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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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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