This article first appeared in the St. Louis Beacon, Nov. 30, 2011 - No one questions the fact that optometrists and ophthalmologists both want to do as much as possible to give children good reading skills and attain the best possible vision for everyone. For some optometrists, vision therapy -- exercises to train and strengthen the eye muscles -- has helped both children and adults to read and see better. But some opthalmologists are skeptical about its efficacy.
"The bottom line is that there is almost no data to support what (vision therapists) do -- it is almost all anecdotal," said Dr. Gregory Lueder, professor of ophthalmology and vision science at Washington University.
The problem, says Lueder, is that families spend time and money on vision therapy, and by the time they decide to have surgery, the child's strabismus (crossed eye, turned eye, wandering eye) can be fixed, but the child is behind developmentally.
In 2009, the American Academy of Pediatrics along with the American Academy of Ophthalmology "essentially declared war" on developmental optometry, as Judith Warner wrote in a New York Times article. In a joint statement, the two academies issued guidelines for treating dyslexia and learning disabilities. Children suspected of having these problems should be referred for educational, psychological, neuropsychological or medical assessment. "Diagnostic and treatment approaches for dyslexia that lack scientific evidence of efficacy, such as behavioral vision therapy, eye-muscle exercises or colored filter and lenses, are not endorsed or recommended."
Alyson Aviv, a neuropsychologist, supports these guidelines. Dyslexia, a language-based disability, cannot be cured by vision therapy. Some of her patients undergo initial neuropsychological assessment after having done a course of vision therapy and still have significant learning difficulties.
In reply, the American Academy of Optometry and the American Optometric Association state that they do not claim that their treatments solve learning disorders; they can, though, alleviate symptoms that make reading uncomfortable or impossible.
Both Lisa Dibler and Gail Doell, who received their doctorates at the School of Optometry at the University of Missouri St. Louis, are careful to note in their literature that their therapies do not cure dyslexia, attention deficit disorder, autism spectrum disorders or similar problems.
"After we treat an autistic child for a vision problem," says Doell, "the child may have better visual function but will still be autistic."
On the other hand, she notes, the underlying assumption for all therapies is that the condition treated can be modified -- perhaps not fully cured but improved.
Neurophysiologists Do Their Own Studies
In the meantime, neurophysiologists (those who study the function of the brain) have found increasing evidence for brain plasticity well beyond childhood. Learning can establish new neural pathways. Stroke patients can learn to perform tasks even though the parts of the brain that formerly directed those tasks have been impaired.
In a 2009 book, "Fixing my Gaze: A Scientist's Journey into Seeing in Three Dimension," Susan Barry, a professor of neurobiology at Mount Holyoke College, tells how she unexpectedly learned how to see in three dimensions at age 50 after being "stereoblind" all her life. Three childhood surgeries had corrected her crossed eyes and she functioned normally, driving and even playing tennis.
But when Barry's eyes began to trouble her, a developmental optometrist found that she was not focusing both eyes but rapidly alternating visual input from either eye. With exercises to correct her "shimmery" vision, she came to see the world in 3-D. As Oliver Sachs, who wrote about her in the New Yorker as "Stereo Sue" says in the foreword to her book, her experience shows the "brain's ability to change and adapt."
Beginning back in the 1990's, neurophysiologists Gadi Geiger and Jerome Lettvin from MIT's Research Laboratory of Electronics began on their own to explore the relationship between vision and dyslexia. They compared the visual behavior of dyslexic and normal readers in the United States, Italy, Germany and Israel.
Dyslexic children were referred to them by learning professionals who classified them according to tests standard at the time to the country they were working in. Geiger says he still uses the definition of dyslexia from the 1970 conference of the World Federation of Neurologists -- difficulty in reading in spite of adequate intelligence, adequate training in reading and absence of obvious pathologies.
They found that normal readers focus on the word they are looking at and "mask" out the surrounding words. They really will not see words on the periphery of their vision. Dyslexic children, on the other hand, are not able to "mask," and see many words at the same time.
They devised a simple treatment. Children read a limited chunk of words through a window they could move along the page. The artificial masking alone in many cases led to a dramatic improvement in reading level. They concluded that dyslexia does indeed have a visual component. Today, as Geiger continues his research, he adds a component of eye-hand coordination to his therapy -- making art.
The artificial masking technique, incidentally, is one that Ladue reading teacher Joanne Curran has used for many years.
And in Conclusion
No question that both sides of the controversy are well-motivated, but they have differing viewpoints. As Lueder put it, to most ophthalmologists, the eye is a camera and the brain is a computer. To developmental optometrists and the neurobiologists described here, the eyes and the brain are a system.
It is true that vision therapy is expensive. Insurance will in some cases pay for all or part of the initial examination, but only a small percentage pay for the therapy, which is usually given in increments of eight weeks. Fees vary, although the clinic at UMSL School of Optometry has a fee scale considerably lower than private practitioners'.
Meanwhile, research and applications of the therapy continue.
Boston Children's Hospital, a Harvard hospital, offers vision therapy to its clients. As Dr. David Hunter, chief of ophthalmology, wrote in response to an email query: "While I'm aware that most of my colleagues feel that vision therapy has neither scientific support nor clinical proof of effectiveness, I believe there are enough anecdotal stories of success that the topic warrants more study."
He went on so say that they have planned clinical trials and that "properly conducted trials might address the claims of vision therapy in a way that makes sense to optometrists and ophthalmologists alike, or at least to provide a model for larger, multi-center clinical trials of specific forms of therapy."
Jo Seltzer is a freelance writer with more than 30 years on the research faculty at the Washington University