Vision Therapy — Where is the Evidence?


The recent article about Vision Therapy in the New York Times Magazine has created a good deal of debate and discussion.  By Monday afternoon, when comments were no longer being accepted, there were 248 comments!  As I read through many of the comments, it occurred to me where the line was being drawn in this debate.  On one side are the many patient, parents and behavioral optometrists who see lives changing because vision therapy is an effective treatment for so many patients.  On the other side are the skeptics, who have had no experience with vision therapy and can only say, “where is the evidence?”

Evidence-based medicine is defined as the “conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”  The process of evidence-based medicine BEGINS with the interpretation of clinically relevant research.  It ENDS with the careful consideration of all relevant information for an individual patient.  Evidence-based medicine has the potential to improve the clinical outcomes for patients with any diagnosis.  However, the impact of evidence-based medicine is limited by the difficulty of getting from the BEGINNING to the END.  This is where Clinical Practice Guidelines have become so important in bridging that gap.

Clinical Practice Guidelines, or CPGs, define evidence-based practice for specific diagnoses or clinical entities.  After finding and evaluating the research, a panel of experts applies the evidence by developing patient care protocols.  These protocols help the doctor determine what diagnostic and therapeutic procedures are most appropriate for an individual patient.  CPGs ARE the evidence and much more.  They help the doctor put the research into practice.

The American Optometric Association has published 20 CPGs.  They “combine the best available current scientific evidence and research with expert clinical opinion to recommend appropriate steps in the diagnosis, management, and treatment of patients with various eye and vision conditions.”  They are all available online.

For the skeptics who ask, “where is the evidence?,” here it is:

Pediatric Eye and Vision Examination

Care of the Patient with Amblyopia

Care of the Patient with Strabismus: Esotropia and Exotropia

Care of the Patient with Accommodative and Vergence Dysfunction

Care of the Patient with Learning Related Vision Problems

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8 comments

  1. I would like to add if anyone wants a listing of the research behind optometric vision therapy all they need do is to go to http://www.covd.org.

  2. Excellent post, Dr. Mozlin. The NY Times Magazine article is a classic example of an attempt by its author, Judith Warner, to manipulate readers’ opinions though the manner in which she frames her presentation.

    Daniel Kahneman and Amos Tversky pioneered in the field of behavioral economics, putting science behind the art of how we make choices. Sheena Iyengar, at Columbia University, illuminates Ms. Warner’s ploy of “manipulation by presentation”. We, of course, are familiar with The Joint Organizational Policy Statement of the American Academy of Pediatrics and the American Academy of Pediatric Ophthalmology and Strabismus (AAP/AAPOS) as a perfect example of an attempt to manipulate public opinion.

    Sheena Iyengar writes:

    “Clearly, the way we frame information for ourselves or for others can make a big difference in how we see and respond to choice. Every time we encounter new information or reexamine old information, we’re influenced by its presentation. We can use framing to our advantage, but sometimes it has a negative impact on the quality of our decisions.”

    Judith Warner bought into the framing bias of the AAP/AAPOS Joint Policy Statement in her recent book “We’ve Got Issues”, from which the article you cite was derived. Dr. Stan Appelbaum did a marvelous job in re-framing her frame such that the NY Times Magazine article toned down her bias. Toned it down, but did not eliminate it. It fascinated me to discuss this article with colleagues, as some read it as positive; some read it negative; others were unsure.

    The same spread of opinion held as I sampled colleagues about their reaction to the readers’ comments. Some felt the comments to be generally supportive; some were incensed by the negative comments; others were undecided. I went through the comments assigning either a (P) if they were positive; an (N) for negative; and (?) for neutral or off-topic.

    I was pleasantly surprised by the final tally:

    135 (P) 69 (N) 43 (?)

    Regarding the negative comments, more awareness of the AOA’s CPGs, as you note above, will be a huge aid to patients and other professionals making informed, quality choices. I would also encourage more awareness of the AOA position papers in the Clinical Care Section on:

    Vision: A Collaboration of Eyes and Brain

    http://www.aoa.org/x5417.xml

    — as well as:
    Vision, Learning and Dyslexia

    http://www.aoa.org/x5420.xml

  3. Excellent article and comments Dr. Mozlin! Thank you for post!

  4. I think one of the most important things to do is recognizing first the problem. Many of eye’s problems remain silenced and then, it’s a little too late for appropriate treatment. So before any diagnosis, the patient needs to understand how serious is the thing.

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