Dr. John's Blogs

Dr. John has been invited to write blogs for EyeCodeRight.com.  We are pleased to present them here for your education and enjoyment.  You may check out the link at http://eyecoderight.com/community/blogs.php

Why Vision Therapy (2/12/06)

Pablo was eight years old when I first met him. His family was from Mexico and his father worked for the Mexican consulate in Boston. Pablo entered second grade at a private school and struggled with reading. He typically came home from school with a headache, especially if they had a long exam that day or did a lot of reading in class. Although he was a bright child, his grades suffered. At the time, I was a fourth year student at the New England College of Optometry and working in the Pediatric clinic. He had been diagnosed with convergence insufficiency and my assignment was to treat him with vision therapy. Who would have thought that what I learned from him would change my professional life forever?

I remember Pablo as a good kid with a big smile and a good sense of humor. He came to his weekly visits well prepared and had obviously spent time doing his homework. Although we worked hard through the vision therapy sessions, we also had fun. He teased me about my haircut and I would call him "Pablo Diablo". I tried to use humor to motivate him.

After just a few months of treatment, Pablo finished vision therapy. At the last visit, his father said to me: "I know that you are not one of the doctors on staff here, but I want to thank you for helping with my son. He enjoyed working with you." Kind of embarrassed and very pleased, I said "Thank you very much. It was my pleasure to work with him. Pablo is a great kid. By the way, did the therapy help him?" I was shocked at the response. "Did it help him?" his father asked incredulously. "His headaches are gone, he finishes him homework in half of the time, he enjoys reading, and his grades are better. He loves school now! Did it help him? You bet it did!"

I stood there, stunned. I was in the last month of my last year in optometry school and no one ever mentioned that if you treat the visual problem in a child who has a learning difficulty, they will often show dramatic changes in their schoolwork. I did not know it could have such an effect. If it had not been for Pablo, I might have never learned that lesson. I knew vision therapy would be part of what I offered.

I never forgot the lesson I learned from Pablo. He taught me the power I had to change the life of a kid struggling in school. He taught me that vision and learning are related. He taught me that when there is a vision problem in addition to a learning problem, you can help the learning by improving the vision.

Now, about 70% of my practice is vision therapy connected, and most of that is children who have vision related learning problems. They are diagnosed with ADHD, non-verbal learning disabilities, Asperger's, autism, developmental delay, Tourette's, and many other labels. But they all share one thing in common: they lack an efficient visual system, and that slows down their academic progress. It is the fastest growing part of my practice and the reason why I was able to open a private practice (with a partner) a year and a half ago. Every optometrist should offer vision therapy, or refer to someone who does, just like you would refer a retinal tear to a retinal specialist. Your patients will be better served, your practice will grow, and you will receive more satisfaction than you get from "which is better, one…. Or two?" Isn't it time you learned that lesson too?

The Power of the Doctor-Patient Relationship (1/8/06)

Ryan was 8 years old when I first examined him. A very bright boy, he was referred to me for a behavioral optometric evaluation related to learning difficulties. He also had "attentional issues" that the school had noted, but was not on any medications. He had problems with reading, spelling, and math. Ryan did not enjoy reading. He skipped words and lines when he read, or else he used his finger to keep place. Comprehension suffered. Copying from the blackboard was difficult. His mother said he hated anything to do with writing or drawing. He was always last to finish assignments. In fact, he hated school in general. His mother said it was difficult getting him ready to go to school in the morning. He would fight, scream, throw a tantrum, and just refused to go. Ryan's Individual Educational Plan in school mandated a special reading class and occupational therapy twice a week, which made him feel like he was a failure. The occupational therapist noted a "tracking problem" and thought I could help him.

His mother thought it was unusual that Ryan should have a "vision problem" when his vision was 20/20. He passed the "eye exam" at school and at the pediatrician's office, but she made the appointment anyway. My examination did indeed show 20/20 vision in each eye at distance and near. Yet, he over-converged at near (convergence excess), had miserable eye movement skills, and had difficulty clearing plus at near in accommodative facility testing. He had great difficulty moving his eyes without moving his head. I was careful to demonstrate everything that I saw to his mother, so she could clearly see what my concerns were. I also could tell that he was a very
bright boy.

In the case consultation, I informed Ryan's mother of the significance of the findings and how I thought his eyes and vision were interfering with his academic performance. We discussed treatment options, including the use of a mild pair of reading glasses which were found to make it a little easier for him to read. Then I looked him straight in the eyes and said "Ryan, I think you are a very smart kid, but I think your eyes are holding you back. If you will let me, I can help you." We then discussed the option of vision therapy to improve his visual skills and exactly what that would entail. Ryan said he wanted to do it. His parents later discussed vision therapy and decided to proceed.

The first thing I do with every vision therapy patient on the first VT visit is ask them why they are here. (You would be surprised at the answers!) The second thing I do is ask them what they want to get out of it, what their goals are. Ryan said he wanted to do better in baseball and basketball, and to get his homework done faster (most of the kids I do therapy with want that). His mother, naturally, wanted him to do better in school, to have an easier time with the academic work load, and to read better. I then explained how they will notice changes in performance in the exercises he was doing from week to week, but that it would take about a month to notice changes outside of the specific exercises, such as with homework or reading.

His mother immediately stated "This has already made a difference." I was shocked. We had not even started the first exercise at his first VT appointment in the office yet. How could this have made a difference? We hadn't done anything. I did not understand. She then explained "Ryan no longer fights me when it comes time to go to school. You told him he was not stupid, but that the problem was with his eyes. It has already made a huge difference."

I was wrong in assuming I had done nothing yet. I had done nothing in terms of procedures for his visual system yet. But we are treating more than just the visual system. We are treating the patient. We all, as eye doctors, understand how eyeglasses, contacts, prisms, and medications can have powerful effects on our patients. But the words we use with our patients and how we say what we say can make a huge difference as well. Ryan is a great example of the power of the doctor - patient relationship. He is currently in vision therapy. I will give you an update on his progress when he finishes.

The Ultimate Responsibility of a Doctor (12/9/05)

Frank had end stage congestive heart failure, bilateral pneumonia, and his kidneys were shutting down. He was 83 years old and dying. My job was to bath him, change his linen, clean him when he soiled himself, and try to keep him comfortable. He could not eat, so I had to make sure his IV line was open and flowing, and periodically would wipe his drying mouth and tongue with an awful tasting lemon swab for moisture. He was my patient for the week, and as it was my first week on the job, I was assigned to work with him.

For eight hours each day, I cared for him the best I could. He was a large man, probably 6 foot 3 inches and at one time weighed over 230 lbs, I guessed. He was now down to 168 lbs, bed ridden, and clinging to life. As I rode my bicycle to work each day, I would imagine what I would be doing for him. How could I make him feel better? I remember the horrible sound of him coughing as the nurses would try to suction his lungs to allow him to breathe better, and the smell of rotting flesh that seemed to emanate from his lungs. I felt so bad for him. After caring for him for four days, I walked into the nurses’ station and asked where Frank was. I was told he passed away the previous night. I was in shock. “I had just taken care of him yesterday” I thought. It made me realize how tenuous life was.

When I think of Frank now, I think about what Dr. Schaeffer said at an ophthalmology meeting in 1988. He was 80 years old and was recounting the changes that he has seen in his practice lifetime. The advances in cataract surgery, antibiotics, glaucoma medications, laser surgery, etc. The list goes on and on. And then he said that there was one thing that has not changed in all his 50 years of practice. And that is, to cure – rarely, for there are very few things that we can actually cure. To improve – often, for while we may not be able to cure the underlying disease, we can often provide treatment to improve the lives of our patients. And to comfort – always, for even in the most terminal of situations, you can always provide comfort for your patients, and that, ultimately, is your responsibility. His words struck a cord within me, and I have remembered them to this day. And I can see that, ultimately, comfort was the only thing I could give to Frank, and that was my responsibility.

I am now a behavioral optometrist in private practice in a small town west of Boston. About 65% of my practice is related to vision and learning, although I see all sorts of patients. I have been invited to write a blog for eyecoderight.com with a leaning toward behavioral, pediatric, and binocular vision issues, and thought I would use the story of Frank to illustrate where I am coming from, at least from a philosophical perspective. To write anything well, you need to have something to say. I will try to make the blog informative, insightful, often humorous, but always thoughtful. I would invite you, if you should have any comments, to send me an email at drjohn@greatvisioncare.com. Whether you agree or disagree, I would encourage the dialogue.