Below is my official response to the Canadian Journal of Optometry to the piece reported back in Vol 76, Issue 2 of this year.
It is insufficient to simply present facts to rebut academic attacks, but to confront deep-seated misunderstanding and bias where they begin. The response below has been submitted and I am given to understand it will lead the pack in the upcoming flurry of discussion around the initial ‘research study’ printed in the CJO.
Prior to engaging in full-time advocacy around the dire and unmet need for adequate child vision management, I was privileged to study and work in neural science, neuropsychology, psychometrics, education, and high tech. In all of these instances, I have been called upon as an expert to provide professional advice, solutions, and guidance to customers, clients, parents, and administrators, and diverse audiences. There has never been any doubt about my experience, and people have most often found my advice to be insightful and well worth the consideration.
In stark contrast, when vision is discussed – in the sense of vision function and its training through visual rehabilitation – doctor eyes glaze over. It is truly one of the oddest things I have ever encountered in my professional life. Teachers get it, OT’s and PT’s get it, and a growing number of psychologists get it: Vision matters, and there’s more to vision than simple ‘blur’. Part of this differential response is due to training. General OD’s and many MD’s still have trouble with these concepts and will decry the notion that OVT has any place in … well … anything because of a fairly narrowed professional experience. We can speculate until the cows come home as to why, but in reality, it is simply a matter of professing expertise where none exists.
My thanks to Editor in Chief Ralph Chou for doing such a great job walking the tightrope on this. There is politics, then there is fact, knowledge, and clinical efficacy. Dr. Chou, it is true that many dispute the value of ‘VT’, but in my considerable experience, there is little doubt left that those who still sneer are strictly confined to the subset of doctors who simply do not know because they have not looked in the right places.
There remains no doubt that vision is a core function to humans: Not sight, or the ability to point the eyes, but the whole bundle including sensory inputs to vision, vestibular integration, diverse cortical and sub-cortical connections for planning and execution. When vision is askew, so is development, so is learning. When we address vision as a larger entity, we see not only improvements in visual targeting, but global improvements in the child’s performance and demeanor. Even a cursory survey of principles involved will convince even the greatest doubters – if they are honest at all. It astounds me that so many would ignore the broader picture of vision, beyond the eyes and 20/20 acuity, when we are so rooted in vision in nature, and now almost to the exclusion of other senses, in the the classroom. There is a real blindness in health and education that contributes to ever widening learning gaps, and increasing budgets.
Ignoring child vision development is easily the most obvious removable obstacle in pediatric health and early education in our computer-centric world, and those who look at the facts immediately recognize that as a plain truth. Don’t even get me started on OVT for strab, amblyopia, TBI, geriatrics, behaviour enhancement, ergonomics…
Footnote: I know that many of my colleagues and I have many free hours available for drafting and publishing position statements for the CAO on the topic of vision development as there are none. We are also all only too happy to engage in the child vision month activities initiated recently by the CAO, and look forward to raising awareness again this Fall. More needs to be done on this as we’re all paying too high a price to ignore it.
In Volume 6, Issue 2 of the Canadian Journal of Optometry, your editorial refers to the practice of optometry as a diverse profession, managing a wide variety of conditions for our patients, calling upon broad knowledge to understand how to accomplish this. Just a few pages later, one article in particular seems to go far afield professionally in order to justify how optometrists should do just the opposite: Limit diversity in practice, manage a narrower variety of concerns, and forget their extensive knowledge and experience in doing so.
The title of the article in question itself asks the question of whether there is evidence to support use of vision therapy (Optometric Vision Therapy, ‘OVT’, or simply, ‘VT’) for LD. See: CJO Vol 6, Issue 2, “Diverses modalities de traitement des troubles d’apprentissage scolaire par therapies visuelles: quelles sont les evidence scientifiques?”. The title immediately identifies the bias of the authors, but also points to a lack of specific knowledge: Any doctor who has undertaken training vision rehabilitation through any of the behavioural schools in the United States, or through COVD, OEP, or NORA would never ask the question of ‘if’ there is evidence, and would sooner engage in discussion around the evidence itself, and how to best implement this in practice. Modern optometric vision rehabilitation has advanced treatment of amblyopia, strabismus, and reaches beyond this to include the care of TBI, child development, and learning concerns. ‘VT’ is not simply eye exercises, lenses and filters, as the authors seem to suggest –evidence that we are not discussing the same topic.
More concerning is the professional bias in this purported research piece. There is a longstanding push on the part of some professionals to marginalize optometric vision rehabilitation, ‘VT’, as ‘unscientific’ or not based in ‘evidence’ – a somewhat less provocative turn of phrase than ‘quackery’. This is presumably in order to protect the public against unscrupulous doctors who make irrational promises regarding children’s vision and then never deliver on the results. Similar concerns can be raised about virtually every profession of healthcare, psychology, and education, but for some reason there is a need to level doubt at a noble profession. OVT, not publicly funded, will always remain at the mercy of the unlimited funding of medicine, so the bias matters.
Among the obvious responses to such a paper is that some patients will be discouraged from seeking what is often the only treatment that will help. OVT has an important role to play in child development and learning disorders, yet the article summarily and somewhat condescendingly dismisses it: This is evidenced through marginalising remarks like ‘LD’ “are complex problems, sadly with no simple solutions” – impugning the OVT view of LD is a ‘simple solution’. Also, if there is truly no evidence of efficacy, what then are we to conclude of those who profess otherwise and continue to practice in this domain?
It is precisely this misunderstanding of the profession that leads me to question the frame of reference and goals of those who seek to disparage OVT in the treatment of learning disabilities. The proof is there: Stating there is no evidence only exposes a lack of relevant knowledge and training in the area of primary concern.
Academic honesty also requires the full light of scrutiny, and there is in this case no possibility for scrutiny other than of those who have promoted this paper to publication because of language of publication. Also, the authors speak from an academic perspective, where anything can be justified by means of selective citation. I have therefore translated the article to allow my English-speaking VTOD colleagues from around the world to also respond. My primary goal is to invite dialog: Clearly there is an important gap in understanding, and bias in care delivery that needs to be addressed urgently – Ignoring VT is costly.
With respect to rhetorical and clinical errata in the paper, I will remark on only a few. First, the authors assert that since individual procedures and methods do not cure dyslexia, these should be avoided. Indeed, there is no cure for dyslexia, and much of what is now accepted as standard care of children with learning disabilities lacks robust scientific support. Despite a clear bias in the evidence referenced, many of the works cited do themselves support use of certain VT elements in child development and learning. VT works in a variety of contexts for very good reasons, both clinically and scientifically; my colleagues who work in this field know this. It is disappointing the authors would ignore this knowledge and experience.
Next, the authors repeat throughout that visual impediments are an important source of exacerbation in comfort and reading, and that these should be addressed when children are suspected of having learning disabilities. On this we agree. The great preponderance of evidence also shows vision is critical to learning, that it is trainable, and that many visual conditions are subclinical and will not be detected, even with ‘comprehensive eye exams’.
Finally, the authors recommend following science-based approaches to dealing with learning disabilities, but offer none. OVT is deemed ‘not evidence-based’, but no OVT references are provided. Of interest, OVT is also omitted from their recommendations for a multi-disciplinary approach. To suggest optometry and science do not support OVT for learning disabilities is simply untenable logically, clinically, and factually.
What we call ‘evidence’ may be gleaned through observation in practice, rationalization, or both. We should never simply discard an important profession and element in therapy on conjecture alone. VT’s critical role in child learning and development deserves more than a cursory dismissal.
Charles A. Boulet, BSc, BEd, OD
Black Diamond, Alberta
- “Impact of Simulated Hyperopia on Academic-Related Performance in Children”, S. Narayanasamy, S. J. Vincent, G. P. Sampson, and J. M. Wood; Optometry and Vision Science, Vol92, No 2., 2015 – Sample, showing even simple hyperopia interferes with learning behaviour.