eLetters to:

FROM THE AMERICAN ACADEMY OF PEDIATRICS: American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists Learning Disabilities, Dyslexia, and Vision Pediatrics 2009; 124: 837-844 [Abstract] [Full text] [PDF]

eLetters published:

Response to the Joint Statement "Learning Disabilities, Dyslexia, and Vision"

Marjean Taylor Kulp, Susan Cotter, Mitchell Scheiman, Richard Hertle, G. Lynn Mitchell, Convergence Insufficiency Treatment Trial (CITT) Executive Committee Members   (26 August 2009)

Vision Therapy has Value

Alan kwasman M.D,, Benjamin Kohn O.D.   (2 September 2009)

Evidence-based Medicine or Bias?

David H. Biberdorf, OD, FCOVD   (13 September 2009)

Response to the Joint Statement "Learning Disabilities, Dyslexia, and Vision" 26 August 2009
Marjean Taylor Kulp, Associate Professor The Ohio State University College of Optometry, Susan Cotter, Mitchell Scheiman, Richard Hertle, G. Lynn Mitchell, Convergence Insufficiency Treatment Trial (CITT) Executive Committee Members Send letter to journal: Re: Response to the Joint Statement "Learning Disabilities, Dyslexia, and Vision" kulp.6{at}osu.edu Marjean Taylor Kulp, et al.	We agree with the authors of the Joint Statement-Learning Disabilities, Dyslexia, and Vision that “scientific evidence should be the basis for treatment recommendations.”(1) However, we are perplexed they stated, "Symptomatic convergence insufficiency can be treated with near- point exercises, prism convergence exercises, or computer based convergence exercises. Most of these exercises can be performed at home, and extensive in-office vision therapy is usually not required.(2-4) Alternatively…reading glasses with base-in prism(4) or minus lenses can be used as treatment." Unfortunately, the references provided(2-4) to support this view are two editorials and a descriptive opinion-type paper that contain no scientific data and are at odds with the scientific evidence reported from recent NEI-funded multi-center randomized clinical trials.(5,6,8) Specifically, a recently published randomized clinical trial for children with symptomatic convergence insufficiency (CI) found that 12 weeks of office-based vergence/accommodative therapy with home reinforcement resulted in significantly greater improvements in both patient symptoms and clinical measures, and a greater percentage of these children reached the predetermined criteria of success when compared to children randomized to home-based pencil push-ups, home-based computer vergence/accommodative therapy and pencil push-ups, and placebo therapy.(6) Office-based vergence/accommodative therapy with home reinforcement was successful in approximately 75% of patients and was the only treatment studied which was more effective than placebo treatment.(6) In addition, the authors ignored the results from the only randomized clinical trial on base-in prism reading glasses when they stated, “reading glasses with base-in prism…can be used as treatment.” In fact, when compared to placebo reading glasses for the treatment of symptomatic CI in children, it was found that base-in prism reading glasses were no more effective in alleviating symptoms and improving clinical signs than placebo reading glasses.(7) Furthermore, there are no studies that have demonstrated that “minus-lenses” are an effective treatment for symptomatic CI. References 1. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus and American Association of Certified Orthoptists. Learning Disabilities, Dyslexia, and Vision. Pediatrics 2009;124;837-844 2. Kushner BJ. The treatment of convergence insufficiency. Arch Ophthalmol. 2005;123(1):100 –101 3. Wallace DK. Treatment options for symptomatic convergence insufficiency. Arch Ophthalmol.2008;126(10):1455–1456 4. Petrunak JL. The treatment of convergence insufficiency. Am Orthopt J. 1999;49:12–16 5. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. 2005;123(1):14 –24 6. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336 –1349 7. Scheiman M, Cotter S, Rouse M, Mitchell GL, Kulp M, Cooper J, Borsting E and the Convergence Insufficiency Treatment Trial (CITT) Study Group. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br. J. Ophthalmol. 2005;89;1318-1323 8. Scheiman M, Rouse M, Kulp MT, Cotter S, Hertle R, Mitchell GL, Treatment of convergence insufficiency in childhood: a current perspective. Optom Vis Sci 2009;86:420–428 Authors Marjean Taylor Kulp, OD, MS, The Ohio State University College of Optometry, Columbus, Ohio Susan Cotter, OD, MS, Southern California College of Optometry, Research Professor, Department of Ophthalmology, University of Southern California, Fullerton, California Mitchell Scheiman, OD, Pennsylvania College of Optometry at Salus University, Philadelphia, Pennsylvania Richard Hertle, MD, Chief of Pediatric Ophthalmology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania G. Lynn Mitchell, MAS, The Ohio State University College of Optometry, Columbus, Ohio Convergence Insufficiency Treatment Trial (CITT) Executive Committee Members Conflict of Interest: None declared
Vision Therapy has Value 2 September 2009
Alan kwasman M.D,, developmental pediatrician FAAP, Benjamin Kohn O.D. Send letter to journal: Re: Vision Therapy has Value kwasman_a{at}yahoo.com Alan kwasman M.D,, et al.	Dear Editor, We would like to comment on the AAP policy on learning disabilities, dyslexia and vision which was published in Pediatrics (August 2009 Vol. 124 # 2). Although the policy is correct in the sense that vision therapy is not a cure for dyslexia, it casts a shadow on vision therapy. Vision therapy, which is physical therapy for the eyes, helps reduce reading-related visual dysfunctions. Some of the signs and symptoms which are helped by vision therapy, include: words that blur in and out of focus when reading, letters vibrating, skipping lines and words when reading, and headaches during reading. Only a qualified developmental optometrist can make the diagnosis. We challenge you to substitute the word “eyeglasses” for “vision therapy” when reading the AAP policy on learning disabilities. The policy would then essentially read- eyeglasses are not a cure for dyslexia or learning disabilities and not a substitute for educational therapy. That statement is also correct but ignores the important role of good vision in reading and learning. We feel there is a role for vision therapy in the care of selected patients and the aforementioned policy does a disservice by singling out vision therapy. Sincerely, Alan Kwasman M.D. FAAP Developmental Behavioral Pediatrician Benjamin Kohn O.D. Developmental Optometrist Conflict of Interest: one author (B.K. is a practicing vision therapist)
Evidence-based Medicine or Bias? 13 September 2009
David H. Biberdorf, OD, FCOVD, Optometrist private practice Send letter to journal: Re: Evidence-based Medicine or Bias? drbiberdorf{at}valleyvision.net David H. Biberdorf, OD, FCOVD	Your Journal article on Learning Disabilities, Dyslexia and Vision presented an entirely biased and non-scientific statement, "Symptomatic convergence insufficiency can be treated with near-point exercises, prism convergence exercises, or computer based convergence exercises. Most of these exercises can be performed at home, and extensive in-office vision therapy is usually not required.(2-4) Alternatively…reading glasses with base-in prism(4) or minus lenses can be used as treatment." This amounts to Level V evidence (expert opinion) trumping Level I evidence, the recent NEI funded Level I "gold standard" findings of the Convergence Insufficiency Treatment Trial (CITT). In the interest of science, public welfare and your Journal's credibility, this statement should be retracted. Conflict of Interest: None declared