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Styles and Levels of Optometric Vision Care

There are various styles of practice that reside under the heading of optometry or eye care.  Many optometrists are now practicing in a way that very closely resembles ophthalmology.  There are numerous issues to be addressed when looking at alternatives in vision care.  Conditions like nearsightedness, farsightedness, astigmatism, strabismus, amblyopia or lazy eye are treatable in a variety of ways. It is worth taking a little time to learn which approach is best in your particular case.

The two main categories of eye care providers are optometrists and ophthalmologists.  Both of these disciplines have evolved over the years.  Science marches on, providing new insights and new technologies.  Both professions have taken what they feel is useful and both tend to ignore things that seem to go against their beliefs, which of course is an essential part of human nature.  There is also a tendency for these practitioners to look down upon, or even fear concepts they do not understand – also human nature.

There are two main groups of “eye care” professionals – optometrists and ophthalmologists.  Both include various sub-specialty practitioners.  Behavioral optometry is a sub-specialty of optometry.  Behavioral optometrists use vision therapy as their primary treatment approach.  Behavioral optometrists also use lenses therapeutically to improve performance and comfort.  There are many variations in the style of practice within behavioral optometry as well.  It pays to be well informed when attempting to select a professional practitioner.

There are various styles of practice that reside under the heading of optometry or eye care.  Many optometrists are now practicing in a way that very closely resembles ophthalmology.  There are numerous issues to be addressed when looking at alternatives in vision care.  The two main categories of eye care providers are optometrists and ophthalmologists.  Both of these disciplines have evolved over the years.  Science marches on, providing new insights and new technologies.  Both professions have taken what they feel is useful and both tend to ignore things that seem to go against their beliefs, which of course is an essential part of human nature.  There is also a tendency for these practitioners to look down upon, or even fear concepts they do not understand – also human nature.

Medically oriented professionals who focus on the physical aspects of the eyes have a strong tendency to ignore the functional, behavioral and developmental aspects of the visual process.  Those who do claim to address these issues tend to do so in a very mechanical way rather than treating things wholistically and developmentally.  The medical approach does not address the complex functional and developmental issues that permit the visual process to function smoothly.  Not every doctor will listen to us in the way we really need to be heard.  Behavioral optometrists, by their very nature, tend to emphasize the importance of hearing what a person has to say about their problems and goals.  However, it is up to each individual to inform herself the best she can rather than depending solely on the advice of experts.

The eyes are relatively simple organs whose structure is fairly well understood.  The visual process, which is a mind/body process, is extremely complex and not nearly so well understood.  Vision is a dynamic process.  The primary purpose of the visual process is to derive meaning, and direct action.  Good vision maximizes our potential in activities like reading, writing, working at a computer, arts and crafts, driving, and sports.  Our performance suffers to some degree when there is any disturbance in the visual process.  Vision is learned, and develops throughout our lives.  This means that either breakdown or enhancement can occur at any time.

Ophthalmology vs. Optometry

Ophthalmology is a specialty area within the practice of medicine devoted to diseases of the eye.  Ophthalmologists are medical doctors who diagnose and treat all diseases of the eye.  The typical choice of treatment begins with medications and/or surgery.  Eye muscle surgery is the ophthalmologists' treatment of choice especially in cases of strabismus (eye turns), also known as 'lazy eye' as well as amblyopia. Optometrists are also permitted to prescribe lenses.  Optometry is a profession unto itself.  Optometrists are trained to diagnose all, and treat some diseases of the eye.  They are trained to prescribe lenses as well.  All optometrists are trained in recognizing and treating functional deficiencies, that is, eye teaming, focusing, and eye tracking problems to name a few.  The vast majority of optometrists and ophthalmologists choose not to place emphasis on such functional and developmental issues, particularly when they are less obvious in nature.

This means that the majority of these problems go undiagnosed even in the face of evident symptoms, complaints, and reduced ability to function.  It is not unusual for an individual suffering from these problems to be told that their eyes are fine.  Technically, this may be true.  The eyes themselves probably are healthy.  However, this does not negate the possibility of a functional or developmental vision problem, one that can be diagnosed and treated by someone who is specially trained in this area – a Behavioral Optometrist.  Behavioral optometrists base their practices on the knowledge that vision is a dynamic process that develops throughout our lives.  The visual process is trainable, and can be enhanced using therapeutic lenses and/or Vision Therapy.

Compensation vs. Enhancement of performance

Various approaches are available to deal with any visual problem.  Some approaches are aimed at compensating for the problem.  That is, finding a way to simulate the absence of a problem.  This type of approach deals with surface issues, the symptoms that have become outwardly noticeable.  Other approaches (vision therapy for example) are aimed at attacking the root of the problem by dealing with the causes of the outward signs.  One example is nearsightedness or myopia, that condition where a person cannot see clearly in the distance without lenses.  Typically, nearsighted people are prescribed compensating lenses.  Compensating lenses are prescribed to help a person see clearly when this can seemingly no longer be achieved without lenses.  These lenses are usually called corrective lenses.  However, this is not an accurate description since they do not correct anything.  They serve to mask the focusing problem, and in fact, will contribute to a worsening of the condition over time, in most cases.  Lenses prescribed to enhance performance can actually help to improve the condition.  It is necessary to perform a thorough evaluation of total visual performance and development in order to prescribe such lenses.  It is not sufficient to simply assure that the eyes are healthy and that the eye chart can be seen clearly.  An assessment of development, performance and comfort are necessary to assure the highest level of care.

It is a fact that all lenses create perceptual and functional side effects.  That is, a person must respond in some way to having lenses on.  This fact, when taken into account, can be used in a fairly predictable way to effect positive changes.  When ignored, the changes that result will also be somewhat predictable, but not usually positive.   The resulting side effects are almost always undesirable in the case of compensating lenses.  For some people the effects are minor, for some they are critical.  For example, a person who wears glasses all day long because of difficulty seeing far away is putting almost constant extra strain on their visual system and their eyes.  This is due to the fact that such lenses are designed for seeing things that are at least twenty feet away.  Anything that is closer than that distance requires that the visual system work much harder than it would without the glasses (or contact lenses).  The closer the viewing distance the greater the strain on the visual system.  The longer this goes on, the more long-term damage is done.

Medical approach vs. Functional approach

In general, all ophthalmologists and the vast majority of optometrists utilize a medical approach to eye care, which means drugs, surgery and compensating lenses.  Developmental/behavioral optometrists evaluate the entire visual process, not just the eyes, within a functional/developmental framework.  The medical approach holds that all conditions are based either on heredity or on some mechanical breakdown.  Until quite recently it was not widely accepted that emotional states or stress could cause a wide variety of what seemed to be mechanical breakdowns.  The medical approach still tends to deal with these issues based on physical consequences.  The tendency is to focus strictly on the surface issues, those either mentioned by the patient or obvious to the doctor.  The problem is addressed by treating the apparent broken part or malfunction with medication or surgery.  This approach is the cornerstone of the compensating strategy previously mentioned.  It does not usually deal with the root of the problem, but tries to mask it by making things look good on the surface.

The functional approach looks at the dynamics of the situation by trying to find the root of the problem.  The condition is dealt with in a more thorough way, trying to eliminate those activities, substances, or behaviors that have led to some breakdown in performance and/or structure.  The functional/developmental approach considers most physical breakdowns to be a result of improper use of some sort unless proven otherwise.  This approach is much less likely to use drugs and surgery as a first choice in treatment.  Instead, some type of therapy will be used to bring about deeper changes.  The medical approach attempts to provide a “quick and easy” solution.  However, nothing comes without a price.  Most medications have side effects, some subtle, some obvious and all surgery is irreversible.  Surgery also has its own, sometimes subtle, side effects although this is not a widely acknowledged issue.

Nearsightedness/myopia is an excellent example of this way of thinking, which on the surface means that a person cannot see far away as clearly as expected without wearing artificial lenses.  The medical approach believes this to be an inherited condition that cannot be reversed or prevented.  Their only treatment is to prescribe compensating lenses, or more recently, to surgically alter the shape of the eye.  These treatments simply mask the fact that the person cannot see clearly.  The functional approach understands that most cases of nearsightedness result from improper use of the eyes.  Since this is a functional problem it can often be treated in a way that prevents or reverses the condition.  This can be done, in some cases, with therapeutic (rather than compensating) lenses and vision therapy.  The more subtle issues deal with the fact that people develop their nearsightedness naturally.  That is, the changes take place over time as a result of how a person deals with the visual demands they face throughout their lives.  Whatever inconveniences this may present, this is an organic process and must be treated in a more natural way whenever possible – and this turns out to be quite often.

Vision Therapy

Vision Therapy is part of a developmental/functional/behavioral approach to improving visually based performance.  Visually guided activities include reading, writing, driving, sports and all other activities involving eye/hand coordination.  The purpose of vision therapy is to provide a person with opportunities to experience just how their visual process works under a variety of conditions, in response to different types of demands.  Vision therapy enables the individual to observe and understand various aspects of visual behavior, and helps the brain to discover more effective, more comfortable styles of visual performance.  There are various approaches and styles to providing this type of treatment.

Originally, vision therapy was limited to what is known as “orthoptics.”  Orthoptics essentially relies on compensating lenses or prisms and a few “eye muscle exercises” usually to treat obvious strabismus (lazy eye) – the inability of the brain to properly integrate the teaming of the two eyes or amblyopia - the inability of an eye to see as clearly as the fellow eye, even with lenses.  Modern vision therapy is infinitely more than exercising eye muscles.  According to all medical standards of evaluating eye muscles there are only infrequent cases of faulty eye muscles.  This is even true of most people who have eye muscle surgery to cosmetically align the eyes.  In most cases of strabismus there has been a breakdown of communication that has disrupted the ability of the brain to coordinate and integrate how the two eyes aim together.  Many turned eyes can be straightened non-surgically if caught early.  The important thing is that when the eyes are straightened through vision therapy they not only look straight but they will be teaming better.  This almost never happens with simple surgical cosmetic alignment of the eyes.

Vision occurs in the brain, and good vision therapy trains the brain to make better use of visual abilities, information processing and communication between the two eyes and various parts of the brain.  Some offices utilize computers for much of the training.  Generally, this means that the trainee is seated a short distance from a computer, and remains seated and basically motionless throughout the training session.  Research has shown that improvement of visual performance proceeds at a faster pace, with more comprehensive results if the subject combines physical activity with visual learning.  This cannot occur while sitting at a desk or in front of a computer.  Don’t be fooled into thinking that because computers are more modern the therapy done with them is superior.  State of the art visual training requires physical involvement, the dynamic use of lenses, and constant overseeing by the doctor, including dialogue – to increase the doctor’s understanding of the person seeking help, and to increase the person’s understanding of how they use, and can improve their visual process.

Lenses

The first issue regarding lenses was brought out in the section dealing with Compensation vs. Enhancement.  In the vast majority of offices, only compensating lenses are utilized.  I firmly believe that the greatest results in visual training will be achieved only when lenses are used in a more dynamic, therapeutic way.  This has been clinically proven in my office for over twenty years.  Various lenses should be used throughout the therapy program.  In addition, therapeutic lenses must be prescribed and worn throughout the process, and most likely afterward.  Therapeutic lenses can help stimulate visual development, help prevent deterioration of acceptable visual performance, or help to reverse negative visual conditions.  Compensating lenses tend to encourage functional deterioration while therapeutic lenses are truly corrective in nature.  The appropriate lenses, sometimes even without active visual training, can provide a great deal of positive impact on overall, long-term visual performance.

Doctor vs. Therapist/Technician

Most providers of vision therapy utilize therapists or technicians to provide the actual treatment, and in some cases, to create the program itself.  In many cases the treatment program is pre-arranged, and based strictly on a specific diagnosis and/or a computer program.  This means that there is a “cookbook” approach; a certain diagnosis implies that a certain series of activities will cure the symptoms.  This can have a positive effect.  The elimination of symptoms can lead to improved performance and comfort.  However, there are more powerful, far-reaching benefits available from a more dynamic, in-depth approach to vision therapy.

Typically, in such technician-based practices, the doctor is not present other than for periodic re-evaluations.  There are significant limitations to the therapy process when the doctor is not directly involved on an ongoing basis.  Technicians tend to come and go which greatly interferes with the continuity of the treatment.  Even though some technicians have some formal training, it is unlikely that they will have the background or the insights of an experienced developmental/behavioral optometrist.  All but the most experienced technicians have significant limitations on their ability to handle unusual circumstances.  This means that they can only do what the cookbook allows even if this is not providing the optimal experiences for that individual, at that moment.  This may never become an issue in very simple cases, though in more complex situations this can be a major drawback.  Having the doctor providing the therapy allows for much greater flexibility in dealing with each individual.  This maximizes the benefits available during each session, as well as over the course of the entire program.

Splinter skills vs. Global performance enhancement

Splinter skills are basic abilities that are necessary for the performance of a given activity.  An example would be the ability to accurately converge (cross) the eyes.  This ability is necessary for all near visual tasks and many people have trouble doing this effortlessly.  A person can be taught simply by repetition to perform this particular skill at a higher level.  Global performance enhancement includes improved splinter skills.  However, this benefit is provided within a much broader context that provides a wider range of improvement.  For example, with a more global approach, improvement in the basic skills needed for school performance or increased visual comfort will evolve along with improved self-esteem, better eye/hand and general coordination, enhanced depth perception, faster information processing and many intangible improvements in how we relate to ourselves and the world around us.  Splinter skills are improved more as a side benefit with this type of approach, not as the primary or only goal.   Every skill becomes more of an automatic ability by training the use of that skill within a variety of contexts.  In this way, each skill becomes available for use in a more flexible way; that is, in a wide variety of everyday situations.  Technician based therapy is generally limited to training splinter skills.  The doctor as therapist is better able to provide enhancement of comfort and performance on a more global scale.

This has hopefully given you some insights into what you want to consider as you search for the most appropriate type of care and the most appropriate practitioner for your specific needs.

Contact Dr. Gallop for more information about behavioral optometry, vision therapy or any specific questions you may about your vision.

Resources

There are several organizations that can provide further information as well as help in finding behavioral optometrists in your area.

Optometric Extention Program Foundation  www.OEPF.org

College of Optometrists in Vision Development  www.COVD.org

Optometrists Network  www.optometrists.org (more…)