Behavioral optometry

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Behavioral optometry also known as functional optometry is an expanded area of optometric practice that uses a holistic approach to the treatment of vision and vision information processing problems. The practice of behavioral optometry incorporates various vision therapy methods and has been characterized as a complementary alternative medicine practice by the American Academy of Ophthalmology because they don't study this area of practice.[1][2] The field has been subject to criticism because other than the Convergence Insufficiency Treatment Trial (CITT) there are few other gold standard level studies of its effectiveness, similar to surgical interventions (like surgery, therapy cannot be double blind in studies).[3] The American Optometric Association has published a clinical guideline for the practice of vision therapy, the methods and techniques utilised in behavioural optometry.[4]


Behavioral optometry is considered by some optometrists to have its origins in orthoptic vision therapy. However, Vision therapy is differentiated between strabismic/orthoptic vision therapy (which Orthoptists and Ophthalmologists practice) and non-strabismic vision therapy.[5] A.M. Skeffington was an American optometrist known to some as "the father of behavioral optometry".[6] Skeffington has been credited as co-founding the Optometric Extension Program with E.B. Alexander in 1928.[6]

Part of behavioral vision care is concerned with impact of visual "skills" on performing visual tasks. Various behaviors and poor performance during visual tasks may suggest non-optimal visual skills. For example this could manifest as eyestrain symptoms experienced during visual tasks, or adopting poor posture (e.g. leaning in too close to visual material). Another example, could be difficulty understanding maps, difficulty recalling visual information, difficulty completing jigsaws and difficulty drawing/copying/interpreting visual information.[citation needed]

Current science supports the clinical benefits of visual rehabilitation for many areas of concern, in particular post traumatic brain injury, vision-related learning and behavior concerns, balance, and transient disease conditions that affect visual alignment and control. The effect of visual neuro-rehabilitation and neurosensory integrative rehabilitation are wide-ranging and will impact on obvious visual processing concerns, but also with symptoms similar to cognitive, behavioral or language disorders such as ADHD and dyslexia.[citation needed] It is not uncommon for children with extreme visual dysfunction to go unnoticed, or diagnosed with other conditions. It is growing in popularity among parents who may not want their children to be stigmatized by being labeled with a cognitive or language impairment. [7][not in citation given]


In 1944-1945 the Wilmer Eye Institute of Johns Hopkins Hospital in Baltimore undertook a study of the use of behavioral optometry in the treatment of myopia.[8] The training was undertaken by A. M. Skeffington and his associates, who traveled to Baltimore for the purpose, but who used a clinic outside the hospital, and were carefully kept apart from the staff in the Wilmer Institute who assessed their progress. The 103 candidates were school students and young adults with uncomplicated myopia. Independent examination before and after training was undertaken using Snellen charts, and use of a retinoscope after introduction of a cycloplegic agent. The examining physicians "were impressed by a psychologic improvement in a number of patients. Some patients while exhibiting no material change in their visual acuity, were nevertheless convinced that they saw better and that they used their eyes with greater satisfaction to themselves." The objective results were as follows. Of the 103 subjects:

  • 30 showed some improvement on all measures
  • 31 showed overall improvement, but not on all measures
  • 32 showed no overall change
  • 10 showed deterioration of vision

The report's author concludes "With the possible exception of educating some patients to interpret blurred retinal images more carefully and of convincing some others that they could see better even though there was no actual improvement, this study indicates that the visual training used on these patients was of no value for the treatment of myopia."

A review of the data undertaken in 1991 by two behavioural optometrists and published in the Journal of Behavioural Optometry, concludes that there were statistically significant positive changes in visual acuity due to the exercises and that the original conclusion that myopia reduction vision training is ineffective is unfounded. [9] Visual neuro-rehabilitation for congenital/developmental concerns as well as visual concerns related to trauma and pathology are well founded.

A review in 2000 concluded that there were insufficient controlled studies of the approach[10] and a 2008 review concluded that "a large majority of behavioural management approaches are not evidence-based, and thus cannot be advocated."[3] There is some question as to the value of such assessments, as most behavioral domains, such as psychology and education do not lend well to the strict requirements of evidence-based medicine (EBM). Indeed, many common medical practices also have not been supported by EBM, such as off-label use of medications, or use of medication for learning and reading disabilities.

Case studies[edit]

In 1994, behavioral optometrist Antonia Orfield reported having reversed her own myopia from -3.87 dioptres and -3.37 dioptres to -.50 dioptres and -.25 dioptres, over a period of seven years. She credited "nutrition, exercise, yoga, outdoor walks, postural training with the Alexander technique, and advanced chiropractic".[11]

In 2006, neurologist Oliver Sacks published a case study about "Stereo Sue" (Susan R. Barry), a woman who was strabismic and stereoblind since early infancy and who developed stereo vision after undergoing vision therapy.[12] Barry, a professor of neurobiology, later published a memoir, Fixing My Gaze: a Scientist's Journey into Seeing in Three Dimensions,[13] describing the therapy, the science underlying it, and her experience with it.

See also[edit]


  1. ^ American Academy of Ophthalmology (2001). "Complementary Therapy Assessment: Vision Therapy for Learning Disabilities.". 
  2. ^ American Academy of Ophthalmology (2004). "Complementary Therapy Assessment. Visual Training for Refractive Errors.". Retrieved 15 June 2012. 
  3. ^ a b Brendan T. Barrett (2008). "A critical evaluation of the evidence supporting the practice of behavioural vision therapy". Ophthalmic and Physiological Optics 29 (1): 4–25. doi:10.1111/j.1475-1313.2008.00607.x. PMID 19154276. 
  4. ^ "Optometric Clinical Practice Guideline". Retrieved 22 June 2012. 
  5. ^ Birnbaum MH. "Behavioral optometry: a historical perspective." J Am Optom Assoc 1994 Apr;65(4):255-64. PMID 8014367.
  6. ^ a b "A.M. Skeffington, O.D.: The Father of Behavioral Optometry." Visionaries (Reprinted from January–December 1991 Issues of Review of Optometry) Review of Optometry. Accessed February 5, 2012.
  7. ^ Judith Warner (March 10, 2010). "Concocting a Cure for Kids With Issues". New York Times. 
  8. ^ Woods, Alan C. (January 1946). "Report from the Wilmer Institute on the Results obtained in the Treatment of Myopia by Visual Training". American Journal of Ophthalmology 29 (1): 28–57. 
  9. ^ Trachtman, J N, Giambalvo, V, The Baltimore Myopia Study, 40 Years Later, J of Behavioral Optometry, v 2, No. 2, 1991, p. 47,
  10. ^ Jennings (2000). "Behavioural optometry – a critical review.". Optometry in Practice 1 (67). 
  11. ^ Antonia Orfield, M.A., O.D. (1994). "Seeing Space: Undergoing Brain Re-Programming to Reduce Myopia" (PDF). Journal of Behavioral Optometry 5 (5): 123–131. 
  12. ^ Sacks, Oliver (June 19, 2006). "A Neurologist's Notebook: "Stereo Sue"". The New Yorker. p. 64. 
  13. ^ Barry, Susan R. Sacks, Oliver. (2009) Fixing My Gaze: A Scientist's Journey into Seeing in Three Dimensions. New York: Basic Books. ISBN 978-0-465-00913-8

External links[edit]

National and international organizations[edit]