words of my book that I would dedicate it to her memory.

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  8. Hi Sue,
    I have also read your book and am a big fan! My little girl Paris is three and has anisometropia. She has perfect vision in her left eye and is -5 in her right, so quite a huge difference. She copes very well with the script and we also patch a few hours per day (she has an intermittent outward squint). I have heard such conflicting views on VT. My opthalmologist says patching is the best vision therapy she can do and sort of brushed off my thoughts on anything other than that. However a local behavioural optometrist seems to think Paris could benefit from VT? I am not sure what to do. Do you think with such a large difference between the eyes she would be a good candidate? Many thanks Sue.
    Ingrid

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    • Dear Ingrid,
      Dr. Len Press has given you some very good advice and nice explanations. Convergence insufficiency is not the only type of exotropia that can be helped by vision therapy. Pages 225 and 228 of my book include references for papers demonstrating the effectiveness of vision therapy for other types of exotropia as well as for amblyopia. In general, a developmental optometrist, after starting a patient on optometric vision therapy, will re-evaluate after a month or two to determine whether the vision therapy is working.
      I hope this information is helpful to you.
      Sue

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  9. Hello, Ingrid. I’ll let Sue address this from her point of view, but wanted to mention that having -5 in one eye positions Paris for better ultimate success than if she had +5 in one eye. During the first year of life she was perfectly focused with the -5, even without correction (glasses) within a region of about 8 to 10 inches from her eyes. Even though the eye with -5 is quite different from her other eye, with vision therapy there is a very good chance she can learn to use both eyes together more effectively.

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  10. Hi Len,
    Thank you so much for your response. It’s funny you should say that about her first year of life becasue her eyes were perfectly aligned until around 11 months, that’s when I started noticing the drift from time to time. I always wondered why it was fine up until then. This is what led us to see an opthalmologist and she was diagnosed with anisometropic ambloypia (with intermittent exotropia). The last visit to the orthoptist recently showed she was close to 20/20 in her weak eye (with correction of course), a big improvement from when we began this journey. She seems to do very well with coordination, however I guess time will tell when she starts school how she goes with reading/writing/copying from the black board etc and this is what scares me. The opthamologist said ultimately a contact in her short sighted eye would be much better becasue of the difference in magnification between the two lenses but would wait another couple of years at least for that. So as far as maintaining the vision in that eye and wearing the glasses full time, that seems to be on track, however I am still not happy with the drift in that eye and I really think the VT could help with that. Can I ask why a -5 in that eye is better than if she had a +5? Also I am amazed that the eyes can develop like this. There is no history of any eye conditions on either side of the family and she was a full term healthy baby. I guess I am always looking for an answer as to why she has this. I will admit to worrying and stressing probably too much about it. I know there are much much worse things but I am absolutely determined to everything I can possibly do to make sure I help her as much as I can and I will do whatever it takes. I think it’s only when you have a child with vision issues you realise just how important the eyes are and how multi faceted the visual system is. I admit I have taken it for granted that my other two children have no vision problems. Thank you so very much for taking the time to respond and I hope I don’t come accross as a neurotic mother!! I am just wanting to do the best I can.
    Thanks again, Ingrid.

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  11. Sorry Len,
    I meant to also say, you are spot on when you say that many opthalmologists brush off the mention of VT. One Opthalmologist we have seen said “patching IS vision therapy and if there was anything else that would help Paris do you not think I would be referring you?”. Another said that the only type of exotropia that can be helped with VT is convergence insufficiency? where the eye drifts when looking at objects close up. Paris’s drift manifests itself more when looking in the distance. Needless to say the whole thing is very confusing.

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  13. You’re welcome, Ingrid. The answer to your question as to why -5 is better than +5 is this: The focal point where a -5 uncorrected eye is perfectly in focus, without any lens in place, is 8 inches. That means that before Paris received her glasses, whenever she was looking a something within 8 inches of her eyes, both eyes were simultaneously in focus. Under the age of 6 month, children spend a significant amount of time focusing within that near space. Beyond 6 months of age there sphere of visual regard progressively moves outward. As Paris spent more time looking at further distances, the -5 eye was disadvantaged relative to the other eye. The less it was used, the more it became amblyopic. Her brain is pretty smart, so it began to alter the signal to the -5 eye to decouple it’s muscle action from the normal eye, hence the outward drift.

    I do agree that a contact lens for the -5 eye instead of glasses, but I see no need to wait. Why not prescribe the contact lens now to give her the benefit of the best development of binocular vision possible. It’s not just the magnification difference. Through glasses there is a prism effect induced every time she looks off center, but with a contact lens the unwanted prism effect is eliminated. If you take Paris to a developmental optometrist, indicate your interest in seeing that she be fit with a contact lens instead of the glasses.

    Hope this has made the issue less confusing. As far as ophthalmologists giving you the brush-off, here’s my latest commentary:
    http://visionhelp.wordpress.com/wp-admin/post.php?post=2476&action=edit

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  15. Thank you so very much Len. It is very kind of you to take the time to answer my questions. I am definitely going to raise the contact lense idea with the developmental optometrist. Do you think VT at this early stage (3 years) would be beneficial in improving the drift? We are really hoping to avoid surgery.
    You have really cleared up my questions. Thank you.
    warmest regards,
    Ingrid

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    • My pleasure, Ingrid. Yes, VT would be beneficial in improving the drift, provided that the conditions can be arranged for improvement. That will be a combination of Ingrid’s ability to participate in meaningful therapy, and the doctor’s skill in organizing the delivery of therapy. As long as the exotropia remains intermittent, there is no need to rush to surgery. See what Paris can accomplish through active vision therapy first (I say active as differentiated from the “she doing enough therapy by wearing glasses” false sense of security).

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      • My daughter’s PO said almost exactly “she’s doing enough therapy by wearing glasses”. He said that her intermittent exotropia wouldn’t be helped by anything else and that we basically just have to hope she can control it. Then if she continues to get worse, we’d have to look into surgery sometime in the future. She’s been wearing the same prescription since she started wearing glasses last March.

        Do you think that there ARE certain conditions that would not be helped by VT? What’s the optimum age to start?

        Thanks,
        Stephanie

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  16. Thank you very much Sue. I have just read the amazing debate between Dr Granet and Dr Len Press. Absolutely fascinating! I must say how articulate they both are in expressing their profound knowledge in their respective fields. I have learned so much from reading it. I am definitely going to go down the VT path with Paris and I am really looking forward to posting on her progress.
    Thank you to all you wonderful people for your input.
    Kind regards,
    Ingrid

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    • Glad you found it illuminating, Ingrid. Too often ophthalmologists based their comments about VT on impressions, and make those comments either behind closed doors or in the selective, pseudo-scientific trappings of one-sided policy statements. Dr. Granet’s comments were merely one very public example of what you have experienced on a local level. I have made the case for an open discussion of facts based on the limitations of the pediatric ophthalmologic/orthoptic framework of visual development. Sue is the prototype of an intelligent, informed patient who has inspired hundreds if not thousands of patients and parents to have their voices heard. By continuing to weigh your options intelligently, and sharing your experiences, you give meaning to our efforts. Above all, best wishes for success in seeing Paris develop to her full visual potential.

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  17. Thank you so much Len. You are sbsolutely right, Sue is the perfect prototype of an informed, intelligent patient. I have read an overview of her book on line and have ordered it straight away. I will certainly continue to share our experiences as we embark on this VT journey and having had your very valuable input has made me feel much more confidant in doing so. Thank you. I am in Australia by the way, so the one-sided comments are certainly world-wide! I will keep in touch. Thank you for your kind words of encouragement. It means a great deal.

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    • Ingrid, best of luck with vision therapy and please do keep us posted! I’ll do the same! It’s exciting work, and I’m sure you’ll find it all very fascinating–I know I do. There will be challenging moments, but also breakthroughs and progress to keep you confident and moving forward…. that’s been our experience.

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  19. Stephanie :
    My daughter’s PO said almost exactly “she’s doing enough therapy by wearing glasses”. He said that her intermittent exotropia wouldn’t be helped by anything else and that we basically just have to hope she can control it. Then if she continues to get worse, we’d have to look into surgery sometime in the future. She’s been wearing the same prescription since she started wearing glasses last March.
    Do you think that there ARE certain conditions that would not be helped by VT? What’s the optimum age to start?
    Thanks,
    Stephanie

    To be brief, Stephanie, there are very few non disease conditions that can’t be helped by VT, Stephanie. A congenital or traumatic cataract, a hazy cornea, or any damaged structure that is an optical component of the visual system typically needs a surgical or medical assist. Large amounts of nearsightedness, farsightedness or astigmatism are difficult to alter with vision therapy. Nystagmus, which is an involuntary “wobbling” motion of the eyes, is difficult to improve with vision therapy, and so forth. Barring a damaged part of the eye or visual pathway, most visual conditions respond quite well to optometric vision therapy. Once the Doctor of Optometry determines that vision therapy can be of benefit, the optimum age to start is when a child is cognitively and behaviorally ready. It’s cradle to grave, so to speak, yet very individualized based on each patient’s circumstances.

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  20. What of a 3 year old girl who has had surgery for strambismus and has an astigmatism (I think) with a prescription of +7/+8? Is there any hope that she could have depth perception? My husband has -7 lenses and has had surgery for crossed eyes…has depth perception. I have had several surgeries and patching as a child, but have only one “good eye” though I didn’t have glasses until college. In fact, I don’t like to wear my glasses as I see very well in my home but it’s longer distances I don’t see as well.

    My daughter’s surgeon told me that she doesn’t expect her to gain depth perception. I’ve asked the question before, she’s never really commented so starkly. She believes my daughter was born with crossed eyes (not so, when she was little I have photos of her and her eyes didn’t cross until she was almost a year). I had hoped her vision could improve, but learned this last visit that the goal was for straight eyes. I wanted more for my child if possible, depth perception and possibly improved vision overall. I know the cosmetic is important expecially socially, but what is the surgery for really if it cannot correct depth perception and the eyes don’t work together? Could we not have waited on surgery rather than push it so soon (a little over a year rather than wait and do some sort of therapy?). I had surgery and so that’s what I thought you would do…

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    • Hello christainlady and welcome to this important discussion!

      I’m the author of this post and my daughter (Stella) is moderately farsighted (about +3 and +4) and has astigmatism and amblyopia.

      I must include a disclaimer here–I’m only a parent and not qualified to give medical advice! BUT I have to say that the surgeon’s statement is practically unethical. Vision therapy has been proven time and time again to encourage binocular fusion and help people gain stereoscopy (3D vision/depth perception). Please read “Fixing My Gaze” by Sue Barry! She had no stereoscopy until she was 48. That’s when she did vision therapy and went from a flat world to a three dimensional world! I think that your doctor is selling you short, and it’s unacceptable. Just my opinion but it’s a strong one! 🙂

      When it comes to surgery and vision therapy–they are not mutually exclusive. Sometimes both are necessary for optimal outcomes. Surgery and getting the cosmetic piece taken care of is great. But vision therapy can take it to the next level by teaching the brain how to use both eyes together, which is necessary for stereoscopy (3D/depth perception). I encourage you to bring your daughter to a developmental optometrist for a consultation. See what they say, and then decide.

      You can find a qualified developmental optometrist by clicking on the “Locate a Doctor” link in the upper right hand corner of the http://covd.org/ home page.

      I also recommend the book “Jillian’s Story”, which I am reading now. Written by the mother of a little girl who was born legally blind in one eye (not discovered until about age 5), this book shares how vision therapy refurbished her daughter’s sight and changed her life in amazing ways.

      I hope these resources are helpful. Good luck!

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