VT Mismatch

Written By Guest Blogger: Jessica Zwilling, COVT


Everyone has their own “style.”  We hear this and say this often in our world of Behavioral Vision Therapy.  As a COVT who has worked for different doctors over the last 20 years, I can attest to that fact.  Optometrists and Therapists alike, all have their own style in the VT room.  Of course, we all learn the broad outline of how to treat different visual disorders and which activities to utilize and in what order, but I believe that it is a rare find to have two VT practices practicing the same way.  Of course, we usually achieve the same end goal, just not always in the same way.  Why is that?

I can’t speak with authority on this, but I assume that heart surgeons across the country perform certain procedures in the same way just as dentists across the country fill cavities the same way.  Of course, there are exceptions with everything from the type of patient to the tools available to the doctor, but in general, there seems to be a little more uniformity within other fields of healthcare.  I think Vision Therapy’s lack of uniformity can be both our rise and downfall in the eyes of other healthcare providers and educators.

Recently, we had a patient come for an evaluation who showed me this lack of uniformity in her notebook that she brought with her to the last SIX, yes, SIX, vision exams.  The patient is an adorable, good natured, 25 month old little girl with Triple X Syndrome and intermittent exotropia in one eye (divergence excess-type).  My doctor found no blaring refractive error or signs of amblyopia at this time.  Her syndrome doesn’t seem to slow her down much, as she is determined to do everything her twin brother does.  She does toddle around more like a 16-18 month old, but she does talk some and overall seems to be a cooperative and happy little girl.  Of course, my Doc recommended VT, and why not?  There are tons of things I can do with this kid, and lots the parents can do at home.

After scheduling our first VT session, Mom pulled out the notebook and gave me the brief history of the other six doctors’ recommendations.  #1 and #2 were both pediatric ophthalmologists who both recommended eye muscle surgery along with the scare tactic that it should be done right away.  #3, a Developmental OD, found no eye turn at all and sent them on their way.  #4, a Developmental OD, sent the parents home with a TBI unit to use during the night while their daughter was sleeping.  #5, a Developmental OD, told the parents that they primarily use computer orthoptics for treating vision disorders and to come back when she is 8 years old.  #6, also a Developmental OD, recommended yoked prism (not sure what kind) for full time wear and some convergence training.

Now, keep in mind, this is all the parents’ wording and I have no way to find out all the details of all the recommendations without calling each doctor personally.  I am so not going there, nor do I need to.  I’m not one to say that my way is better or worse than anyone else, and I certainly am not here to say that anyone was right or wrong.  Remember, we all have our own style and skill set with which we are most comfortable.  My concern is that the parents, now at eye doctor #7, are confused and frustrated by conflicting or differing recommendations, yet hopeful and determined that they will find someone to help correct their 2 year-old’s vision.

Are all these different opinions helping or hurting our field?  Are cases like these the reason ophthalmologists say we practice voodoo when the family goes back for a follow-up?  Are cases like these the reason so many pediatricians say Vision Therapy doesn’t work?

Should we strive for more uniformity of treatment plans within our field?  VT docs learn about standard treatment plans in textbooks, clinic, and during residency.  Often doctor’s will grow into their own VT style through years of clinical practice, tips from a mentor, and shared ideas within our community.  A therapist’s knowledge base usually comes directly from the doctor under which they work and from any independent reading they do.  There are many areas to which many therapists never get exposed.  We have lots of gold standards in our field that we all use from Brock Strings and vectograms, to accommodative flippers and Marsden Balls.  Yet, one can go visiting from practice to practice and find so many variations.  Some incorporate primitive reflex training, vestibular stimulation, syntonics, and even yoga!, while others primarily use computers,  and Hart Charts for most of the training.

JZ2I think it’s wonderful that we have so much diversity, open mindedness, and creativity within our field, and that we are all so willing to share our different approaches with one another.  However, if you put yourself in the shoes of parents, teachers, and other healthcare clinicians, Vision Therapy can be down-right confusing!  There must be some middle ground.

That’s my concerned rant, for the moment.  I don’t have the answers, just the observations.  I’d love to hear input and opinions from our readers!

“We make our discoveries through our mistakes; we watch one another’s success; and where there is freedom to experiment, there is hope to improve.” – Arthur Quiller-Couch


Posted on May 16, 2015, in From My Perspective.... Bookmark the permalink. 8 Comments.

  1. Nice post and mostly agree. I don’t think the approaches in medicine and dentistry are as different from us as you might think. How many dentists might “watch” an area needing a filling and how many aggressively recommend filling right away. During a lecture to ODs, a retinal OMD indicated that 80% of the men’s they use are “off label.” Now, am I supporting everyone can do whatever they please? Not at all! We do need more consistency and we also need to recognize our limitations and help the patient navigate to the next level when it is beyond our comfort level. The OMDs don’t seem to want to know. The ODs should be aware of all steps in the process and should consult/refer with an OD colleague to get the patient to the most appropriate type of care for the patient when outside their level of comfort. Some patients need basic intervention and some need more aggressive and complicated intervention in order to achieve the best outcomes. Your patient is a good example of the patient having needs that were not met by six previous individuals holding a doctorate degree – and maybe some were even “certified.” Even within those certified, there are significant differences in practice even as “simple” as determining the use of lenses. Keep up the good work – and let’s all work together in the best interest of the patient.


  2. jzwillingcovt

    Dr. Steele, thank you for your input. I couldn’t agree with you more about “knowing what to do when you get outside of your comfort zone. ” So, so important!

    Liked by 1 person

  3. Thanks for your article, Jessica – very thought provoking. I’d like to submit too that I believe there is a difference in what we do from dentists, heart surgeons and even opthalmologists. And that is that while they generally do things TO people (e.g. surgery, fillings, extractions, etc.) our goal is to encourage change in tandem WITH people. To effect change to the visual system, our patients engage with us, with the activities that will bring them “aha” moments, with their helper or parent, and indeed with their own “selfness”. (As in, “what is it” , “where is it”, and “where am I”?) It’s an entirely different dynamic, and the outcome can be hugely impacted based on the individual design of the program for that particular individual. I know I (and I’m pretty certain my therapist colleagues) constantly look for a way “in” to the particular personality of the human being before me because the better I know that person; what they value, how stimulation of certain types affects them, etc. etc., the better I can tailor the general activities prescribed for them by the doctor. All of this means that there isn’t a “one size fits all” for any one given diagnosis. Even prescribing lenses, which would seem to be pretty straight forward, involves what THAT particular patient does with those lenses. That’s the art of what we all do, but I also submit that this very “individualizing” is what makes comparisons difficult for parents making decisions sometimes. Again, my thanks for tackling a difficult subject!


    • jzwillingcovt

      Thanks, Jenni, for your insight on this subject. So true that we don’t do cookbook therapy, and so glad we don’t!


  4. Each patient is a bit different although some generalities do apply. A very complete history is very important. School performance, general health, accidents, any head injury, etc. I agree with Jenni and her insight, no cookbooks for us!!! Functional Optometry is such a wonderful profession and such a rewarding way to spend one’s professional life. I get phone calls from individuals who were my patients as school aged children who were failing miserably in school. They are usually questions about where they can find help for their own children who are facing the same kinds of challenges at school as did their parent(s). I still have contact with many of these individual who are now successful in their professions and recognize that they would not be where they are if not for vision rehabilitation! As Jenni mentioned each patient is an individual and while there are many overlaps in problems, there are many similarities. Optometric Vision Rehabilitation is indeed a great gift for the population of students who have been told they “just don’t try hard enough”. etc. I’ve yet to meet a child/student who didn’t want to do well. They want smiley faces on their work and not frowning faces. Optometric vision rehabilitation can make this possible. It is a wonderful way to spend one’s professional life. 50 years ago I stumbled into Dr. Tole Greenstein’s office responding to the employment agency he had contacted. After a long afternoon of conversation about what he did in his practice I was enthralled. We didn’t discuss the job and I left full of very interesting information. He called me the next day asking if I could come to work the following week. I immediately answered “Yes”. I had no idea what the job was or what it paid, I simply knew that the conversation we had was fascinating and intriguing. What he really wanted was a front office person to make appointments, collect fees, etc. It became very apparent that this was not my skill set., So he said, “I think you may be very good at the special part of my practice, let’s talk about it! The rest is history. I fell in love with the work he showed me in basic vision therapy. He sent me to OEP meetings and other group workshops dealing with functional vision rehabilitation. I was “hooked”. I do remember him saying to me, “once you have entered this professional you will be forever enthralled!!” How true that was. Functional Optometry can change lives, can give children who are failing and feel like failures a new lease on life. I still get messages from many of the children with whom I worked who now have children of their own and want referal to an Optometrist who could do for their child what was done for them. It is indeed a wonderful way to spend ones working life. I am forever thankful for the opportunity affored me in this great profession.


  5. Dr. Gary J. Williams

    Jessica and Robert,
    It is a positive sign that we can discuss this in an open, receptive forum and that doctors and therapists are both involved with the goal of more consistently helping our patients.
    Gary J. Williams, OD


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