Blueberries, Bagels and Gravity


Published on

Evidence based medicine, the lack of it or the misuse of it should be hard to ignore. Well, maybe. Read this to find out more.

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Blueberries, Bagels and Gravity

  1. 1. Editorial 4 Blueberries, Bagels, and Gravity Dominick M. Maino, OD, MEd, Chicago, Illinois Keywords: evidenced-based practice, don’t have to pick it up and throw it away!).optometric vision therapy, strabismus After careful consideration, I have come to thesurgery, vision screening conclusion that it must be in the blueberry’s nature to go to ground. It is in their genetic Blueberries innately go to ground, makeup and just what is predicted of them They seek gravity, no matter the situation. They seek down. Genetically they appear to know … Evidence-Based Clinical Practice that up isn’t where they wish to go. The American Optometric Association and Bagels are a steadying force, various state associations are supporting and not blueberry repellant, of course. programs that present the very best evi­­ …and gravity is what it always does… denced-based care in optometry.1,2,3 The pulling downward just because. College of Optometrists in Vision Development (COVD) has bibliographies of articles that I am often a creature of predictability. offer research supporting the evidence-One instance of this is that I am turning into based care we offer our patients.4 Thea consistent eater of berries. Blueberries, Optometric Extension Program Foundationstrawberries, blackberries, and raspberries; (OEPF) and COVD have long supportedthey all attend me at breakfast. I lightly toast journals that publish the science behind thea bagel, put a schmear of cream cheese on evidence-based functional vision care usedeach side, sprinkle a cinnamon dusting upon to solve patient problems.5,6 COVD andit all, and then add the berries. OEPF have now joined with the Australasian Strawberries think this is a good idea and College of Behavioral Optometry7 to supportobediently rest upon my well-prepared bagel a new scientifically-based professionalbed. Blackberries and raspberries appear to journal, Optometry & Visual Performance.8enjoy the company of the strawberries and The functional optometrist uses evidence-stay where I place them on the bagel as well. based clinical diagnostic care, while pushingBut blueberries seem to seek out gravity. the envelope to discover new and excitingWhen I put them on my bagel, they often roll methodologies that use the principles oftowards the earth with abandon. The good neuroplasticity in our therapeutic is that if my berry-loving pit bull, Cali, is We acknowledge that using evidence-basedaround, the downward-seeking blueberry is clinical care is appropriate. Based on thisquickly captured, eaten, and digested (and I approach, we then modify and improve theOptometry & Visual Performance 75 Volume 1 | Issue 2
  2. 2. existing diagnostic and therapeutic care Dr. Mitchell Scheiman) has publishedgiven to take this care to the next level for the numerous papers showing that optometricbenefit of our patients. We do not inherently vision therapy (office-based vergence/discount the science available just because accommodative therapy with home therapywe disagree with the outcomes of a particular procedures) results in a significantly greaterresearch project. improvement in symptoms and clinical measures of near point of convergence andIgnoring and Misusing positive fusional vergence with a greaterResearch Outcomes percentage of patients reaching the criteria It may be that like the blueberries I men- of success when compared with other formstioned previously, organized medicine, and in of therapy.11 The therapeutic effects wereparticular many of our ophthalmological col- found to be long lasting.12leagues, must also go to the ground, talking Other articles published in major journalsdown whenever optometry is involved in the by this group noted “A successful or improveddiscussion. Perhaps it is just in their genetic outcome after Convergence Insufficiency (CI)make-up, or it is a habituated behavioral re- treatment was associated with a reductionsponse learned over the years. We should in the frequency of adverse academicnot, however, accept these automated, behaviors and parental concern associatednonsensical, and irrational responses. We with reading and school work as reportedshould, in a spirit of congeniality and colle- by parents.”13 “Vision therapy/orthopticsgiality, point out where the science clearly is effective in improving accommodativeshows the illogicality of their beliefs. amplitude and accommodative facility in This is treacherous ground we walk upon, school-aged children with symptomatic CIhowever. Science also clearly shows that and accommodative dysfunction,”14 and thatthose who hold mistaken beliefs do not give those with ADHD like behaviors should bethem up easily.9,10 If we do not try to place evaluated for the presence of CI.15 We alsothese colleagues on a path that leads to a discovered what does not work: “Base-better approach to patient care, all suffer. in prism reading glasses were found to be no more effective in alleviating symptoms,CITT, Prescribing Glasses, improving the near point of convergence, orVision Screening, and Strabismus improving positive fusional vergence at nearSurgery Outcomes than placebo reading glasses…”16 and that the pencil push-up technique for CI is theConvergence Insufficiency least effective form of treatment available.­ 17Treatment Trial Unfortunately, some of our eye care The Convergence Insufficiency Treatment colleagues refused to accept the evidence-Trial (CITT) group (Primary Investigator based outcomes of these clinical trials usingOptometry & Visual Performance 76 Volume 1 | Issue 2
  3. 3. personal opinion, bias, and experience are good enough and that they are all that isas proof.10,18 One of our protagonists needed to ensure the visual welfare and eyewrote, “Although every question cannot be health of our children. The research does notaddressed by a randomized clinical trial, the support this. The Cochrane Collaboration (abest available evidence should be sought and group that takes a critical look at clinical trialsused to guide treatments.” Since he seemed and other research), have time and againto be saying one thing to one audience19 brought this into question. They have stated,and something quite different to another “The review found that there is currently notaudience,20 my response was “So what enough evidence to determine whetheris it to be? Is belief and clinical experience or not screening programmes reduce theenough to disregard the evidence-based, proportion of older children and adults withresearch-based findings of the CITT study? amblyopia. The authors concluded thatIs it appropriate to write one thing if you there is, therefore, a need for some robustsupport the outcomes of a clinical trial, but to evaluation of the screening programmes thatwrite another if you do not?”18 This particular are in place to see if they are truly effective orindividual never did respond to my concerns, not. Any such evaluation would have to alsoeven though he was invited to do so. look at how much screening programmes cost and what effect untreated amblyopiaPrescribing Eyewear has on quality of life” 22 and “The aim of this Many of my colleagues tell me that review was to find studies that evaluatedthe author of the next article I am going to the effectiveness of school vision screeningdiscuss is actually a great fellow. I do not programmes in first identifying children withdoubt the word of my colleagues; I do doubt reduced vision. No eligible randomisedthe so-called research when its sole purpose studies were found. There is a clear need forhas been foretold by its title even before reliable evidence to measure the effectivenessthe data was collected.21 This particular tid- of vision screening.”23 They have also notedbit of pseudo-science was conducted by a that not only is there little evidence for usingmember of a profession least known for their vision screenings for children, there is alsorefracting acumen, and yet bold enough to little evidence that screening outcomes arecall into question the integrity of another viable within the adult community as well.24,25profession that is considered the expert I have reviewed the validity of visionwithin the realm of refractive care. screening multiple times using various modes of written and digital communication.26 TheVision Screening American Optometric Association has clearly Time and again our ophthalmological spelled out the limitations of vision screeningcolleagues tell us that vision screenings are for our children27 and the InfantSEE® 28adequate for the nation’s children, that they program has demonstrated the need forOptometry & Visual Performance 77 Volume 1 | Issue 2
  4. 4. full and comprehensive eye and vision Strabismus Surgery Outcomesexaminations for our children time and again. Various Cochrane Reviews of strabismus They also note that: surgery research currently available have • in 10 children is at risk from undiagnosed 1 noted they “did not find any randomised vision problems trials that compared treatment to another • in 30 children will be affected by 1 treatment or to no treatment. A large, multi- amblyopia – often referred to as lazy centre, non-randomised trial found that eye – a leading cause of vision loss in children operated on earlier had better people younger than 45 years binocularity at age six compared to the • in 25 will develop strabismus – more 1 late surgery group. This group had been commonly known as crossed eyes – a operated on more frequently however risk factor for amblyopia and there was no significant difference in • in 33 will show significant refractive 1 the angle of the squint after surgery in error such as near-sightedness, far- either group. This review does not resolve sightedness, and astigmatism the controversy regarding the best type • in 100 will exhibit evidence of eye 1 of surgery … It highlights a need for disease – e.g. glaucoma further research in this area.” 30 In a review • in 20,000 children have retinoblastoma 1 of the use of botulinum toxin, it was found (intraocular cancer), the seventh most that “The results showed no prophylactic common pediatric cancer use for botulinum toxin in sixth nerve palsy, How can ophthalmology continue to poor effect in adult horizontal strabismusignore the science? How can they throw without binocular use of the eyes, andaside the fact that evidence-based support no difference in response for retreatment ofof vision screenings is non-existent? Do infantile esotropia or acute onset esotropia.they care so little for America’s children that It was not possible to determine dosethey place an organizational political agenda effect because of the different types andahead of the welfare of our little ones? It doses of botulinum toxin used in each trial.certainly appears that way since organized Complications from the use of botulinumophthalmology, along with various third-party toxin (Botox or Dysport) included transientpayers and other entities with a fiscal interest ptosis and vertical deviation and combinedin the future of vision screening, have tried rates for these complications ranged fromto block the Pediatric Essential Eye Health 24% to 55.54%. This review identified aBenefit program.29 We would hope that an need for more randomized controlled trialsevidenced-based health care profession to provide further reliable evidence on thewould know better. Apparently, they do not. effective use of botulinum toxin for the treatment of strabismus.”31Optometry Visual Performance 78 Volume 1 | Issue 2
  5. 5. Another review of the research noted trials above shows that accommodativethat the number of placebo-controlled, dysfunctions can be successfully treated withdouble blind, prospective, and randomized therapy.14 Although we do not have researchstrabismus surgery outcome clinical trials at the level of a clinical trial in some areas,was zero.32 Ophthalmology has pointed out we do have an evidence-based platform thatto me how difficult such a study would be strongly suggests OVT is effective for manyusing the same reasons optometry used dysfunctions of the binocular vision system.34prior to the CITT study. Optometry managed These same companies often fiscally supportto create and complete this clinical trial. diagnostic and therapeutic procedures thatShouldn’t ophthalmology also be held to a do not have clinical trials supporting theirsimilar standard?33 use. Is this an example of discriminative third-party coverage rules for two similar butIgnoring and Misusing different health care professions?Research Outcomes Misusing research outcomes appears to Blueberriesbe one way to limit access to optometric Are those who disparage OVT, bettervision care by some third-party payers. These eye health for our children, and appropriatemisguided companies will demand that 12 access to the care optometry provides reallysessions of home-based vision therapy be blueberries?instituted before in-office optometric vision Blueberries innately go to ground,therapy can begin. None of the clinical trials They seek gravity,or other available appropriately conducted They seek down.research that I am familiar with even remotely Genetically they appear to know …suggests that this be done. Another similar that up isn’t where they wish to go.scheme is to limit in-office optometric visiontherapy (OVT) to 12 sessions. Nowhere did M aybe not, perhaps these protagoniststhe research indicate that 12 sessions was are more like gravity….the number of visits needed for success. As …and gravity is what it always does…we know, each patient is different, and they pulling downward just because.may require different approaches to care andeither more or fewer visits for the completion … and what about optometry? Since weof that care. have always reached out to every individual, profession, organization, and institution with These third-party payers may also state open arms, I think we are more like the bagelthat vision therapy is only effective for CI …and not for other binocular vision disorders. Bagels are a steadying force,We do know that at least one of the clinical and not blueberry repellant, of course.Optometry Visual Performance 79 Volume 1 | Issue 2
  6. 6. References 16. Scheiman M, Cotter S, Rouse M, Mitchell GL, et al.1. 6th Annual Evidence Based Care in Optometry Conference Randomised clinical trial of the effectiveness of base-in Last Accessed February 25, 2013. prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J2. American Optometric Association. AOA participates in Ophthalmol. 2005;89:1318-23. international evidence-based guidelines conference. Last Accessed February 25, 2013. 17. Scheiman M, Mitchell GL, Cotter S, Kulp MT, et al. A ran- domized clinical trial of vision therapy/orthoptics versus3. American Optometric Association. Evidence-based pencil pushups for the treatment of convergence insuffi- optometry in sight. Last Accessed ciency in young adults Optom Vis Sci. 2005;82:583-95. February 25, 2013. 18. Maino D. An open letter to David K Wallace, MD, MPH (and4. College of Optometrists in Vision Development. Research other disbelievers and holders of outdated and biased and White Papers. Last opinions and beliefs). Optom Vis Dev 2008;39:178-80. Accessed February 25, 2013. 19. Wallace DK. Evidence based medicine and levels of5. Optometry Vision Development. evidence. Am Orthop J 2010;60:2-5. OVP. Last Accessed February 25, 2013. 20. Wallace D. Treatment options for symptomatic convergence6. Journal of Behavioral Optometry. insufficiency. Arch Ophthalmol. 2008;126:1455-56. journals. Last Accessed February 25, 2013. 21. Donahue SP. How often are spectacles prescribed to7. Australasian College of Behavioral Optometry. http:// “normal” preschool children? JAAPOS. 2004:8:224-9. Last Accessed February 25, 2013. 22. Powell C, Hatt SR. Cochrane Reviews. Vision screening8. Optometry Visual Performance programmes for amblyopia (lazy eye). July 8, 2009. http:// Last Accessed February 25, 2013. Last Accessed February 25, 2013.9. Tavris C, Aronson E. Mistakes Were Made (but not by me): 23. Powell C, Wedner S, Hatt SR. Cochrane Reviews. Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Screening school aged children and adolescents for Acts. Mariner Books, NY, NY; Reprint edition, 2008. reduced vision caused by the need for glasses. July 8,10. Maino D. Mistakes were made (Yes by you!). Optom Vis 2009. Last Accessed Dev 2011;42:66-9. February 25, 2013.11. Convergence Insufficiency Treatment Trial Study Group. 24. Desapriya E, Wijeratne H, Subzwari S, Babul-Wellar S, et Randomized clinical trial of treatments for symptomatic al. Cochrane Reviews. Vision screening of older drivers to convergence insufficiency in children. Arch Opthalmol prevent road traffic injuries and deaths. March 16, 2011. 2008;126(10):1336-49. Last Accessed February 26, 2013.12. Convergence Insufficiency Treatment Trial Study Group. Long-term effectiveness of treatments for symptomatic 25. Smeeth LL, Iliffe S. Cochrane Reviews. Community convergence insufficiency in children. Optom Vis Sci. screening for visual impairment in the elderly. July 16, 2009;86:1096-103. 2008. Cochrane Reviews. Last Accessed February 26, 2013.13. Borsting E, Mitchell GL, Kulp MT, Scheiman M, et al. Improvement in academic behaviors after successful 26. MainosMemos. USPSTF Children’s Vision Screening treatment of convergence insufficiency. Optom Vis Sci. Recommendations Will Harm Ongoing Efforts to Reverse 2012;89:2-8. High Rates of Preventable Vision Loss. February 8, 2011. Last Accessed February 27,14. Scheiman M, Cotter S, Kulp MT, Mitchell GL, et al. 2013. Treatment of accommodative dysfunction in children: Results from a randomized clinical trial. Optom Vis Sci. 27. American Optometric Association. Limitations of Vision 2011;88:1343-52. Screening Programs. Last Accessed February 25, 2013.15. Rouse M, Borsting E, Mitchell GL, Kulp MT, et al. Academic behaviors in children with convergence insufficiency 28. InfantSEE. Last Accessed with and without parent-reported ADHD. Optom Vis Sci. February 25, 2013. 2009;86:1169-77.Optometry Visual Performance 80 Volume 1 | Issue 2
  7. 7. 29. American Optometric Association. AOA’s Patient Access 32. Maino D. The number of placebo controlled, double blind, Message Takes Hold in Federal Plan for Health Law prospective, and randomized strabismus surgery outcome Implementation. Last Accessed clinical trials: None! Optom Vis Dev 2011;42:134-6. February 25, 2013. 33. MainosMemos. Strabismus Surgery: The Discussion30. Elliott S, Shafiq A. Cochrane Reviews. Different treatments Continues January 15, 2013. for a squint (deviation of the eye) that occurs within the Last Accessed February 27, 2013. first six months of life. August 10, 2011. 34. College of Optometrists in Vision Development. Research Cochrane-trtmts. Last Accessed February 25, 2013. and White Papers. Last31. Rowe FJ, Noonan CP. Cochrane Review. Botulinum toxin Accessed February 27, 2013. for the treatment of strabismus. February 15, 2012. http:// Last Accessed February 25, 2013.Optometry Visual Performance 81 Volume 1 | Issue 2