...Pediatric Optometrist or Pediatric Ophthalmologist?

How to choose an eye doctor for a child who is having problems with learning, reading and behavior or who has been diagnosed with LD, learning disabilities, developmental delays, attention deficit disorder (ADD), attention deficit hyperactivity disorder (attention deficit hyperactive disorder, adhd, AD/HD, hyperactive), dyslexia or autism.

A parent recently asked why I recommend that her child be examined by a pediatric optometrist rather than a pediatric ophthalmologist. The answer comes from my understanding of these two types of eye doctors and my personal experience.

Both types of eye doctors examine and prescribe glasses, diagnose and treat eye disease, and can evaluate how well a person uses the eyes together. However, each profession is unique.

Ophthalmologists are trained to do surgery. I credit one with saving the eyesight of my daughter, who at age five sustained an eye injury. Optometrists are schooled in the functional (or developmental) aspects of vision. They are more apt to use lenses, prisms and vision therapy to enhance and improve visual function. These interventions often improve children's visual, academic and other abilities.

Eyesight and vision are not synonymous. Eyesight is the sharpness of the image seen by the eye. Vision is the ability to focus on and comprehend that which is seen. Research has shown that while most children with special needs do not have eyesight problems, many have visual dysfunction. If a child has motor delays, vestibular difficulties, or health problems, vision is often compromised.

The American Optometric Association (AOA) recommends that children have vision examinations by six months. A good eye doctor can test many aspects of function at this young age and quickly effect changes with intervention.

Most school vision screenings check only eyesight - only at twenty feet, not at reading distance. They rarely tell us whether a child has a clear image at nearpoint or how the eyes work together. The only information they provide is whether a child can see the blackboard. Many vision problems thus go undetected when parents have false security and brag, "My kid's eyes are 20/20!" To learn what visual skills need to be tested as part of a child's comprehensive Eye Exam, visit the eye exam page at children-special-needs.org.

Vision--like reading, mathematics and language--is learned. Giving meaning to what is seen begins at birth. In the developmental hierarchy, infants move without purpose, while their eyes learn how to work as a team, to sustain focus. Toddlers use movement to drive vision, such as shaking a rattle for its sound before looking at it. Finally, children can visualize without movement. Thus, for children to be successful in school, vision must purposefully direct their actions.

We hear a great deal about individual learning styles."My child is a kinesthetic learner," a mother told me. She meant that her child is still using touch and movement to get information about the world. From a developmental standpoint, this learning style is more primitive than getting information visually.

Well-functioning individuals store all types of sensory images and can visualize and retrieve them upon demand. They no longer need to touch and move to experience their world. Vision directs their thinking, organization, listening and actions.

Vision plays a major role in language and social-emotional development. Children with language delays, attention deficits, pervasive developmental disorders and autism all have inefficient visual systems. If a toddler is not speaking or relating to others, a vision evaluation is essential.

A developmental optometrist can prescribe therapeutic and pleasurable activities to be done at home, during floor time, occupational and language therapy, or at day care. Combining the visual system with touch, movement, audition and social experiences benefits all areas. Begin Where They Are, a workbook designed by vision therapists and available through the DDR (see link below), has good ideas for pre-verbal children and toddlers.

Scientific evidence indicates that interventions such as vision therapy, used by behavioral optometrists, work. If your child has developmental delays of any kind, choose to have all aspects of vision evaluated. The Doctor Directory can help you locate eye care professionals qualified to evaluate even the most difficult, non-verbal children.

The American Optometric Association publishes a monograph, The Efficacy of Optometric Vision Therapy, containing 238 references; it is available free of charge from the Developmental Delay Resources.

The Developmental Delay Resources is a not-for-profit organization whose mission is to educate parents and professionals who support children with developmental delays about healthy options for treating the whole child. Telephone: 301-652-2263

   

Excerpted article from the book:

Buzzards to Bluebirds -- Improve Your Child's Learning and Behavior in Six Weeks

by Educators, Allen and Virginia Crane
(ISBN: 0-943599-87-3)

Pediatric Optometrist or Pediatric Ophthalmologist?

"The emphasis of ophthalmology is eye disease and eye surgery; this is their domain, their area of expertise. Dr. Malcolm L. Mazow, an opthalmologist, wrote in the discussion section of his paper "Acute Accommodative and Convergence Insufficiency,"¹  "My impression is that many ophthalmologists handle this disorder poorly and many of the patients end up under the care of optometrists." Another opthalmologist, Dr. David L. Guyton, in the same article said, "I agree with Dr. Mazow … we have probably abdicated the study of accommodation and convergence to the optometric profession. A perusal of the literature will reveal that most of the advances in this area are being made in the optometric institutions by vision scientists who use definitions and terms with which we are not even familiar."

All optometrists are thoroughly trained to detect eye disease, examine binocular vision and convergence, and perform refraction (the fitting of eye glasses and contact lenses). Beyond that, in postdoctoral study, optometrists learn one or more specialites. Some specialize in contact lenses, some in geriatrics, some in functional vision, some in sports vision. Specialists in behavioral optometry or developmental optometry treat individuals with developmental or functional vision problems. Specialists in neuro-optometric vision therapy or rehabilitation work with individuals who have visual disturbances with neurological causes (i.e.: birth trauma, brain damage, head trauma).

When unable to detect a vision problem quickly, the non-functional vision specialists may suggest that your child be referred to a psychologist or psychiatrist to explain your child's symptoms. Remember that if your child develops symptoms during reading, this indicates a vision problem and your child probably does not require a pyschologist or psychiatrist.

Be sure to screen eye doctors to find an optometrist who will do the comprehensive testing you require and will be able to give the assistance you need to correct any vision problems. Free and immediate referrals to specialists in behavioral optometry or developmental optometry can be obtained by filling out a form at the Doctor Directory.

Hypophoria, hyper, hypertropia, vertical misalignment

The authors, Allen and Virginia Crane, believe that the most overlooked problem in vision is vertical misalignment: wherein one eye aims higher than the other (sometimes one eye is actually placed physically higher than the other in the child's face); technically termed hyper- or hypophoria or tropia. The established allowable norm used by many eye doctors is two diopters (a unit that expresses the power of a lens).²  This means that one eye may normally aim about 1/4 inch lower at reading distance than the other eye. This is a large amount. In comparison, behavioral optometrists use 1/2 diopter as the allowable norm.

Sample of the difference 1/2 diopter can make.

In some cases, 1/4 of a diopter can prevent a child from learning the alphabet and reading properly because of all the extra effort required to keep a clear image. The child can do this for only a short period of time and comprehension can be poor. The eyes can keep good alignment only for a short time and then must be rested. This can explain why many children are labeled as having a short attention span, being hyperactive or having attention deficit hyperactive disorder (ad/hd, adhd, attention deficit hyperactivity disorder). Actually, many are resting their eyes, an involuntary physical need. A vertical alignment problem is easier to correct than to diagnose. During our research, we found that only behavioral optometrists diagnosed and corrected vertical problems directly.

In our experience, directly training vertical alignment at the beginning of vision training activities shortens the total time required to eliminate visual symptoms.

Note that a behavioral optometrist may correct vertical alignment problems by including the proper amount of prism in glasses to compensate for the problem (prismatic lenses or prism lenses). These doctors use several methods to determine the prism correction necessary. One technique is patching one eye for up to forty-eight hours, then remeasuring the vertical alignment. A second technique is a fixation disparity test which takes special equipment and about twenty minutes.³  A series of prisms is used and a vertical alignment curve plotted to determine the amount of prism needed.⁴

In order to locate an eye doctor who has the competence and knowledge to help you, search through the Directory of Vision Care Providers at www.vision3d.com. These eye doctors have passed extensive written and oral examinations by certifcations boards in behavioral optometry. If there is no eye doctor listed in your community, contact the nearest doctor listed in the Directory and ask for more information regarding a qualified person in your area.

The information contained within is provided by ADD-ADHD.ORG. All information is for informational purposes only and not intended as medical advice. This publication is provided "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED.

   

                

¹  Malzow, M.L.; France, T.D.; Finkleman, S.; Frank, P.; Jenkins, P.; "Acute Accommodative and Convergence Insufficiency," Tr. Amer. Opth. Soc., Vol LXXXVIII, 1989.
²  Boorish, I.M. Clinical Refraction, 3rd edition, Chicago, IL: The Professional Press, Inc., 1970. p. 869.
³  Scheinman, M.; Wick, B., Clinical Mangement of Binocular Vision. Philadelphia, PA: J.B. Lippincott Co., 1994. pp. 40-41.
⁴  Ibid, pp. 1-13.