AAP and AAO on vision therapy


Interview with: Walter M. Fierson, MD,
Chair of Learning Disabilities Subcommittee
of Ophthalmology Section, American Academy
of Pediatrics

In “Groups Assail Vision Therapy as Remedy for Learning Disabilities,” Crystal Phend of MedPage Today reported that the American Academy of Pediatrics and American Academy of Ophthalmology jointly issued a statement calling the use of well-known vision therapies unfounded and ineffective.

SAN FRANCISCO, July 27 — Behavioral vision therapy, eye exercises, and colored lenses have no role in treatment of dyslexia and other learning disabilities, according to the American Academy of Pediatrics.

The academy came down hard on these “scientifically unsupported” alternative treatments in a joint statement with the American Academy of Ophthalmology and other vision organizations.

The AAP, which has published many valuable statements about Learning Disabilities in the past, made unequivocal statements about the problems with these therapies. In the accompanying audio clip, Dr. Walter Frierson provides good explanation of the rationale for the recommendations.

Learning disabilities, including reading disabilities, are commonly diagnosed in children. Their etiologies are multifactorial, reflecting genetic influences and dysfunction of brain systems. Learning disabilities are complex problems that require complex solutions. Early recognition and referral to qualified educational professionals for evidence-based evaluations and treatments seem necessary to achieve the best possible outcome. Most experts believe that dyslexia is a language-based disorder. Vision problems can interfere with the process of learning; however, vision problems are not the cause of primary dyslexia or learning disabilities. Scientific evidence does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions. Diagnostic and treatment approaches that lack scientific evidence of efficacy, including eye exercises, behavioral vision therapy, or special tinted filters or lenses, are not endorsed and should not be recommended.

Pediatrics 2009;124:837–844

Faithful readers of LD Blog will remember that there have been perhaps a half-dozen posts here on the mistaken (at best) therapies promoted to families of individuals with Learning Disabilities. It is valuable to have prestigious organizations such as the AAP and AAO issue statements that support the observations presented here.

Teachers, psychologists, and school administrators: Please advise the parents of your students with reading problems not to waste time and money on colored lenses, eye tracking and eye teaming, and other similar therapies.

Read Ms. Phend’s report. Download the full statement by the AAP. Visit the AAP Web site, especially its section on Learning Disabilities.

15 Responses to “AAP and AAO on vision therapy”


  • This policy statement is seriously flawed and driven by politcal objectives without any regard for patients’ well being. The National Institutes of Health, National Eye Institute supported research that clearly demonstrates the efficacy of optometric vision therapy (http://www.youtube.com/watch?v=dAgyojExdHI). It should also be noted that this statement uses old out of date references for support. A full response form the America Optometric Association will be forthing coming soon. I hope this blog will pulbish that as well. In the mean time for up to date research in vision go to http://www.mainosmemos.blogspot.com. Thanks.
    Dominick M. Maino, OD, MEd, FAAO, FCOVD-A; P rofessor of Pediatrics/Binocular Vision, Illinois Eye Insitute/Illinois College of Optometry dmaino@ico.edu

  • Thank you for allowing for commentary on this important concern. Optometrists do not treat specific reading disability, nor do responsible optometrists claim to. For this “AAP” statement to suggest that they try to, and to use the outdated, poorly-defined term of dyslexia to cloud the issue, is disingenuous.
    You should also consider that several national testing organizations, including medical licensing boards, consider these “subtle eye or visual problems” so disabling that they retain optometrists as consultants on visual and eye conditions that impair reading in test-takers in order to comply with the Americans with Disabilities Act. Ophthalmologists write the letters claiming these conditions are disabling to test-takers. Archives of Ophthalmology published two well-conducted, multi-center studies — one in 2005 and the other just last year — that were funded by NIH that demonstrated how incorrect this AAP position statement, which was first published by the AAO in 1972, is on vision therapy. The American Academy of Ophthalmology (and, unfortunately, the AAP) is clearly not in step with the rest of medicine on this issue. It is time for the AAP to disavow this outdated and misleading opinion piece.
    David A. Damari, O.D., FCOVD, FAAO
    Chair, Department of Assessment, Southern College of Optometry
    Consultant on Visual Disabilities

  • Carol L. Scott OD, FCOVD

    Even though this statement is as flawed in it’s assumptions as the previous ones (that vision therapy claims to treat dyslexia for instance) it does state that vision problems can interfere with learning. Students who have a convergence insufficiency for instance, have a much higher indicidence of being diagnosed with ADD, and have difficulty with reading and comprehension. Any logical person can understand that if when reading one gets headaches, sees double, sees words moving, and loses their place constantly it will affect learning abilities. Parents know when their children are struggling with these issues and it makes sense to them that when these problems are remediated, learning will be easier.

  • A Joint Policy Statement in the Journal Pediatrics … appears to cobble together outdated research and vision science… in an attempt to discredit optometric vision therapy…The … statement… ignores the evidence of the proven benefits of vision therapy, such as in well-designed studies, most notably the Convergence Insufficiency Treatment Trial (CITT), which was funded by the National Eye Institute. … Leonard Press, O.D., chair of the AOA’s Pediatrics and Binocular Vision Committee and prominent member of the College of Optometrists in Vision Development (COVD) notes that “The references at the end include outdated research literature, and are padded with 23 references to the Irlen lens concept. None of the positive studies on vision therapy from optometric literature is included.”….Other prominent … educators also took issue with the “joint policy paper.” …“It should … be noted that every school and college of optometry teach courses in and provides clinical experiences for students in the area of vision therapy and that the procedures used in vision therapy have been codified within text books published by major publishers throughout the United States and the international community,” said Dominick M. Maino, O.D., M.Ed., Professor of Pediatrics/Binocular Vision at the Illinois College of Optometry and editor of Optometry & Vision Development…“Optometric vision therapy is a scientifically sound series of therapeutic procedures used successfully for a number of vision disorders from amblyopia to learning-related vision problems,” Dr. Maino said….“In this era of evidence-based medicine it is disheartening to [see these]… ‘experts’ purposefully misleading the reader by disregarding recently published randomized clinical trials and the only quality research about the effectiveness of treatments for convergence insufficiency,” said Mitchell Scheiman, O.D., chief of the Pediatric/Binocular Vision Service and a professor at Salus University. Dr. Scheiman was the study chair for the year-long CITT study…http://newsfromaoa.org/

  • Dan L. Fortenbacher, O.D.,FCOVD

    As I have treated thousands of patients in my 30 years specializing in office-based vision therapy, I am very concerned about the public who will be misinformed by this recent AAO/AAP statement. Over the years I have witnessed many parents who are surprised and upset when they have been previously told by a doctor that their child has no vision problem (or need for vision therapy), only to learn that their child indeed had a binocular vision problem such as convergence insufficiency. It is understandable why a parent would feel this way when their child has a treatable condition that leads to years of frustration and emotional pain associated with their symptoms surrounding reading and learning problems.

    It is also very surprising to me that, in 2009, the two organizations listed above would publish a policy statement that lumps together vision therapy into a category of ineffective treatments. Are the individuals writing these policy statements simply out of touch with the current research that is published in their own literature?

    Taking this misinformation one step further, this LD Blog suggests that teachers, psychologists and school administrators should advise parents to, “not waste time and money on …eye tracking, eye teaming and similar therapies.” So when did teachers, psychologists and school administrators become experts in vision problems? With all of the other pressing responsibilities of educators they are now expected to function as doctors and provide medical advice?

    The problem with the AAO/AAP policy statement is that it is suggesting that patients should not listen to their doctor…instead they should rely on the advice of an organization’s statement that is clearly flawed and not even in sync with the current “gold standard” research. This is a very slippery slope!

    In the interest of the public health and best care for children who struggle with reading and learning problems, parents should seek the advice of a doctor who has experience working with children and preferably one who is Board Certified in Developmental Vision and Therapy by the College of Optometrists in Vision Development…a doctor who has FCOVD after their name. A doctor locator can be found at http://www.covd.org

  • It is wonderful to see the informative posts from several colleagues. Yet I am wondering: Why there aren’t any responses from the LD Blog master, yet alone anyone associated with the flawed Joint Policy Statement? Why have none of the rebuttals of earlier versions of this biased and flawed Policy Statement been addressed in its subsequent re-packagings? Silence or misdirection is a sad commentary when one champions the public interest.

    Dr. Fortenbacher’s point deserves a comment from you, if not a reply. Why would you write: “Teachers, psychologists, and school administrators: Please advise the parents of your students not to waste time and money on colored lenses, eye tracking and eye teaming, and other similar therapies.”?

    One wonders. Let’s take the subset of students who continue to struggle despite everything recommended in the AAP & Co. Policy Statement. Let’s accept that their parents read to them; that they spend countless hours doing homework with them; that they’ve received abundant support, remediation, classroom aides; that they’ve had Section 504 accommodations, and/or IEPs; that they’ve been through programs such as Sylvan, Huntington, Kumon; have received interventions such as Orton-Gillingham, Wilson, or Lindamood-Bell; worked with private tutors, psychologisits, and neuropsychologists; OTs, PTs,and speech therapists; have been on Ritalin, Stratera, Wellbutrin, and Paxil.

    Let’s assume, after all is said and done, and thousands upon thousands of dollars and countless hours expended on the well-intended expert advice and guidance from all the professionals
    that the AAP & Co. Joint Policy Statement suggests one consults. What as a parent am I supposed to do if my child is one of those children that the Policy Statement admits exists? If it is just those among the 5% who have convergence insufficiency, we’re talking about tens if not hundreds of thousands of children nationally.

    Would you still assert that having one’s vision evaluated and treated the way developmental optometrists approach vision-based learning problems would still be “a waste of time and money” for that subset of parents? If so, then this blog does a great disservice in uncritically passing along information that has a thinly veiled agenda. The fact that the AAP/AAO/AAPOS Joint Statement encourages parents to consider virtually every profession known to mankind except optometry should raise eyebrows.

    Your post reminds me of a cartoon in the New Yorker several years ago, borrowed from the line by Gore Vidal. It shows two dogs seated at a bar with ties on, raising their martini glasses in a toast: “It is not enough that dogs succeed; cats must also fail.”
    Developmental optometry will not fail, precisely because – as Dr. Fortenbacher notes, we have helped so many thousands of patients, with evidence-based scientific studies now supporting the basis for our success. Please look into the sites cited above by my colleagues.

    We are not a panacea, nor do we work in isolation. I only wish you had the opportunity to talk to the myriad parents who ask us after their child’s struggles have diminished through vision therapy: “Why is it that no one ever suggested I consider this before?” They are not just saddened, they are angered by the type of advice you are brokering here regarding vision. They are offended that professionals and public interest sites paint them as merely gullible. They are too bright and dedicated to their children to be patronized. They do not want other families to have to struggle the way they did. And we will continue to speak out on their behalf.

    Susan R. Barry, Ph.D., a neurobiologist at Mt. Holyoke College, has become a wonderful advocate to counter misinformation about vision and learning. She struggled as a child in school, in part because of the lack of guidance from authority figures about her vision (she details this beautifully in her recent book, Fixing My Gaze). She rues having waited until adulthood before receiving the benefits of optometric vision therapy. Her dream is that physicians and developmental optometrists find common ground instead of battlegrounds. In her Blog, Eyes on the Brain, Sue writes something very powerful. And I will paraphrase it here by concluding that the only thing worse than giving parents and children false hopes, is giving them false hopelessness.

    http://www.psychologytoday.com/blog/eyes-the-brain/200905/false-hopelessness

  • To those advocates of optometric training who have replied here so far (and those who may later comment): Please continue to state your arguments about why optometric therapies help individuals with reading problems. I’m not ignoring you. I want a complete catalog of your arguments. Please make a list of falsifiable arguments favoring eye-training effects on reading.

    More specifically, given that LD Blog advocates evidence-based practices, please provide references to integrative reviews of evidence that eye-training programs are effective. Why, as a scientific matter, should LD Blog recommend optometric training as a means of addressing LD? Is the study funded by the National Eye Institute the main case?

  • Robin Price, OD, FCOVD

    I’m trying to look at this from a parent’s point of view, because I have two children in elementary school, learning how to read, and learning how to learn. If my child is struggling, I want to help them any way I can. I rely on authority figures — teachers, pediatricians, reading specialists, sites like this, etc. — for helpful information regarding my child. I assume that these authority figures will give me honest information based on scientific research and proven methods. I do not expect them to use scare tactics, such as is seemingly coming from the AAP and AAO, to steer me away from scientifically proven help like optometric vision therapy. So when I read the statement from the AAP and AAO warning parents that it is a waste of time and money because of lack of proof that vision therapy works, yet I read a study from the National Eye Institute proving that optometric vision therapy is by far the most effective treatment for convergence insufficiency — a condition that is known to cause reading struggles — I am confused why prestigious national organizations like the AAP and AAO would issue such a statement when in their own journals they have published these studies showing the benefits of optometric vision therapy (see the journal Ophthalmology in October 2008, or go to the National Eye Institute website and search for vision therapy or convergence insufficiency). I am confused why the AAP and AAO ignore this and numerous other research studies showing the benefits of vision therapy (see http://www.childrensvision.com/effectiveness.htm). My trust in the AAP and AAO drops dramatically.

    In the book, “When Your Child Struggles,” Dr. David Cook addresses seven visual skills needed for reading and learning: distance visual acuity, eye teaming skills, the ability for the eyes to change focus from far to near, eye tracking skills, visual perception skills, visual memory skills, and eye-hand coordination. We are not born with these skills — they must be learned. Most people think of good vision as the ability to see 20/20. But there is so much more involved. Most of the learning that takes place in school comes through the eyes and ears. These senses and the skills involved need to be working well in order for the child to succeed. Unfortunately, most people think that because a person has healthy eyes and 20/20 eyesight, they have perfect vision, and therefore if they are struggling to learn it is impossible for the visual system to be part of the problem. Have you ever experienced the stress of reading aloud in public, and maybe stumbling over the words a little, and then not remembering well what you just read? The added stress affected your ability to read and comprehend. Now picture a child who experiences that same frustration every time he/she reads. Imagine experiencing eye strain and double vision every time you read for more than 5-10 minutes. And imagine being labeled and LD child, and not knowing where to turn for help. Imagine being put in special ed classes for years and years. When help is available via optometric vision therapy, and this help has been validated by organizations like the National Eye Institute and Harvard University (http://huhs.harvard.edu/OurServices/VisionCare/VisionTherapy.aspx), not to mention the American Optometric Association, the College of Optometrists in Vision Development, the Optometric Extension Program Foundation, I want that help for my child.

    To the administrator of the LD blog: I know you’re listening. I know you must be confused as well. I hope that you will objectively weigh the evidence for and against vision therapy. I hope that you will read the stories of the thousands of people who have been helped through vision therapy (some of these can be found at http://www.visiontherapystories.org) I hope that you will talk to people like Susan Barry, PhD, or Larry Fitzgerald, star receiver of the Arizona Cardinals, who have benefited tremendously from optometric vision therapy. And I hope that you will help the thousands of parents out there who are trying to find help for their children realize that vision therapy is a very important piece of the puzzle.

    Thank you.

  • Dear John L.
    Please give us evidenced based practices and references (preferably double-blind, randomized clinical studies) of any single approach for children with reading problems that work. I’m not being a wise-guy here, but if there is such research, I haven’t seen it. As far as I know…not one single approach works for all kids. First of all your question is all wrong…we do not teach reading, we improve, remediate, “fix” those learning related vision problems associated with reading difficulties…and yes there are NEI funded studies (and others) that show they work. Just do a PubMed search on convergence insufficiency (CI) for example….even ophthalmology agrees that CI can interfere with reading and cause ADHD like symptoms. I the meantime take a look at some of the papers at http://www.covd.org/Home/ResearchWhitePapers/tabid/188/Default.aspx I really appreciate your efforts to understand what we do….thank you…
    Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
    Professor of Pediatrics/Binocular Vision
    Illinois Eye Insitute/Illinois College of Optometry

  • Dear Dr. Loyd…
    Some research in your literature:

    M-Stream Deficits and Reading-Related Visual Processes in Developmental Dyslexia Boden, Catherine; Giaschi, Deborah Psychological Bulletin, v133 n2 p346-366 Mar 2007
    Abstract:
    Some visual processing deficits in developmental dyslexia have been attributed to abnormalities in the subcortical M stream and/or the cortical dorsal stream of the visual pathways. The nature of the relationship between these visual deficits and reading is unknown. The purpose of the present article was to characterize reading-related perceptual processes that may link the visual deficits to reading problems. We identified contrast sensitivity, position encoding, oculomotor control, visual attention, parafoveal/foveal interactions, and saccadic suppression as potential reading-related dorsal stream processes. We then evaluated the role of each process in reading and the status of each process in dyslexia. In theory, a number of dorsal stream processes (e.g., oculomotor control and visual attention) might contribute to reading problems in developmental dyslexia. More work is needed to demonstrate the connection empirically.

    But they found a connection…there’s more if you want me to post it.
    Thanks
    Dominick

  • Had to add just one more for you to look at

    …Atzmon, D., Nemet, P., Ishay, A., Karni, E.: A Randomized Prospective Masked and Matched Comparative Study of Orthoptic Treatment Versus Conventional Reading Tutoring Treatment for Reading Disabilities in 62 Children. Binocular Vision and Eye Muscle Surgery Quarterly, 1993, pages 91-106.

    Dominick

  • Dr. Price, you are correct in asserting that I am “listening” but I don’t feel confused. I evaluate evidence for a living. And, one of the consequences of doing so is that I do not accept anecdotes and testimonials as proving the veracity of propositions or hypotheses.

    Dr. Maino, thanks for the references. I am working on obtaining a copy of the Atzmon paper. From its title, it appears to merit review.

    I have to agree that there is no “miracle cure” for dyslexia. There have been multiple experimental studies that document effective teaching procedures, though. For examples, please see Lee Swanson’s meta-analysis, among other sources.

    Swanson, H. L. (1999). Reading research for students with LD: A meta-analysis of intervention outcomes. Journal of Learning Disabilities, 32, 504-532.

  • Dear Dr. Lloyd,

    Great to see you digging into the actual literature rather than relying on second hand information from the AAP/AAPOS selective review. As a complement to the original Atzmon citation provided by Dr. Maino, please also review:

    Correlation between reading skills and different measurements of convergence amplitude. Yair Morad, Robert Lederman, Isaac Avni, Daniela Atzmon, Emmanuelle Azoulay, Ori Segal.
    Current Eye Research 2002;25(2):117-121.

    I would also encourage you to look at the work by Dr. Harold Solan, one of the eminent researchers in the Vision-LD-Reading fields. His work and the work of others is summarized well in:
    Solan HA. Learning-Related Vision Problems: How Visual Processing Affects Reading Efficiency. Learning Disabilities: A Multidisciplinary Journal 2004;13:25-32.

    A deeper version of this, definitely worth reading, is:
    Solan HA. Models of Reading Disability and Their Implications. In: GK Hung, KJ Ciuffreda, eds. New York: Springer-Verlag 2002.

    I would also hope, at the very least, that you remove the insulting and unprofessional tag line at the top of this post “bologna”. That seems to trace to your blog post from July 21, 2006 about a website promising a cure for dyslexia about which you wrote:
    “They recommend teaching sight words, seeing developmental optometrists, and lots of other nonsense.”

    Frankly I’ve never heard of that site nor in visiting it do I see that any developmental optometrists are involved with it. I would hope to see terminology on a public advocacy site regarding a respected discipline used with more discretion. Thank you.

  • Dear Dr. Llyod…
    Your reference is 10 yrs old (Swanson, H. L. (1999). Reading research for students with LD: A meta-analysis of intervention outcomes. Journal of Learning Disabilities, 32, 504-532.). It doesn’t make it bad…just out of date with current research. I am going to look at it however…
    Thanks.
    dominick

  • This was a Great write up, I will be sure to bookmark this post in my Clipmarks account. Have a good evening.

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