Frequently Asked Questions

Each individual insurance policy is so unique that it is difficult to say whether or not your insurance will cover Vision Therapy (VT). Vision Therapy is considered a medical treatment and therefore is never billable to Vision/Eye Insurance. It is always best to call your Medical/Health Insurance carrier to verify if they will cover VT or not.

The Procedure Code you will need to ask if your insurance company covers is: 92065 “Orthoptic Training” (Vision Therapy)

Vision Therapy is not typically a covered health benefit. Some Health Insurance plans will cover Vision Therapy but only for specific diagnoses. Commonly that diagnosis is Convergence Insufficiency (H51.11).

In this era of insurance cost cutting measures, it can be difficult to receive adequate insurance coverage. Patients are much more effective in getting reimbursement when they pursue their claims directly, armed with knowledge and facts from the doctor’s office. There are national optometric guidelines formulated for covered conditions and length of treatment. The College of Optometrists in Vision Development (888-268-3770) has an insurance committee that offers to conduct peer review of claims when it becomes obvious that the individual or individuals reviewing the claim are not optometrists.

Ultimately the patient must consider the following:

  • What problems or concerns are you having with your vision or performance?
  • What options have you tried other than vision therapy, and what has been the result?


If you have not had success pursuing other interventions, and the doctor’s diagnosis and treatment proposal make sense, what value would you place on improvement?

Vision therapy is rarely the first form of help that patients discover. If the patient or family is struggling, and other suggestions have not borne fruit, investing in vision therapy makes sense. Insurance reimbursement is helpful, but not all our decisions about our welfare, or our children’s future, are made based on someone else paying for it.

Although Academy of Vision Development does not accept assignment from insurance companies, our office will make every reasonable attempt to help with the collection of insurance benefits due the patient. The necessary forms are completed as services are rendered. Patients can forward these to an insurance carrier. Upon request, we will submit a prior approval/denial request to a patient’s major medical insurance company for these treatments.

We recommend each patient contact their insurance carrier to determine the exact steps required to receive PATIENT REIMBURSEMENT FOR PAID IN FULL SERVICES RENDERED. This includes forms needed to submit for “Out-of-Network Provider, Patient Reimbursement”, Prior Authorization (if necessary) or Physician Referrals (if required).

Patients having the most success with getting some insurance coverage for vision therapy are the ones willing to take the time and put in the effort of making numerous phone calls, emails and faxes to their insurance provider. We apologize for any inconvenience this may have on you, but our small, specialty business concentrates on providing patients with a unique Program of life-changing Vision Therapy and Behavioral Optometric Vision Care, leaving little time to deal with the inefficiency of administrative requirements demanded by every single insurance carrier.

Due to the massive overhaul changes to insurance coverage, the cumbersome and inefficient insurance submission requirements and the extremely unique coverage for each individual patient, AVD is not considered In-Network for any insurance providers. However, the majority of Vision Therapy providers are also considered Out-of-Network. Therefore, some insurance companies will make an exception because there are “No In-Network Vision Therapy Providers within a 75-mile radius.” While they may not cover vision therapy, they may at least apply it to your In-Network Deductible.

Eyesight is simply, how clear things look. When we are told our vision is 20/20 it simply means we have acceptable eyesight. VISION is much more than just 20/20. Vision is the process our brains use to gather information, process that information and then use it to react to our environment. There are many visual skills that make up our Vision, some of these include:

  1. The ability to follow a moving object smoothly, accurately, and effortlessly with both eyes and at the same time think, talk, read, or listen without losing alignment of eyes. This pursuit ability is used to follow a ball or a person, to guide a pencil while writing, to read symbols on moving objects, etc.
  2. The ability to aim the eyes on a series of stationary objects quickly, with both eyes, and at the same time know what each object is. This is a skill used to read words from left to right, add columns of numbers, read maps, etc.
  3. The ability to change focus quickly, without blur, from far to near and from near to far, over and over, effortlessly and at the same time look for meaning and obtain understanding from the symbols or objects seen. This ability is used to copy from the chalkboard, to watch the road ahead and check the speedometer, to read a book or watch TV from across the room, etc.
  4. The ability to team two eyes together. This skill should work so well that no interference exists between the two eyes that can result in having to suppress or mentally block information from one eye or the other. This shutting off of information to one eye lowers understanding and speed, increases fatigue and distractibility, and shortens attention span. Proper teaming permits vision to emerge and learning to occur.
  5. The ability to see over a large area (in the periphery) while pointing the eyes straight ahead. For safety, self-confidence and rapid reading, a person needs to see “the big picture”. This skill aids the ability to know easily where they are on a page while reading and to take in large amounts of information, (i.e., a large number of words) per look.
  6. The ability to see and know (recognize) in a short look. Efficient vision is dependent on the ability to see rapidly, to see and know an object, people or words in a very small fraction of a second. The less time required to see, the faster the reading and thinking.
  7. The ability to see in depth. A child should be able to throw a bean bag into a hat 10 feet away, to judge the visual distance and control the arm movements needed. An adult needs to see and judge how far it is to the curb, make accurate decisions about the speed and distances of other cars to be safe.


Vision abilities are learned coordination and processing skills developed by the brain. These skills and processing are not just functions of the “eyes” but a process that links what we see with many other Neuro-behaviors and senses: movement, speaking, hearing, language, touching and feeling, etc. Normal development of the senses relies heavily on a normally developed visual system. Full Sensory Integration is an important aspect of any meaningful Vision Therapy Program.

As defined in a Joint Organizational Policy Statement of the American Academy of Optometry and the American Optometric Association, vision therapy is a sequence of activities individually prescribed and monitored by the doctor to develop efficient visual skills and processing.

Vision Therapy is prescribed after a comprehensive eye examination has been performed and has indicated that vision therapy is an appropriate treatment option. The vision therapy program is based on the results of standardized tests, the needs of the patient, and the patient’s signs and symptoms. The use of lenses, prisms, filters, occluders, specialized instruments, and computer programs is an integral part of vision therapy.

Vision therapy is administered in the office under the guidance of the doctor.
Optometric Vision Therapy is a treatment plan used to correct or improve specific dysfunctions of the vision system. It includes, but is not limited to, the treatment of strabismus, amblyopia, convergence insufficiency, disorders of accommodation, ocular motor function and visual-perceptual-motor abilities. When functional vision problems exist, intervention is often necessary. Vision Therapy is a treatment regimen that is a viable and effective approach to correcting such visual disturbances.

Vision Therapy = Physical Therapy for your Eyes!
In some respects, vision therapy is like physical therapy for the eyes. Rather than treating the muscles of the body, it works on the eyes and visual system through eye-brain connections. It is an invaluable tool that changes not only the vision of our patients, but improves many related areas of their lives as well. It can literally be life changing!

Vision Therapy is not just “eye exercises”.
This is because developing effective visual skills is done largely by integrating what is seen with the other sensory systems of the body. Vision Therapy is retraining the brain to use the eyeballs properly to gather information, process that information and form a response based on these learned skills.

Vision Therapy is a professionally managed and administered treatment program that works on providing the student with the necessary visual coordination and perceptual skills for enhanced performance. This works through a series of programmed treatment procedures giving the student awareness and feedback plus sensory integration as visual development is improved and accelerated.
Through the guidance of the Doctor, the student develops proper Neuro-motor control of visual coordination skills and learns better visual processing skills, visual perception and visual integrative abilities in an accelerated process.

The Prescribed Vision Therapy Program and treatment duration wholly depends on the patient’s Comprehensive Binocular Vision Examination and Neuro-Processing Evaluation results and diagnoses. The Comprehensive Binocular Vision Examination is an hour-long examination of binocularity, functional vision, sensory awareness and visual behavior. Depending on the results, age of the patient and their major reason for the initial examination, some patients (mostly the academically challenged) are recommended to receive further Neuro-processing Evaluation. This consists of two hours of Neuro-processing testing by the Doctor which includes reading assessment, dyslexia screening, handwriting evaluation, retained primitive reflex testing, visual processing, visual memory, spatial and body awareness, and more. Then a separate one-hour, “parent only” Consultation is scheduled with the Doctor, usually within a week of the Neuro-processing Evaluation, to go over the testing and report results and discuss the treatment plan.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

In a word, yes. Studies on vision therapy are on a par with the published literature in parallel rehabilitative interventions such as physical therapy and occupational therapy. Furthermore, the data which supports vision therapy is considerably more impressive than the data which has substantiated other forms of visual intervention before these were put into public use by eye care practitioners. The same profession (Ophthalmology) which calls for “more scientific” studies of vision therapy had no qualms about recommending elective procedures such as eye muscle surgery or refractive surgery prior to any scientific study whatsoever.

The most concise source of information regarding scientific studies on vision therapy can be found on the website of the College of Optometrists in Vision Development. See Vision Therapy References for other publications.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

Research on Vision Therapy*

There are now many excellent compilations on the subject. Let’s start with a recent review, published in the highly regarded Cochrane Database Reviews on the National Center for Biotechnology Information’s Website. The citation is Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev 2011 Mar 16;(3):CD006768.

Office-based vision therapy is far superior to any other form of intervention
Convergence insufficiency, or CI, is a condition for which research has proven that office-based vision therapy is far superior to any other form of intervention. Two important points to keep in mind about this gold standard study, the citation for which is as follows:

Scheiman M, Cotter S, Mitchell GL, Kulp M, et al (CITT Study Group). Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126:1336-49.

A successful or improved outcome was found in 73% of the office-based therapy group, 43% of the pencil push-up group, and 35% of the office-based placebo therapy group, and 33% of the home-based computerized therapy group.
The results of this study are now being used by some insurance carriers to support the need for office-based vision therapy, but only of 12 weeks duration, as was used in the CITT study.

This demonstrates several very significant points about research on optometric vision therapy:

Unlike drug studies, in which the patient takes a placebo pill, it is challenging to design a placebo therapy group. Placebo therapy must be designed well enough that neither the patient nor the therapist knows that the therapy is not directly addressing the condition. The CITT group did a brilliant job designing this group, which is why they were able to generate such a good rate of improvement that came about from improving sustained visual attention – in fact a couple of percentage points greater than the home-based computerized therapy group!

Although the outcome after 12 weeks of therapy was impressive at a 73% rate of improvement, we do not settle for that in our practice. Why would you want only a 73% rate of improvement if by going beyond 12 weeks, and/or adding additional procedures, you can generate a 95% rate of improvement?

Even if we take what the CITT has proven at face value, since ophthalmologists and pediatricians profess to practice only evidence-based medicine, this means that in the four years since the CITT was published the field should have been transformed to the point where these professionals are now following the research outcomes of the CITT. Despite this, the majority of pediatric ophthalmologists do not recommend or prescribe office-based vision therapy.

A nice summary of recent research compiled by Dr. Dominick Maino at Illinois College of Optometry, including PubMed citations can be found on Bright Eyes Family Vision’s Website.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

Vision Therapy is not necessarily strengthening eye muscles. The premise of VT is with specific, perfect practice and repetition of visual skills, Vision Therapy changes neuro-synapses in the brain. Rewiring the brain is accomplished with many, many repetitions of the skills being learned over an extended period of time and over increasingly difficult demands.

Treatment recommendation for Vision Therapy typically consists of approximately 40 weekly, one-hour, In-Office Vision Therapy Sessions with the Doctor, which are amplified by homework activities intended for 15-20 minutes a day, five days per week. A typical Amblyopia/Strabismus Vision Therapy Program or Brain Injury Vision Therapy Program may take a year or longer of weekly In-Office Vision Therapy Sessions.

Those patients who are motivated and put forth good effort reap the most benefits in the shortest amount of time from their Vision Therapy Programs. Research shows that strict adherence to the homework regimen is a strong predictor of a positive outcome by assimilating the skills being taught with consistent practice and repetition throughout the week. Retraining the brain is going to take effort and hard work!

This is a typical complaint from parents (and teachers) of patients in a Vision Therapy Program. We try to educate parents to expect worse behavior, temper tantrums, unusual emotional outbursts (even for 10+ year olds), anger, sadness, unwillingness to participate in activities and general crankiness. This is because the first portion of Vision Therapy works to break down all their bad visual habits (8-12wks), then we help them rebuild their visual skills to work properly (10-14wks), then we help them learn to apply and use those visual skills under all circumstances and demands (14-20wks).

Imagine doing something a certain way your whole life. You’ve used this strategy to try to get the right answer in school and in life. This strategy may not be efficient or easy but it’s what you know. Now, imagine someone tells you that you are no longer allowed to use that strategy and stops you from using it. This can make everything in life seem like a struggle! While the “cranky” or “emotional” period is different for each patient there is eventually an AHA moment where things get easier and easier and behavior gets better.

While there are some Home Computer VT programs available, studies show that routine visits for In-Office Vision Therapy are the most effective and efficient treatment for Visual Dysfunctions. Computer-based home therapy programs in isolation were only as effective as placebo. We incorporate home-based computer Vision Therapy only to supplement our In-Office Vision Therapy Programs after the patient has attained certain skills “in real space” (outside of a computer). Often these Home Based Computer Programs will be prescribed after graduating from a Vision Therapy Program to help the patient maintain the skills learned in the office.

Vision problems often can and do interfere with reading and learning. Optometrists do not claim that vision therapy is a direct treatment for learning disabilities, such as LD, dyslexia or ADD. Vision therapy is directed toward resolving visual problems which interfere with educational instruction. The statement on vision therapy and learning disabilities by the American Optometric Association and the American Academy of Optometry makes it clear that a multidisciplinary approach to learning disabilities is recommended, and that vision is but one aspect of the overall picture. Statements to the effect that vision therapy has no place in the treatment of learning disabilities are inaccurate and misleading.

Vision therapy can improve visual function so the patient/student is better equipped to benefit from educational instruction. In 1991, Firmon Hardenbergh, M.D., the Chief of Ophthalmology at Harvard University Health Services, had this to say regarding a double-blind scientific study of children with reading disability and convergence difficulty:

“The application of orthoptics [included in vision therapy] to all learning/reading disabled or deficient children who manifest convergence insufficiency should be the first line of therapy.”

Regarding visual processing and learning disabilities, Corinne Smith, Ph.D., Associate Dean of Education at Syracuse University, noted in her 1997 text on Learning Disabilities that students with visual perception disabilities have trouble making sense out of what they see.

“The problem is not with their eyesight, but with the way their brains process visual information.”

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

According to law in many states, if a child is classified as having a specific learning disability, the school is required to either provide the necessary therapy, or to pay for the parents to obtain the necessary help not provided by the school. This puts educators in a tight spot. Funds are limited, so schools understandably try to minimize expenditures. Regarding perceptual impairment or visual processing disorders, educators are sometimes faced with two basic choices:

  • Have someone already on staff provide the therapy necessary or
  • Deny that the therapy has anything to do with the child’s learning problems


Some school systems try to adopt the latter approach simply due to ignorance of Vision’s effect on learning or limited funds available for ever-increasing diagnoses of children with learning disabilities.

In the case of the former, the school might assign the child to a staff Occupational Therapist. OTs are highly skilled in helping children with developmental, gross motor, and fine motor activities particularly handwriting, but they are not trained or licensed in vision therapy. Specifically, occupational therapists cannot administer important vision therapy procedures which involve lenses, prisms, and devices that insure that both eyes work together as a synchronous team.

Fortunately, we are seeing an increase in schools that recommend that parents of children with visual problems seek evaluation and treatment with a licensed optometric vision therapist.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

Vision occurs as collaboration between the eyes and the brain, informed by feedback from the rest of the body. The science of vision therapy is therefore rooted in the ability to guide an individual to make changes through feedback and awareness. As in any effective therapy, there must be a differential diagnostic process identifying which aspects of the visual system are mal-developed or in need of rehabilitation. Intervention can then be designed in accordance with generalized principles of therapy.
Vision Therapy Should Be Individualized and Customized
The science of therapy has established that to be maximally effective, the therapy should be individualized and customized to the needs of the patient. The vision therapy may be implemented by a trained therapist, but must be administered under the supervision and guidance of a knowledgeable Doctor of Optometry. The patient must internalize changes and understand that the visual system is modified therapeutically not by procedures done to the patient, but to the extent the patient is responsible for viewing differently.
Technology has greatly aided the science of optometric vision therapy but placing the patient in front a computer cannot substitute for active observation and interaction with a therapist. In the next section we review research on vision therapy, but there is one major study that is crucial in understanding the science of vision therapy.
The CITT, or Convergence Insufficiency Treatment Trial, is a multicenter study funded by the National Institutes of Health. It began in 1992, when I was part of the planning group that met at the SUNY College of Optometry, where I was Chief of the Vision Therapy Service. The original name of the study was CIRS, or Convergence Insufficiency and Reading Study. At that point had you asked eye doctors what the one condition was about which we could all agree, it would be CI. We knew its signs and symptoms, how to test for it, how to diagnose it, and how to treat it. Even in classic ophthalmology textbooks, the one condition for which “orthoptics”, a primitive form of vision therapy was best suited, was CI.
However, once the biostatisticians got involved the planning changed. The name of the group was changed to CITT because we had to prove the science behind what was already known. Gold standard scientific method involved prospective, masked, placebo controlled, double-blind, multi-center design.
The group progressed in stages to publish the CISS, or Convergence Insufficiency Symptom Survey, to prove that pencil push-up therapy or base-in prism glasses used in isolation were not effective, and that home-alone therapy was equivalent to placebo therapy. This is where the science becomes pivotal. Anyone currently treating convergence insufficiency without the benefit of supplemental in-office procedures is essentially dispensing placebo therapy until proven otherwise.
*adapted/paraphrased from Dr. Leonard Press’ website and interview:

You’re probably referring to Irlen Tinted Lenses and no, they’re not a substitute for vision therapy. Experiments continue to try to look for passive means such as filters to improve vision and reading. What sources tend to overlook is Irlen’s caution when she introduced the concept of SSS, or Scotopic Sensitivity Syndrome, as a possible basis for reading difficulty with some dyslexics. Many of the symptoms of SSS overlap with visual dysfunction such as instability of print, loss of place when reading, and difficulty concentrating when reading. This prompted Irlen, in her 1991 book: “Reading by the Colors”, to write that individuals interested in being screened for SSS should first see a vision specialist for a complete visual examination.

Irlen, an educational psychologist, recognized the difference between routine eye examinations and a vision therapy evaluation. She noted:

“When individuals take a routine eye examination, the vision specialist normally assesses acuity, refractive status, and binocular function. When the exam is more than routine, additional tests will analyze the visual system in greater detail and will also evaluate focusing ability and tracking skills. The doctor will also check for the presence of eye diseases. For SSS treatment to be successful, existing visual problems need to be treated first. Perceptual skills are based on a solid visual foundation. It is essential for individuals to eliminate all visual problems prior to getting treatment for perception or other learning difficulties.”

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

In the United States, there are two different types of licensed vision care professionals: the optometrist and the ophthalmologist. The optometrist is a doctor of optometry (O.D.) who diagnoses and treats visual health problems as dictated by state law. Some optometrists specialize in vision therapy. The ophthalmologist is a doctor of medicine (M.D.) who specializes in surgery and diseases of the eye. A small number of ophthalmologists work with or refer to vision therapists or orthoptists.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

Behavioral Optometrists typically have a different lens prescribing philosophy than other eye care professionals. Using a holistic approach to lens prescribing helps find the least amount of lens that gives patients the best visual function for all their activities of daily living.

Which is better, 1 or 2? 1 or 2?
This is not a test, there are no right answers and you cannot fail your eye exam! So many patients worry about “failing” the test that it literally changes their prescription because they are over–thinking.

So relax and breathe and let the lenses do the job. If you cannot decide which lens LOOKS BETTER, then try to choose which lens FEELS BETTER. And “they look the same” is also a correct answer!

The numbers we measure during an eye exam on any given day are not set in stone. They can change from hour to hour or day to day based on: how you are feeling, being very tired or well–rested, in a bad/good mood, well – or malnourished, certain medications, if you’ve just received bad news, etc. Many things affect how the brain uses the visual system to gather information. Therefore, we do not let one measurement dictate how we prescribe.

The brain wants to be as lazy as possible! If you’re locked in to focusing up close for hours on end (which everyone is nowadays with cell phones and tablets), your brain says, “OK, if you want to focus up close this much I’ve got to compromise somewhere.” And it gives up clarity at distance in order to focus up close without doing actual work.

We usually do not prescribe distance glasses in an “emerging myope” because their problem is not distance, it’s near stress. Reading glasses to be worn whenever doing 5 minutes or more of near work helps decrease near-sightedness (to a certain extent).

The exam room matters:
By virtue of how we were originally taught to do exams: in a dark room simulating a cave with no windows, our visual systems collapse inward and we experience a myopic shift just by being in the small room!

At the Academy of Vision Development we strive to make conditions similar to that which patients experience every day. Therefore, our exam room is 2 walls of windows. We encourage patients to relax while being refracted “let the lens do the job,” ie stop overfocusing and trying so hard. After the exam we “trial frame” the new prescription (build their glasses in a trial frame) so they can look out the window and actually feel what it feels like to have the different prescription while looking at the real world.

We can usually tell a lot about people and their personality just based on their glasses prescription.

Most myopes like the feeling of being “dialed in” (over-minused). They are typically described as “Type-A”, very rigid and concrete in their thinking, maybe even a little OCD or impulsive.

Hyperopes are usually the opposite: laid-back personality, difficulty making decisions, and they don’t seem to be bothered by much.

Far–sighted/ Hyperopia:
Writing prescriptions based on using eye drops to stop the focus system is an archaic and outdated practice. When in our lives are we ever without our focus system, other than eye drops or death? All this does is relax the focus system so much the prescription is notoriously too high. Once a patient wears that high glasses prescription for a while, they begin to struggle turning on their focus system which makes eye alignment more and more difficult.

To get the absolute best prescription, observing and testing functional vision is the key! Watching HOW a patient performs a visual task while sitting, reading, writing, standing and moving gives the best information about whether or not the prescription is right for them.

We can make patients worse and worse by adding so much lens that their focus system gives up, requiring more lens for clarity, but function suffers! We allow them to turn on and work their focus system by giving them the least amount of plus that still gives good function.

Spoiler alert: Good visual function is not just 20/20. It includes eye movements, teaming, tracking, focusing, scanning, visual memory and visual integration.

Our goals as Behavioral Optometrists and prescribers of lenses is to give the LEAST AMOUNT of plus or minus that still gives functional vision. That also requires counseling patients on what they are seeing and how they should use their visual systems.

In 1993, Paul Romano, MD, the editor of Eye Muscle Surgery Quarterly, conducted a worldwide survey of eye muscle surgeons. He asked surgeons to indicate whether they would favor a surgical or non-surgical approach to the treatment of intermittent exotropia (a form of strabismus). 85% of the international group recommended non-surgical approaches, as compared with only 52% of the American surgeons. Dr. Romano postulated three important reasons why this might be so:

Insurance companies and single-payer systems outside of the U.S. have stricter medical standards in regards to approving payment of eye muscle surgery. Also, they do not pay as well for eye muscle surgery as insurance companies in the U.S.
Non-surgical therapy isn’t as economically rewarding for the surgeon in the U.S. due to the personnel and fees involved.

Due to his lack of training in this area, the surgeon is reluctant to acknowledge the benefits of non-surgical therapy for fear of losing patients.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

The public needs to be aware that ophthalmologists are not the ultimate authorities in all areas of visual health. Ophthalmologists are wonderful surgeons and excellent authorities on eye disease, but as a rule, they’re under informed about subject areas such as visual processing, convergence, accommodation and vision therapy. Some ophthalmologists concede this. In the medical journal, Transactions of the American Ophthalmological Society, eye muscle surgeon and researcher David Guyton, M.D., states: “We [ophthalmologists] 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.”

So, if an ophthalmologist says, “Vision therapy doesn’t work”, remember that this is an opinion from a professional who has little knowledge of the subject. Many of the M.D.s who criticize vision therapy have not done their homework. It is important to consider the source of information. Optometrists who specialize in vision therapy are the authorities regarding developmental vision and vision therapy.

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

First, let’s define the terms. What the public knows as “lazy eye” is technically amblyopia. A diagnosis of amblyopia means that one eye doesn’t see as clearly as the other eye even with proper glasses or contact lenses. Amblyopia can occur with or without strabismus, which is a crossing or turning of the eyes. Strabismus is sometimes attributed to one or more weak eye muscles, however the problem is more often due to a defective neurological signal to the involved muscle(s) rather than to an actual muscular abnormality.

Secondly, allow me to emphasize that, in regards to amblyopia and strabismus, the eye muscle training benefits of vision therapy are medically proven. There is no controversy there. Where eye doctors do not always agree is in regards to this question you have asked. There are eye surgeons who promote the idea that if a child has an eye turn, you must operate by age two to get meaningful results, and if there is amblyopia, or lazy eye, intervention of any kind is only meaningful before age 6 or 7. There are many scientific articles in optometric journals which prove that it’s never too late to treat a lazy eye, but I’d like to refer to a study by an eye surgeon.

In the American Journal of Ophthalmology, von Noorden, a well-known strabismus surgeon and researcher reviewed the records of 408 patients who had eye turns shortly after birth, and divided their surgical outcomes based on age at the time of surgery:

4 months- 2 years
Optimal 24%
Desirable 4%
Acceptable 36%
Unacceptable 36%

2 years – 4 years
Optimal 15%
Desirable 5%
Acceptable 44%
Unacceptable 36%

Older than 4 years
Optimal 16%
Desirable 14%
Acceptable 42%
Unacceptable 28%

Re: surgical treatment, the data above shows that useful results can be obtained by intervening after age 2. The data also shows that there should be no rush to go to surgery after the age of 2, because the outcomes don’t differ that much after that age. By the way, the positive outcomes measured above include cosmetic improvement ONLY, meaning the eyes look straight but still do not function together. Vision therapy aims to do more than simply straighten the appearance of the crossed or turned eyes. It aims to help patients develop useful binocular (two-eyed) vision.

Re: vision therapy treatment, you’ll always get the best results if you intervene at a young age, IF you can get a child’s cooperation. But, children have little motivation to cooperate. It’s been proven that a motivated adult with strabismus and/or amblyopia who works diligently at vision therapy can obtain meaningful improvement in visual function. As my patients are fond of saying: “I’m not looking for perfection; I’m looking for you to help me make it better”. It’s important that eye doctors don’t make sweeping value judgments for patients. Rather than saying “nothing can be done”, the proper advice would be: “You won’t have as much improvement as you would have had at a younger age; but I’ll refer you to a vision specialist who can help you if you’re motivated.”

*adapted/paraphrased from Dr. Leonard Press’ website and interview:

As with any subject matter, the public must be careful to consider the source. Vision therapy is a well-established field within the optometric profession. I would, therefore, recommend that the reader place most credence in information acquired from optometric web sites or from patient or parent advocate sites which look at the subject objectively. Readers need to be aware that some web pages are misrepresenting vision therapy.

For example: Let’s say you were seeking information on the Web about treatment of a hip problem. If you had a question about physical therapy, you would look to a physical therapist (P.T.). For information on surgery, you would rely on an orthopedist (M.D.). In this particular example, you could get accurate information about either treatment options from both professionals. That’s because orthopedic surgeons and physical therapists have learned to work together in the best interests of the patient. Unfortunately, this is not the case in vision care where optometrists and ophthalmologists don’t always agree on vision therapy. Some ophthalmologists have even taken it upon themselves to post unjustifiably negative information on vision therapy on the Internet.
*adapted/paraphrased from Dr. Leonard Press’ website and interview:

Consider joining the Facebook group: Vision Therapy Parents Unite.
This group is an encouraging and supportive group for parents of children with binocular vision issues that are considering or are currently doing vision therapy or have done vision therapy.

I recommend my patient’s parents become members of this group because of all the positive encouragement and the supportive environment this group gives to every member!

I also recommend patients or parents read the book: Fixing My Gaze by Dr. Sue Barry.
Here is a post from a parent on Vision Therapy Parents Unite regarding that book:
“I finally took the time to read Fixing My Gaze. I wish I had done so, as this group suggested, a year ago. It really clarified what is going on with a strabismic eye, but also hit home the need to refrain from panic. And to put the idea of surgery being a possible fix right off the table. Most impactful, however, is how it hit home how important the homework is to the whole process. We are developing a new way for the brain to interact with the world. Developing neurons. Retraining. The same way you develop a system for learning a new instrument. To play flawlessly, without effort, takes both time and commitment. As such, I have stepped up the homework game, chilled out with regards to my nerves around the entire situation, and have relaxed into the idea that this will all be okay. My daughter’s 8 year old brain is capable of figuring this out as long as we keep asking it to try. Breathe.”

Only Vision Therapy gives the patient the opportunity to learn to use the two eyes together as a team.

Atropine drops are used to stop the focusing ability of the “bossy eye”. It’s like patching without a patch. It’s still very disconcerting to have to walk around with your good eye purposely debilitated. It’s cruel and unusual punishment.
Adults recommending or considering this as a viable treatment option for amblyopia should be required to try Atropine drops in their dominant eye to simulate what a child goes through and to understand why they are so resistant to this type of treatment. Try the drops or patch your favored eye and go to work, go to the mall, try to read, attend a lecture where you’re expected to learn something, cook some food, try to play on a playground and drive a vehicle…IT’S HORRIBLE!

Please try the drops in your dominant/favored eye, and see what it feels like all day. Most likely your non-dominant eye is not terrible so you still won’t have the same experience as an amblyopic person. To mimic what your child is going through, find out what the VA is in his weaker eye and borrow a frosted occluder from your doctor that matches that VA to fully understand what your child is experiencing when sending him out into the world with only his student eye to navigate things. Being sent to school, being put in novel situations, being expected to learn, using only an amblyopic eye is very anxiety provoking. No wonder kids with eye patches cheat and peek around it all day.

No one would CHOOSE to dull their favored eye. That is why it’s the favored eye! When patients come from an ophthalmology office and say “we’ve been doing these drops for 2 YEARS and now we are patching”, it breaks my heart. That poor kid! There’s nothing parents are doing wrong, they’ve just gotten misinformation from an ophthalmologist or someone unfamiliar with behavior and vision development and appropriate treatment for amblyopia and strabismus.
Patching and Atropine never allow a patient to learn to use the two eyes together, and that’s ultimately why you’re prescribed this in the first place. Behaviorally, patching for extended periods and/or Atropine drops do not promote BINOCULAR VISION. Our visual systems need the opportunity to learn to work together. Vision therapy is the only functional cure that allows for learning depth perception.

Vision therapy is holistic and uses patches only during specific activities for less than 15 minutes and then gives the two eyes the chance to work together. But never forces someone out into the world “flying blind”.

Patching/ Atropine is cruel and unusual punishment. I don’t think just patching and Atropine alone are necessarily the punishment. It’s then being required to go out into the world. Amblyopia implies a developmentally delayed visual system and the child’s brain figured out the best way for him to get SOME information from the environment (just not 3D). Now, taking away that maladaptation but not replacing it with helping binocular vision develop properly is the punishment part. I feel every ophthalmologist and doctor who recommends this treatment should try it themselves first before subjecting a school-aged child to it.

Whenever I give a presentation to doctors’ offices, schools, and parent groups I always bring along patches, frosted occluders and prisms in a trial frame so that people get to feel what it’s like to have amblyopia, strabismus, convergence insufficiency, etc. Most adults end up removing the implement before the timer goes off because they don’t like how it feels, it makes them anxious, dizzy or sick and some even say they feel like they can’t hear anything. And that’s in less than 5 minutes! Imagine being forced to walk around all day like that!?!
VISION isn’t everything, it’s almost everything!