Pediatric ophthalmologists review how to address vision therapy with parents

Roundtable Participants

Roberto Warman, MD: There are two types of parents. One type asks you about vision therapy because they went to see a developmental optometrist and they have not decided to start. That is the ideal parent in this regard.

The other type is the one whose child, unfortunately, has already been in vision therapy for a year or so and wants to explore other avenues. The approach is a little different in each of these cases, but the bottom line is the same. I am clear, and I tell them, “There’s a big difference of opinion between pediatric ophthalmologists and developmental optometrists. The developmental optometrists are going to tell you that because we are surgically oriented, we say it doesn’t work and we don’t believe in it.”

I tell parents that the AAPOS reviews everything new that comes in from developmental optometrists every 5 years to make sure there is nothing we are missing. Every time the results are the same. Nothing is consistent and reliable. There may be anecdotes but nothing that we can really support.

I also offer them pamphlets from the American Academy of Ophthalmology and AAPOS that clearly state that vision therapy does not work. I tell them that my main concern is that it may be a waste of time.

Another issue I discuss is the commute. It could be an hour drive one way or another, plus the hour in therapy. The child may also need other types of tutoring and support, and they need free time. It usually convinces the parents not to follow the avenue of vision therapy.

Douglas R. Fredrick, MD: I refer to the policy statement. I am clear, and I don’t spend a lot of time arguing with them. I am always respectful. I say, “As the parent, I understand it’s your prerogative to do what you think is best for your child, but I look at every patient as if they are my child, and this is what the evidence shows.”

If I felt there was any reason to do vision therapy, I would do it myself and offer it as a service, but I don’t. Just as Dr. Warman said, it is time and money, and I tell them upfront, “There are much better ways you could spend that $5,000 with your child who has a learning or reading disability, and I’ll give you some examples.”

I like to offer parents alternative options that are valid. Pediatricians are often so overwhelmed with performing vision screening that they will say, “There’s an optometrist. He or she takes care of any eye problem that my patients have. I’m just going to keep sending my patients to them.” I think we need to do a much better job of educating pediatricians that vision therapy is not useful.

I make a clear distinction between orthoptic therapy and vision therapy because that is where it gets a little bit muddled. It is usually the patients with convergence insufficiency who also have ADHD who request vision therapy. I think we just need to be honest. I say, “The final decision is yours. You’re the parent. If you choose to do this, I’m not going to hold it against you. I’ll be available to take care of your child in the future if you have any needs.” I am a little more forthright than I used to be.

Rudolph S. Wagner, MD: I agree. I make a point in these kinds of situations of demonstrating to the parents, especially if they have a normal exam and excellent stereoacuity, that these kids can perform a test well. There are a lot of times they are basing it on the child’s ability to track, which is somewhat non-specific. You can show the parents that their child’s eye muscle system is working quite well, and that reassures them.

The other thing that makes them feel better is if you validate their concerns about the expense of vision therapy. They want to hear whether it works or not.

As Dr. Fredrick said, you have to be honest with them and let them know that our opinion is that we don’t think vision therapy works well or at all in most cases. It is a difficult issue because in some cases they have already spent quite a lot of money on the therapy when they come in, but the fact that they are coming in means that they are questioning it or want an answer. You just have to carefully explain your reasons for not recommending this type of therapy.

Warman: I have a soft spot for patients with ADD and learning disabilities because one of my children has one of these conditions.

Even when I am behind on my schedule, which I often am, I dedicate a lot of time to these parents. I even give them my personal history involving my child and what avenues worked for him. It is not just about telling them that vision therapy does not work. It is about telling them what does work.

The light at the end of the tunnel is that most of these children will get ahead, and what they need is good tutoring and good educational support. We offer the parents information on how to find that support. I have reliable educational people who I refer them to, and the parents often leave feeling positive.

I also offer parents the larger version of the AAPOS pamphlet, which contains all the resources, and I will sometimes go through it a little bit with them. That way, they feel that we know what they are going through and that we can help them, and then I can steer them away from vision therapy more easily.

• Reference:
• Vision therapy. https://aapos.org/glossary/vision-therapy. Updated April 2023. Accessed Dec. 3, 2024.

• For more information:
• Douglas R. Fredrick, MD, of Kaiser Permanente South San Francisco, can be reached at douglas.r.fredrick@kp.org.
• Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
• Rudolph S. Wagner, MD, of Rutgers New Jersey Medical School, can be reached at r.s.wagner@rutgers.edu.
• Roberto Warman, MD, of Miami Children’s Hospital, can be reached at rwarman@eyes4kids.com.

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