Authors: Dr. Kitra Gray in collaboration with Region 11 ESC and TSBVI, January 2018

Keywords: vision therapy, controversy, vision training, visual training, developmental vision therapy, orthoptics, behavioral vision therapy, visual attention, binocular vision, optometric vision therapy, learning disabilities, dyslexia, related service, Local Education Agency, LEA.

If you have ever tried to find definitive answers regarding vision therapy, you might have been met with:

• Vague responses
• Inconsistent responses, depending on the source
• Emotional responses regarding whether vision therapy is a viable educational option or
• Conflicting responses regarding research and benefits of vision therapy.

As we know, programming for children with disabilities must be addressed individually based on their own set of needs and criteria. This article will explore the controversies surrounding vision therapy and provide information so that when the topic of vision therapy arises in regards to a child, you will be knowledgeable enough to know what questions to ask, and how to interpret the answers.

Definition of Vision Therapy

The first area of controversy is understanding what is meant by the term vision therapy. Vision therapy is known by several names, including visual training, vision training, and developmental vision therapy. Some optometrists divide vision therapy into two categories. The first is orthoptics, which focuses on binocular vision including disorders such as strabismus and diplopia, also known as double vision. The second area is behavioral vision therapy, which addresses problems such as “visual attention and concentration which may manifest as an inability to sustain focus or to shift focus from one area of space to another” (Allegheny Intermediate Unit. n.d., para 3). The College of Optometrists in Vision Development (COVD, 2008), a non-profit, international membership association of eye care professionals including optometrists, optometry students, and vision therapists, does not differentiate between orthoptics and behavioral vision therapy, but simply addresses the practice as Optometric Vision Therapy. Thus, you may be confronted with any of these identifiers when someone refers to vision therapy.

No matter what identifiers are used, the overall definition of vision therapy is fairly consistent. Optometric Vision Therapy is an individualized, supervised, medically necessary treatment program that is prescribed by an optometrist using neurological and neuromuscular conditioning over time to address visual dysfunctions, prevent the development of visual problems, or enhance visual performance to meet the patient’s identified needs. (Hatton, D., n.d.; COVD, 2008, p. 1) “Vision therapy trains the entire visual system which includes eyes, brain and body” (Optometrist Network, 1996-2007).

What deficits does vision therapy treat?

The second area of controversy, or confusion, is what deficits can be appropriately addressed by using vision therapy treatments. The only treatment area that appears to have wide reaching consensus among optometrists, as well as ophthalmologists, is convergence-insufficiency which includes symptoms such as double vision and eye fatigue. The following citations substantiate that vision therapy can be beneficial in treating convergence-insufficiency:

• According to Dr. Jose, a well-respected Texas optometrist in the area of low vision, “symptomatic convergence insufficiency can be treated with near-point exercises, prism-convergence exercises, or computer-based convergence exercises (Jose, Rosner, & Cowan, 2012 p. 17).
• A study published in the Archives of Ophthalmology “found that a 12-week program of supervised, in-office vision therapy plus orthoptics produced a functional cure of convergence insufficiency in over half…the children with CI who received this treatment” (Heiting, G., 2017, para. 34).
• The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) states that “orthoptic eye exercises as prescribed by pediatric ophthalmologists, orthoptists, and optometrists can be beneficial in the treatment of symptomatic convergence insufficiency” (AAPOS, 2016).

“Other than for strabismus and convergence insufficiency, the consensus among Ophthalmologists and Pediatricians is that visual training lacks documented evidence of effectiveness” (Allegheny Intermediate Unit, n.d., para.3). The website of the AAPOS (2016) states that:

• Behavioral vision therapy is considered to be scientifically unproven.
• There is no evidence that vision therapy delays the progression or leads to correction of myopia.

Yet, the COVD’s “white paper” indicates that optometric vision therapy can significantly improve the following functional vision problems:

• Ocular motility dysfunction – eye movement disorders
• Vergence dysfunction – inefficiency in using both eyes together
• Strabismus – misalignment of the eyes
• Amblyopia – lazy eye
• Accommodative disorders – focusing problems
• Visual information processing disorders
• Visual sensory and motor integration
• Visual rehabilitation after traumatic brain injury which results in inefficient visual information processing (e.g., stroke). (COVD, 2008, para. 2).

Other deficit areas of discussion are whether vision therapy can treat learning disabilities or dyslexia. Dr. Jose indicates that through a number of studies, it has been determined that “readers with dyslexia have linguistic deficiencies rather than visual or perceptual disorders…Research has shown that most reading disabilities are not caused by altered visual function.” Therefore “…the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities. Thus, the claim that vision therapy improves visual efficiency cannot be substantiated” (Jose, Rosner, & Cowan, 2012, pps. 12,13,19). This is further corroborated by the AAPOS (2016) which notes that, “The scientific evidence does not support the use of eye exercises or behavioral/perceptual vision therapy in improving the long-term educational performance in children with learning disabilities.”

In addition, Dr. Takeshita (2013), a pediatric optometrist in California who set up a foundation to assist children who are visually impaired after he lost his own sight, states that “Vision Therapy Does NOT:

• Cure medical conditions such as autism, attention deficit disorder or learning disabilities
• Strengthen eye muscles. Vision therapy increases the neuro-muscular innervation between the brain and the muscles of the eyes
• Eliminate the need for glasses” (p. 13).

While these sources concur that vision therapy cannot address learning disabilities, confusion persists for educators and parents, because other literature such as the COVD “white paper” indicates that:

“According to the American Optometric Association, 35% of all children with learning disabilities have visual problems. Specifically, at least 20% of individuals with learning disabilities have been found to have prominent visual information processing problems, and 15-20% of them have problems with visual efficiency skills (COVD, 2008, para. 8).”

The source used by the American Optometric Association is not specified and this information was written in 2008; whereas, Dr. Jose’s and Dr. Takeshita’s information is from 2012 and 2013 and the AAPOS statement is dated 2016. Nonetheless, you are probably beginning to see why there are very few definitive answers regarding vision therapy and why parents and educators may be confused as to the efficacy of this treatment method.

Is vision therapy a related service?

One factor that appears to be consistent in the literature regarding vision therapy is that it is a partnership between doctor, parent(s) and student. It is a prescribed treatment plan by an optometrist, or sometimes an ophthalmologist. As indicated by the COVD (2008), “Optometric vision therapy plans typically involve a programmed combination of office treatment and home therapy….As with most therapeutic treatments, the extent of the success is also linked to the patient compliance” (para. 5). Dr. Heiting (2017) states, “this therapeutic process…depends on the active engagement of the prescribing doctor, the vision therapist, the patient (and in the case of children) the child’s parents” (para. 8).

According to IDEA “medical services” that are eligible “related services” are those specific “services provided by a licensed physician to determine a child’s medically related disability that results in the child’s need for special education and other related services.” 34 CFR 300.34 (c)(5)” (Special Education and Disability Rights Blog, 1970, para. 1). Since vision therapy is not necessary for diagnostic purposes, according to this definition it is not a related service under IDEA.

Furthermore, “the Supreme Court has adopted a bright line rule…, finding that medical services that can only be delivered by a physician are not related services and that health care support services, which can be administered by a person other than a physician are related services under the IDEA and therefore the responsibility of the school district See Irving Independent School District v. Tatro, 555 IDELR 511 (1984)” (Special Education and Disability Rights Blog, 2009, para. 2).

Therefore, as vision therapy is a service that has to be delivered by a qualified eye medical specialist, it does not appear to meet the definition of a related service.

What is the role of a Vision Therapist versus the role of VI Education Professionals?

Occasionally parents request that the teacher of students with visual impairments (TVI) or the orientation and mobility specialist (COMS) provide vision therapy without understanding that these education VI professionals are not qualified or certified to provide this medical therapy. Vision therapy is provided by Optometrists (most frequently), Ophthalmologists and certified para-optometric technicians. These eye care professionals “gain training (e.g. medical/optometric courses, clinical practicum, internship, residency, etc.) in optometric vision therapy” (Lawson, Lueck, Moon, & Topor, 2017, p. 5). They are trained to provide “medical treatment that involves neurosensory and neuromuscular activities” (Lawson et al., 2017, p. 4).

The VI education professionals are NOT vision therapists. They are education specialists trained to evaluate and provide services to IDEA eligible students with visual impairments in the school setting, not in a clinical setting. Sometimes parents, and even school personnel, mistakenly refer to the teacher of students with visual impairment as a vision therapist, but this is incorrect. They are teachers who have attended “an accredited university program, typically within a college of education” (Lawson et al., 2017, p. 2).

The role of the TVI as well as the role of the COMS are defined in the 2017 Guidelines and Standards for Educating Students with Visual Impairments in Texas. This document can be found on the Texas Education Agency (TEA) website at: https://www.tsbvi.edu/attachments/EducatingStudentswithVIGuidelinesStandards.pdf According to these guidelines, some of the roles of Certified Teachers of Students with Visual Impairments (TVIs) and Orientation and Mobility Specialist (COMS) include:

• Assessment and Evaluation [regarding special education eligibility and educational programing]
• Direct Instruction in the Expanded Core Curriculum
• Supporting Educational Teams
• Administrative/Record Keeping Duties (Texas Action Committee for the Education of Students with Visual Impairments. (2017, p. 23-24).

In addition, a position paper regarding vision therapy, written by the Association For Education and Rehabilitation of the Blind and Visually Impaired (AER), Low Vision Division, explains that TVIs “are not trained to provide vision therapy services nor does vision therapy fall within the scope of the [TVIs’] professional responsibilities” (Lawson et al., 2017, p. 1). This statement is also true for Orientation and Mobility Specialist (COMS).

What is the Role of the LEA?

Of course, a child should be evaluated in all areas of suspected disabilities. The educational committee must consider evaluation information from a variety of sources (34 CFR§300.306(c)(i)) and not rely on a single source to determine eligibility. More information on eligibility for services as a student with a visual impairment in Texas is available in the Guidelines cited above, and the TEC 30.002.

Nevertheless, it is important to note that a recommendation for vision therapy by an eye medical professional does not automatically mean the student warrants an evaluation, or if evaluated, will meet IDEA eligibility criteria. An LEA should consider each case individually to determine the necessary steps to address a parent concern regarding vision therapy.

Summary

Most likely, vision therapy will continue to be controversial, or at the very least confusing to parents and educators alike because:

• there are no consistent identifiers
• the medical profession does not agree on which deficits can be addressed appropriately and
• people sometimes mistakenly refer to VI educational professionals as vision therapist without understanding the difference in focus and training.

However, the one thing that is not controversial is that since VI education professionals, TVIs and COMS, are not trained in optometric vision therapy methods, they do not play a role in the delivery of vision therapy. Their role is to evaluate and provide services for IDEA eligible students with visual impairments in accordance with the IEP.

References

• Allegheny Intermediate Unit. (n.d.). BVISP FAQs, Vision Education or Vision Therapy? Vision Therapy vs Education of the Visually Impaired. Retrieved from http://www.aiu3.net/Level3.aspx?id=4128
• Association for Pediatric Ophthalmology and Strabismus [AAPOS]. (2016). Vision Therapy. Retrieved from https://aapos.org/terms/conditions/108
• College of Optometrist in Vision Development [COVD]. (2008). What is Optometric Vision Therapy? Retrieved from http://c.ymcdn.com/sites/www.covd.org/resource/resmgr/white_papers/9-_what_is_optometric_vt.pdf A “white paper.”
• FindLaw for Legal Professionals. Irving Independent School Dist. V. Tatro. (1984). Retrieved from http://caselaw.findlaw.com/us-supreme-court/468/883.html
• Hatton, D. (n.d.). Visual Conditions and Functional Vision: Early Intervention Issues: Glossary. Texas School for the Blind and Visually Impaired [TSBVI]. Retrieved from https://www.tsbvi.edu/534-hatton-functional-vision/4627-functional-vision-module-glossary
• Heiting, G., O.D. (2017). Vision Therapy for Children. Retrieved from http://www.allaboutvision.com/parents/vision_therapy.htm
• Jose, R., Prof. Emeritus, Rosner, J., O.D., Cowan, C. (2012). 2012-13 Texas Focus, Vision Therapy-What is the Role of the TVI? [Word document]. Retrieved from https://www.tsbvi.edu
• Lawson, H., Lueck, A. H., Moon, M., & Topor, I. (2017). The Role and Training of Teachers of Students with Visual Impairment (TSVIs) as a Special Educator and Why TSVIs Do Not Provide Vision Therapy Services. Retrieved from https://aerbvi.org/wp-content/uploads/2016/01/Low-Vision_AERBVI-Position-Paper-on-Vision-Therapy-5.4.17.docx
• Position Paper from AERBVI, Low Vision Division.
• Leagle. (2005). 413 F.Supp.2d 1322| Dekalb County School v. M.T.V. Ex Rel. (2005, August 19). Retrieved from https://www.leagle.com/decision/20051735413fsupp2d132211625
• 11 Circuit Court Case
• Musgrove, M. (2014). Office of Special Education Programs, Letter to Kotler. (2014, November 12). Retrieved from https://www2.ed.gov/policy/speced/guid/idea/memosdcltrs/acc-13-020197r-md-kotlereligibilitycriteria.pdf
• Optometrist Network (1996-2007). What is Vision Therapy or Visual Training. Retrieved from http://www.add-adhd.org/textonly/vision_therapy_FAQ.html
• Optometrists Network is a network of interconnected patient education resources and optometric websites which educate the public about visual health and unique aspects of optometric care.
• Special Education and Disability Rights Blog: A2Z Educational Advocates (2009). Related Services: Medical Services. Retrieved from http://a2zeducationaladvocates.blogspot.com/2009/08/related-services-medical-services.html
• Takeshita, B., O.D. FAAO FCOVD (2013). 2012-13 Texas Focus, The Neurophysiology of Reading with Low Vision [Word document]. Retrieved from https://www.tsbvi.edu
• Texas Action Committee for the Education of Students with Visual Impairments. (2017). 2017 Guidelines and Standards for Educating Students with Visual Impairments in Texas. Retrieved from TEA