I’m the Data

Today Jillian and Robin Benoit visited with students at SUNY Optometry via Skype.  Together they told Jillian’s story…… how it was discovered that she had severe amblyopia; how an ophthalmologist treated her amblyopia; how her vision problems persisted even when the ophthalmologists said there was nothing more that could be done to help her; and ultimately how optometric vision therapy changed her life.

There were a few moments in their presentation today that I found particularly thought-provoking:

1.  Vision therapy changed, not only Jillian’s life, but the lives of her family and friends.  If Jillian had never learned to read music and play the clarinet, she and her family would not have traveled to see her play with her school band.  They never would have experienced the myriad of opportunities associated with writing and marketing, not 1 book, but soon to be 2 books!  And they will never have to wonder, what if I had taken her to see an optometrist when she was a baby.

2.  Jillian received an email from an ophthalmologist who seemed intent on using the never-changing defensive strategy to bash optometric vision therapy:  where is the evidence, where is the data to prove that vision therapy works.  Jillian took on the ophthalmologist by telling him, “I’m the data!  VT is for people and the people can tell if it works.”  Bravo, Jillian!

Jillian, I would like to give you another perspective on “show me the evidence, show me the data.”  The results of the Amblyopia Treatment Study 2-A were published in the journal Ophthalmology in 2003.  In that study, children between 3 and 7 years of age with severe amblyopia were randomized to 2 treatment groups: full-time or 6 hours/day of patching.  The results: visual acuity in the amblyopic eye improved a similar amount in both groups.  The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hr group and 4.7 lines in the full-time group.

Despite this evidence that was published in an ophthalmological journal, Jillian was patched for 11 hours/day for 3 years.  What good is the evidence if you don’t put it into practice!

Thanks Jillian  and Robin Benoit for encouraging my students to be Superheroes.  You are developmental optometry’s Rock Stars…… Rock On!  

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It Takes Two

Today I examined a 9 year old boy with autism.  He had been examined 2 years ago and glasses were prescribed for full-time wear.  But his parents never had the glasses made.  They sought a second opinion and were told he only needed the glasses for reading.  Mom would often read with him and never noticed any difficulties and so decided that he probably didn’t need the glasses at all.  Now, two years later, his teacher called home because he was having difficulty seeing anything written on the board unless he walked to the front of the classroom.  So mom brought him back.

This child is VERY hyperopic and astigmatic.  Without lenses, his visual acuity at both distance and near is significantly reduced.  He also has an exotropia (his eye is turned outward) which is much worse when he does not have appropriate lenses.  When I put the lenses on, his vision improved. But he is amblyopic.  Because he has always had blurry vision, he has not developed the ability to see the smaller letters or use his vision effectively.  I expect his vision to improve as he wears the lenses.

I wanted to laugh and cry.  I was happy that I will have a positive impact on this young child’s vision and his life!  He will be able to participate much more actively in all his activities.  His autism surely poses other difficulties in his daily life and I am thrilled to eliminate (or at least mitigate) any visual deficiencies.  I am giving him a chance to interact with his world in a much more meaningful way.  But 2 years lost……… what if he had received those glasses 2 years ago?  What opportunities to learn and grow have been lost because he could not see?

It takes two.  I can do my part but I need help!  I need parents too.  I need parents to bring their children in for comprehensive eye examinations.  I need parents to ask questions if they don’t understand.  I need parents to comply with treatment plans (even if their children are not happy), I need them to return for follow-up care.

Parents, please help me help your child.  Schedule that exam.   Make sure your child wears the glasses in school.  Call me if you have questions or concerns.  Together we can accomplish so much, but I can’t do it alone.

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Amblyopia Therapy — It’s No Longer Just For Kids

Amblyopia therapy –” it’s no longer just for kids.”   These are the words used by Dr. Michael DePaolis in a recent editorial in Primary Care Optometry News.  He describes a big moment in optometry, a paradigm shift in patient care.  New research has made it very clear that neuroplasticity in the adult brain is alive and well, and the implications reach far beyond the treatment of amblyopia.  But let’s start with amblyopia.

Dr. Dennis Levi explored the use of action video games to treat adults with amblyopia.  Why would playing action video games be an effective treatment of amblyopia?  “Action game play is extremely varied in its demands and rich in the set of visual experiences it offers.  Thus…. the very act of action game playing seems to train the brain to learn, on the fly, how to make the best use of the available information in the display, independent of the specifics of this display, allowing for the broad transfer of learning.”  Levi had 20 amblyopic adults play action video games with only their amblyopic eye.  All 20 subjects improved.  Levi speculates that video game playing is “arousing and rewarding.” Neurotransmitters such as acetylcholine and dopamine are released, and these neurotransmitters are associated with enhanced neuroplasticity.   Compliance is also enhanced, because action video games are more interesting and fun to play than many traditional vision therapy activities.

Now consider some incredible research by Dr. Elizabeth Quinlan.   Dr. Quinlan’s presentation at COVD’s annual meeting focused on the treatment of amblyopia, specifically on possible mechanisms to enhance neuroplasticity.  She has been recording the electrical response of the part of the brain associated with vision (aka the visual cortex) resulting from different types of visual stimulation.  In one series of experiments, she created amblyopic animals (in this case, amblyopic rats) by occluding one eye for an extended period of time.  The resulting pattern of visually evoked potentials from portions of the visual cortex was significantly altered in a pattern that reflected the lack of visual input from the occluded eye.  When the occlusion was ended and the animals had a chance to receive normal visual experience, this pattern of altered electrical activity in the brains of the rats did not improve.  In other words, there was no neurophysiological recovery when normal visual experience was restored.   That is, there was no neurophysiological recovery until she put these animals in the dark.  After placing these animals in total darkness for 3-10 days, and then providing a short period of “rat vision therapy,” these rats had a complete neurophysiological recovery.  The visual evoked responses from the visual cortex demonstrated a more balanced input from each eye.  The dark exposure enhanced the neuroplasticity of the visual cortex which is the basis for successful treatment of amblyopia.

Are we ready for another paradigm shift in the treatment of amblyopia?  Of course, this research was done with rats and involved recording electrical activity from electrodes placed into their visual cortex.  That is a very long way from clinical trials that might provide evidence of more effective treatment of amblyopia by enhancing neuroplasticity in the human brain after dark exposure.  But I cannot help but wonder …… can we provide a safe environment of total darkness for adult patients to enhance their neuroplasticity and then provide vision therapy programs that utilize action video games?  who will open the first Hotel Amblyopia?

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Dr. Don Getz — Strabismus and Amblyopia

Developmental optometry has lost another giant.  Dr. Donald Getz has died.  His dear friend and colleague, Dr. Robert Sanet had this to say:  “Don loved many things…. he  especially loved COVD, where he served as President and Master of Ceremonies at the Awards Banquet, and he loved mentoring optometry students.  Don and Lynn opened their home, and Don freely gave enormous amounts of his time and energy to hundreds and hundreds of students who visited him over the years.  Don was a great clinician and a tireless champion of behavioral optometry.  The impact of his generosity, friendship, and knowledge will be carried on through the lives of the patients whose lives were enriched because of his clinical expertise, and through the amazing optometric knowledge he shared with us.”

Dr. Getz received the Skeffington Award in 1988.  I happily re-read his monograph on Strabismus and Amblyopia, which was first published in 1974 by the Optometric Extension Program.  In the acknowledgements, he recognizes his vision therapist, Lora McGraw.  “She did not have the disadvantage of an optometric education, and, consequently, did not know that certain things were impossible.”  Dr. Getz and Lora McGraw were always pushing the envelope and thinking outside the box.

A strabismus is a condition in which the eyes are not aligned. One eye may be turned in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia) relative to the fixating eye.  When the eyes are not aligned, this can cause patients to see double.  Even worse, overlapping images will cause 2 different objects to appear superimposed on the same location in space.   Brains find this “visual confusion” intolerable.  In fact, brains will go to great lengths to avoid double vision and visual confusion.  Having a strabismus will often cause a series of adaptations to avoid double vision, and perhaps permit the visual system to make the most of a bad situation. These adaptations include amblyopia (reduction in visual acuity and other visual functions), suppression (turning off the visual input from the turned eye), eccentric fixation (using an off- center point on the retina to denote straight ahead) and even anomalous correspondence (remapping the processing of spatial coordinates when both eyes are attempting to work together).  It is these adaptations that often make the treatment of a strabismus a difficult task.  These adaptations must be eliminated if a patient is going to learn how to straighten their eyes and keep them straight.

In his book, Strabismus and Amblyopia, Dr. Getz explains the importance of tackling these adaptations and then offers many different activities that can be incorporated into a vision therapy program.  He places great emphasis on the monocular phase of treatment. If monocular skills are not developed and equalized, binocular therapy will be very difficult;   or stated another way, if monocular skills are developed and equalized, binocular therapy will be much easier.

In addition to amblyopia, strabismic eyes have poor spatial localization skills.  The brain has learned to interpret straight ahead while the eye is actually turned.  This process of locating where objects are, and how far away they are, must be relearned, under monocular conditions.  If equal spatial localization exists under monocular conditions, it is almost impossible for the patient to have eccdentric fixation; and if equal spatial localization exists under binocular conditions, it is almost impossible for the patient to have anomalous correspondence.

I have prescribed many of the activities listed in his book as part of a treatment program for amblyopia, but re-reading his book has forced me to reconsider what I am attempting to accomplish.  Dr. Getz has reminded me not to overemphasize the visual acuity of the amblyopic eye.  Instead, attempt to improve and EQUALIZE the performance of each eye during these activities.  The visual acuity will improve along with the improvements in spatial localization and performance.  Even if visual acuity is never equalized, the patient may be capable of binocular function.  Equalizing the behavior and performance of each eye separately should not be overlooked or rushed in the therapy program for a strabismic patient.  The patient will now be ready to match the 2 “ocular circuits” and proceed to the binocular phase of therapy with greater likelihood of success.

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Diary of a Strabismic Kid (part 1)

I have another set of entries outside of the Science and Splash that I would like to share.  I affectionately call it “Diary of a Strabismic Kid.”  As a developmental optometrist that works with Strabismus (eye turns), I get a glimpse into the world of what it is like to have a turned eye or lazy eye. I have learned so much from these patients over the last few months that I would like to share what I am learning with all of you.

Most of us only see what can be seen on the outside.  In many cases, it is very easy to see when someone’s eye is turning.  This can be very devastating to a strabismic person.  More than most of us realize.

One of my patients was a 15 year old named Tyler who had had 3 eye surgeries to correct his eye turn.  When he came to me he was contemplating going in for a fourth eye surgery.  I prescribed vision therapy to address the eye turn.  I remember working with him one day in the therapy room.  We were doing this technique using 3D glasses like they use in today’s movie theaters.  We were asking him to watch himself in the mirror to see if he could get both eyes to point straight.  All of the sudden he got it and his eyes were pointing straight and he said it felt “really wierd.”  I told him that was great and to remember what that feeling was like.  After the vision therapy session, I was talking to his mother about the gains we had made in therapy that day and I looked over at Tyler  who was very intensely pointing both of his straight at me. I said, “Tyler your eyes are straight!”  With a very direct tone of voice he replied, “I know.”

This presents a common misconception about eye turns.  Well, if you have an eye turn, why don’t you just get surgery to straighten it.  The truth is that it is very difficult for eye alignment to last with eye surgery,  because the underlying cause of the eye turn was never treated.  So even if the eyes are surgically aligned, these patients don’t know how to use the two eyes together.  Unfortunately, these patients are rarely sent to learn how to use their eyes in tandem.  By simply hoping for the best, a disconcerting 50% of the time these patients need multiple surgeries because the individual goes back to what he or she knows – turn the eye.  This is never a conscious decision.

With Tyler I remember the first time I examined him, I asked him if he knew where the other eye was turning.  He said he didn’t.  There were times when the eye was turned more and when it was turned less and I asked him if he could purposely make his eye turn more or less – again he told me he could not.  You see, it is a very difficult thing for the brain to learn for the first time how to get the two eyes to point to the same place.  How often do you think about where your eyes are pointing?  But through the expertise and research of many years, developmental optometrists have many tools to teach people how to use the eyes together and in turn straighten them.

Tyler was a very bright and talented young man.  He was a straight “A” student with a resolve to go places and do something with his life.  Though he was a little reserved, I don’t think anyone really felt his eye turn was holding him back in anyway.  Yet listen to what he wrote about his experience.

“Since I was a kid I have had a lazy eye.  Over the years, I was ridiculed and made fun of daily.  People would tell me to “look at them” or ask “What are you looking at?” and then laugh at me.  My self-esteem and confidence started to dwindle.  I had a great sense of inferiority.  I had three cosmetic surgeries in Seattle to fix the alignment of my eyes but sometimes one eye still “looks” off.  Over time, I developed defense mechanisms to try to hide my eye.  I would not look directly at someone, but slightly off to the side so they wouldn’t notice my eyes.

Vision Therapy has helped me get more control of my eye alignment and make better use of my right eye, which used to turn off.  Each time I go to therapy, I feel as if I’m making my eyes better.  I don’t just notice physical changes either, but visual perception and personality changes too.  I am more positive about myself.  My self-esteem and confidence has given me a better feeling of doing well in sports and I am more comfortable socializing with peers.  My Optometrist/Vision Therapist, Dr. Winters, and the therapy program have given me a better outlook on life and myself.  I no longer need my defense mechanisms because of what Vision Therapy is doing for me.”

This gives us a glimpse into what life is like for those who have eye turns.  But, unfortunately, it is only part of the story.  People who do not have good alignment of the eyes are almost always stereo blind.  Stereo blind is the term used for individuals that have not developed stereopsis or depth perception.  Tune in next time to hear more about the far-reaching impact stereo blindness can have on an individual.

If you or someone you know struggles with strabismus, a lazy eye, or an eye turn, contact your local developmental optometrist.  To find one near you click here.

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Another Approach to Treatment of Refractive Amblyopia — The Science

Children with refractive amblyopia often go undetected because their eyes are straight and they don’t have much difficulty with the “activities of daily living.”  When told that they need to wear glasses full-time, this is often quite a shock.  Add in the need to wear a patch for several hours a day, and not surprisingly, compliance with this treatment protocol is poor.  But wearing the lenses and patching is the “backbone” of amblyopia treatment and little or no improvement can be expected if this is not done…… at least that is what “conventional wisdom” has told us to expect.  What this traditional approach to amblyopia treatment fails to recognize is that amblyopia is a BRAIN problem and not an eye problem.  If a child’s binocular (eye teaming) skills can be improved,  this is often accompanied by an increase in visual acuity and other monocular visual skills of the amblyopic eye.  In some cases, these improvements also lead to a reduction in the anisometropia (or difference in lens power between the two eyes) and an associated reduction in the lens power required in spectacles to maximize visual acuity.  Press and Press have termed this treatment “reverse engineering of hyperopic anisometropic amblyopia.”  Everyone is a winner if this can be accomplished.  The amblyopia is successfully treated, the need for eyeglasses is reduced, the cosmesis of the eyeglass prescription is enhanced, and the patient is more compliant during the therapy process.

In the article recently published in Optometry and Vision Development, Drs. Press and Press present a case report that includes the use of Visual Evoked Potentials (VEPs) to measure the brain’s response to visual stimuli under different conditions.  They were able to compare the VEPs with and without glasses, with different prescriptions, and before and after completion of an optometric vision therapy program.  As the visual skills of this 4 year old girl improved and her reliance on the glasses was reduced, her brain’s responses to visual stimuli was significantly enhanced.  The average increase in the amplitude of the VEPs increased by 103% post-vision therapy!!  The VEPs also demonstrated that when presented with smaller, more detailed visual targets, her brain’s response was increased when she wore a minor prescription.  Therefore, at the end of vision therapy, it was decided that it would be in her best interest to wear the glasses when engaged in extended reading and other near activities, but not during outdoor play or watching TV.

Kudos to Drs. Press and Press for using science to demonstrate what we know to be true in clincal practice.  Not only were they able to measure changes in brain activity with optometric vision therapy, but they were also able to determine the best prescription for this young child.  The reverse engineering of the hyperopic anisometropic amblyopia was a documented success!

Read more about amblyopia here.

Here is another article about approaches to amblyopia therapy.

 

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It’s Not About the Patch

Amblyopia, also referred to by the public as “lazy eye”, is a unilateral or less commonly bilateral condition in which the best corrected visual acuity is poorer than 20/20 in the absence of any obvious structural anomalies or ocular disease. Amblyopia is associated with strabismus (an eye turn) and/or anisometropia (difference in refractive status between the eyes).  Amblyopia is the BRAIN’S response to the imperfect and unequal visual input received from the eyes.

Treatment of amblyopia is based on eliminating its most obvious symptom: the reduction in visual acuity.  An amblyopic child cannot read the 20/20 line with the amblyopic eye and this becomes the primary focus of most interventions.  First, children are provided with glasses to neutralize any differences in refractive status between the eyes, then the patching begins.  Patching is a form of penalization.  By penalizing the better seeing eye, the child is forced to use the amblyopic eye, and improvements in visual acuity are measured.   The scientific evidence of the benefits of patching in the treatment of amblyopia is extensive and well-founded.  When evaluating the effectiveness of patching in populations of amblyopic children, most of them show statistically significant improvements in visual acuity….. but not all patients.

At COVD’s annual meeting, Drs. Janna Iyer and Genia Beasley presented a case of a 10 year old girl with amblyopia.  She had been treated with patching and atropine (a pharmacological form of penalization) for YEARS.  She hated the patch and the blur-inducing eye drops and found many ways to “beat the system” and use her better seeing eye.  The visual acuity in the amblyopic eye remained 20/100.  Drs. Iyer and Beasley recommended a paradigm shift.  Instead of focusing on amblyopia as a monocular problem, they began to treat the binocular problem and shifted emphasis to the integration of the visual inputs in the BRAIN from a 3-dimensional world.  Activities designed to use the eyes together in order to make judgements about where things are in space were emphasized.  Activities involving patching and identifying what things are  were significantly reduced.   Her visual acuity improved within weeks of initiating this therapy program.  More important, her academic performance skyrocketed.

Amblyopia is much more than a reduction in visual acuity.  Amblyopic eyes have poor eye movement and focusing skills; the amblyopia causes distortions and difficulty processing spaces between objects.  On any visual task you design, amblyopic eyes will perform slower and with less accuracy.  Even when using both eyes, amblyopic children often do not perform as well as “normal” children.  The consequences of amblyopia are far greater than reduced visual acuity.  Clearly treatment must move beyond the patch to the brain.  Only then will these children begin to demonstrate improvements in their living and learning skills and not just their ability to read the little letters on the doctor’s chart at the end of the examination room.

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What is Amblyopia? What is NOT Amblyopia

This blog post was inspired by a presentation by Dr. Matthew Walsh.  Dr. Walsh is a Resident in Vision Therapy at SUNY Optometry.  All the residents are required to present a 1 hr. continuing education lecture on a topic of their choice.  Dr. Walsh’s presentation was entitled: Visual Pathway Pathology  Masquerading as Amblyopia in Children.

What is amblyopia?  What is not amblyopia?  Let’s consider the definition of amblyopia from the American Optometric Association and its clinical application.

Amblyopia is a unilateral or infrequently bilateral condition in which the best corrected visual acuity is poorer than 20/20 in the absence of any obvious structural anomalies or ocular disease.

In other words, amblyopia can only be diagnosed when ocular disease has been ruled out.  The optometrist must perform a comprehensive examination including a full evaluation of ocular health.  This is likely to include the use of dilating drops in order to examine the retina.  The doctor will also perform additional procedures to rule out specific causes of vision loss.

Functional amblyopia occurs before the age of 6-8 years and is attributable to deprivation, strabismus or anisometropic, although it may persist for life once established.

When other causes of the vision loss are ruled out, amblyopia must be ruled IN, by the presence of an identified amblyogenic condition: strabismus, anisometropia/isometropia, or deprivation.  Strabismus is an eye turn, and amblyopia is more likely to develop if the eye turn is constant and unilateral.  Anisometropia is a a large difference in refractive error between the two eyes; isometropia is very high refractive error in both eyes.  Several physical conditions may cause deprivation of visual stimulation to one eye, such as a congenital cataract or a ptosis (droopy eyelid).  These amblyogenic factors must be present during the “critical period” of visual development, which is considered the first 8 years of life.  The visual system is far less susceptible to disruption after this time period.  Although the condition MAY persist for life once established, the visual system is amenable to treatment at almost any age.  The critical period applies only to the development of amblyopia, and not to its treatment and resolution.

Amblyopia represents a syndrome of compromising deficits, rather than simply reduced visual acuity, including:

• Increased sensitivity to contour interaction effects
• Abnormal spatial distortions and uncertainty
• Poor eye tracking ability
• Reduced contrast sensitivity
• Inaccurate accommodative responses

Amblyopia is not an eye problem, it is a brain problem.  The brain has great difficulty not only recognizing small letters, but also processing and responding to all types of visual information: words printed on a page, faces in a crowd, cars moving down the road, reflections in a mirror, moguls on the ski slope, etc.  That’s why treatment of amblyopia involves more than just patching.  The brain learns how to process visual information in much the same way humans learn most skills… by starting with a relatively easy task, practicing, and then making the task more difficult as competency increases.  Amblyopic brains have to learn many new skills and this is best accomplished in a structured learning environment.  A vision therapy program will also emphasize the integration of vision with other sensory inputs and the ability to use vision to guide motor outputs.

One more point to be considered:  amblyopia is ruled in when ocular disease is ruled out, except in rare instances when amblyopia AND ocular disease coexist.  In addition to performing a comprehensive examination, the optometrist will consider the degree of vision loss and monitor progress during treatment.  Only when all the causes of vision loss are considered can the prognosis be determined and the best treatment plan be put into action.

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Been There, Done That

These comments are based on this article, Neuroplasticity as a proposed mechanism for the efficacy of optometric vision therapy and rehabilitation, written by Dr. Julia Huang.

In the past 10 years, constraint-induced (CI) movement therapy  has become the treatment of choice for patients with an upper-extremity hemiparesis after a stroke.  CI therapy involves forcing the patient to use the paretic arm by restraining the non-impaired arm for several hours everyday.  The patient must be actively engaged in various task-oriented activities which are made more difficult as improvement is noted.  These patients make marked improvements in motor function AND quality-of-life.  These improvements in function correlate with changes in the brain.   Research studies have shown increases in gray matter in both sensory and motor areas, on both sides of the brain.  CI therapy is based on reversing “learned non-use,” which was first described in animal studies.  Monkeys are able to recover function of affected limbs following surgical destruction of selected nerves, when the non-affected limb is tied down.

More traditional occupational and physical therapy focus on teaching the use of the unaffected limb to do all the work.  These studies demonstrate why this approach is ineffective at enabling a patient to RECOVER movement and function of the affected limb. The need for assistive devices, braces, and wheelchairs is lessening because  CI therapy induces changes in brain structure that result in improvements in movement and function.

These principles of CI therapy are now finding their way into other rehabilitative modalities, such as speech therapy.  By preventing patients from using compensatory strategies such as pointing and gesturing, and condensing 30 hours of  therapy into an intensive 2 week program, patients are making significant improvements in language functions.  The scientific community is beginning to embrace the concept that rehabilitation of motor, sensory and cognitive impairments can ALTER brain STRUCTURE and result in the recovery of FUNCTION.  The neuroplasticity of the human brain can be invoked without regard to the age of the patient, or the severity or duration of the loss of function.

Developmental optometrists have been using these same principles for ages, most notably in the treatment of amblyopia.  By patching the non-affected eye for several hours per day, the patient is forced to learn to use the amblyopic eye.  Therapy includes the addition of a series of task-oriented activities which are made more difficult as improvements are noted.  Reversing “learned non-use” occurs in patients of all ages, by strengthening synaptic connections and inducing cortical reorganization.  The induction of neuroplasticity in the treatment of amblyopia uses the same principles as other rehabilitation specialists:  repetition, motivation, loading, multi-sensory integration and feedback.  The only difference is that developmental optometrists were utilizing these principles clinically before they were validated by recent research. Yes I’ve been there and done that!

Recent research from the Pediatric Eye Disease Investigator Group (PEDIG) has provided the evidence of the benefits of patching or pharmacological penalization with atropine in the treatment of amblyopia.  The addition of near activities to a patching regimen has also been shown to be effective.  Now, in addition to having been there and done that, I am here, as the research proves that the clinical practices  I use every day are evidence-based.  As a result, I will continue to think beyond the limitations imposed by current research and  push the envelope to do more to help my patients improve their quality of life.  I will wait patiently for the science to catch up to my clinical practice.   I love my job.

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Evidence Supporting the Benefits of Treatment

Thank you American Optometric Association (AOA).  The AOA has expressed “deep disappointment and concern” about the US Preventative Services Task Force’s (USPSTF) plan to proceed with misguided recommendations on children’s vision screenings. These recommendations, which support vision screenings as the preferred method of identifying visual impairment in children aged 1 to 5, would negate the efforts of eye doctors to reverse the rates of preventable vision loss in children.

The AOA points to the many flaws in a reliance on vision screenings to identify children with visual problems.  First, there is the issue of false negatives.  Many children with vision problems, such as amblyopia, are not identified by the vision screening.  They are categorized as a negative result, meaning that no positive findings were noted.  If they had received a comprehensive eye examination, the vision problem would have been identified.  Therefore, the negative result is a false result.  Many vision screenings result in a very high rate of false negatives.  It might be years before their vision problems are identified and treatment is initiated.  Some of these children are NEVER identified.

Even if a child is identified with a problem at a vision screening, the screening does not provide either a diagnosis or a direct path to treatment.  Research has shown that between 40 and 80 percent of children who fail a vision screening do not receive appropriate follow-up care.  Although the screening has identified the problem and treatment exists, there is a missing link–the diagnostic examination.  It is the treatment that is effective at improving visual outcomes for children, and treatment follows the examination, not the screening. The USPSTF should support a recommendation that “children receive care and treatment” not that “children should be screened.”

The USPSTF seemed overly concerned that the child’s inability to cooperate would render comprehensive examinations impossible to perform on young children.  Optometrists and pediatric ophthalmologists are well-trained in procedures that enable comprehensive evaluations of very young children.  These procedures may require special equipment not typically available to doctors during vision screenings, which only increases the rate of false negatives.  Comprehensive examinations should be the preferred recommendation.

In summary, the evidence of the benefits of treatment should be used to support comprehensive eye examinations for all children, because early detection and timely treatment are essential in addressing the public health crisis of high rates of preventable vision loss in children. Earlier identification and treatment will result in an enhanced quality of life and improved academic performance among children with vision problems.

Read AOA’s statement here.

 

 

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