THE INTERFACE BETWEEN

OPHTHALMOLOGY
OPTOMETRIC VISION THERAPY
&
n Leonard J. Press, O.D. Introduction Orthoptics had its heyday from early to

T
mid-20th century, but was gradually
Abstract he impetus for this pa- transformed from an active therapeutic
Considerable disparity lies between per stems in part from a service into a marginal service. The num-
o p h th alm ologic impressions of meeting that I attended ber of certified orthoptists in the United
optometric vision therapy, and the reality on March 21, 2001, in States dwindled, and those remaining pro-
of optometric vision therapy as practiced Orlando, Florida. Re- gressively engaged in assisting with pre
in the United States. The viewpoint shared viewed in a prior issue of this journal, the and post strabismus surgical measure-
by ophthalmology in particular, and the meeting entitled Why Cant EYE ments and monitoring rather than in per-
medical field in general, is one that is fil- Learn? was jointly sponsored by Jeffer- forming non-surgical therapeutic
tered through organizational policy state- son Medical College and the Section on services. The service itself was diluted
ments and the isolated experiences of Ophthalmology of the American Acad- from an active approach to amblyopia and
influential individual practitioners. This emy of Pediatrics (AAP).1 The subtitle of strabismus therapy to a passive approach
has resulted in a skewed portrayal of this meeting was: Learning Differences for a handful of convergence problems.
optometric vision therapy. The purpose of and Visual Perception from a Pediatric This raises an obvious question. Why,
this paper is to present a balanced per- Ophthalmology and Neuro-psychology if orthoptics was efficacious for a broad
spective on this subject, and one that Perspective. spectrum of binocular applications, was
should be of assistance in creating an in- My participation during this meeting the field virtually vacated by ophthalmol-
terface between ophthalmology and op- was serendipitous. Dr. Harold Koller, who ogy? The answer, to be succinct, is that
tometry that better serves the public. I had known from my days in the Philadel- orthoptics was more than most ophthal-
phia area, was the Chair of the meeting. mologists could manage. This belief is
During his presentation, Dr. Koller made supported by an authoritative textbook on
Editors note several passing references to Optometry Orthoptics from 1949 by Mary Everist
This article originally appeared in Binoc- and vision therapy. Following his invita- Kramer, supervisor of the Orthoptics De-
ular Vision & Strabismus Quarterly, tion to me to give a short [impromptu] pre- partment at the George Washington Uni-
2002; 17(1):6-11. We wish to thank editor, sentation on the subject, I joined the group versity Hospital in Washington, DC.3 The
Paul E. Romano, MD, MS for his permis- on the podium for a panel discussion. The text was edited by Ernest A. W. Shepard,
sion to reprint. questions to me from the audience M.D., Professor of Ophthalmology at the
touched on six areas of concern that I will George Washington University School of
address at the end of this paper. Medicine. In the Preface, we find the fol-
The evolution of optometric vision lowing candid observation:
therapy When ophthalmologists discuss or
To appreciate the science and substance write about orthoptics, their views are
of optometric vision therapy, it is insight- generally based upon the work of an
ful to consider vision therapy as an out- orthoptic technician, the results of whose
growth of orthoptics. This evolution has work they have observed. Since few oph-
been chronicled in detail elsewhere,2 and thalmologists have had the opportunity to
several points need to be elaborated. Al- observe good orthoptists, there is a wide
though ophthalmologists pioneered variance of opinion regarding the role of
orthoptics, it was neither cost-effective orthoptics in the treatment of ocular im-
nor time-effective in their hands. balances.

Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 37

 Consider the following guidelines for tance in the accomplishment of a rapid tional ophthalmologic sources. This is not
successful orthoptic treatment as outlined and lasting cure for her patients. as much as oversight as it is evidence of
by Kramer and Shepard (pp. 154-169): Ophthalmologic practice drifted from the disinterest of ophthalmology in visual
Necessitates frequent office visits at the holistic attributes required for success development from a behavioral perspec-
first, with gradual reduction as the train- as outlined by Kramer. As ophthalmology tive.
ing is carried out at home. was becoming an increasingly medical Ophthalmolgic initiatives to dis-
Approximate length of time of treatment and surgical practice, optometry in credit vision therapy
is usually from two months to two years. mid-century was rendering vision therapy Nature abhors a vacuum and, as optom-
If surgery is indicated the ophthalmolo- services well-suited to these attributes for etrists began to improve patients perfor-
gist may prefer to give orthoptic training orthoptic success. Another text published mance through vision therapy programs,
before surgery, or institute surgery be- in 1949 is essential in understanding the ophthalmologists found themselves hav-
fore orthoptic training. The decision pivotal role that Optometry was about to ing to address inquiries about how a
rests upon the type of case, the age, the play. Entitled Vision: its Development in childs vision might be influencing behav-
physical and mental development of the Infant and Child, this text represented a ior, development, or school performance.
patient, the cooperation of the patient fusion of Optometry, Ophthalmology, In 1972, the American Academy of Pedi-
and parents, and the ease or difficulty of Orthoptics and Psychology.4 atrics, the American Academy of Oph-
making weekly visits to the doctors of- Pediatric ophthalmologists should be thalmology and Otolaryngology, and the
fice. conversant with the collaboration that American Association of Ophthalmology
The training must be intensive to be ef- took place among these fields at the Yale issued a policy statement entitled The
fective. Breaks in training should be Clinic of Child Development. Arnold Eye and Learning Disabilities, which de-
given when the child reaches a point of Gesell, M.D., and Frances Ilg, M.D., were nied any relationship between vision and
saturation after intensive training.
substantially aided by Vivienne Ilg, O.D. learning. The inaccuracies in this policy
More than treating a pair of eyes, and Gerald Getman, O.D., in this effort. statement were swiftly pointed out in an
orthoptics consists of treating the person
Their work was unparalleled in the field of article in the Journal of the American
as a whole, since much of the success of
restoring normal binocular vision de-
child development. The melding of Optometric Association by Flax.5
orthoptics with an optometric perspective Despite Flaxs scholarly refutation of
pends upon the personality, cooperation,
and enthusiasm of the child. served to broaden the basis for optometric the points raised in the 1972 paper, an ad
vision therapy as practiced in the second hoc working group of the American Asso-
Training should be adapted to a childs
mental capacities as well as to his ocular half of the 20th century. Permit me to ciation for Pediatric Ophthalmology and
skills. Some children learn faster than quote from the preface of this text: Strabismus, and the American Academy
others, some retain knowledge better The authors have attempted to achieve of Ophthalmology, issued a policy state-
than others, some have greater concen- a closer acquaintance with the interre- ment in 1981 entitled Learning Disabil-
tration ability than others, some are lations of the visual system per se and ities, Dyslexia, and Vision offering
more attentive than others. the total action system of the child. conclusions similar to those in the 1972.
Causes for failure in orthoptics include This finally entailed the use of the Again Flax, this time with two associates,
inexperience or poor judgement on the retinoscope and of analytic optometry authored a scholarly rebuttal.6 Their arti-
p a rt of the ophthalm ologist or at early age levels where these techni- cle unmasked the sweeping negative gen-
orthoptist, and termination of orthoptic cal procedures are ordinarily not ap- eralizations aimed at optometry with no
training before establishment of good plied. The examinations of the visual conclusive supporting documentation. It
binocular stability. functions and of visual skills were re- points out how the references offered are
Success in administering orthoptics ally conducted as behavior tests, not misconstrued, nonapplicable, and grossly
hinges on a personality profile of dignity only to determine the refractive status distorted.
without arrogance, humility without of the eyes, but also to determine the Organized ophthalmology not only
subservience, mental alertness without reactions of the child as an organism chose to ignore the legitimate critiques of
perceptive tension, and necessary force- to specific and total test situations. its policy statement, but conscripted the
fulness without aggressiveness. Although the Yale physicians antici- American Academy of Pediatrics in its ef-
The ability to impart knowledge is the pated ophthalmologic interest in their forts. As recently as 1998, a subject re-
essence of orthoptic training, for in real- work, that was not to be the case. The view of this area chose to depict visual
ity it is a course of instruction which the Optometric Extension Program, and the training as controversial, unscientific and
orthoptist gives to the patient. A good optometrist A.M. Skeffington in particu- virtually irrelevant to learning.7 Pub-
orthoptist possesses an artistic tempera- lar, proved to be influential in post- gradu- lished in the journal, Pediatrics, this joint
ment and intelligence with all the vir-
ate studies in vision development and policy statement was the latest in an effort
tues. She is teacher, nurse, friend,
vision therapy. They are acknowledged to ensure that as many parents as possible
confidante, advisor, and healer to the pa-
by Gesell et al in the preface to their text. would be dissuaded from undertaking vi-
tient. Her enthusiasm and genuine inter-
est can make the difficult seem easy. In contrast, one is hard- pressed to find sion therapy. It is important to note that
These qualities are the piece de resis- reference to the work done at the Yale In- the pediatric/ophthalmologic policy state-
stitute of Child Development in tradi- ments overlooked a landmark paper pub-

Volume 13/2002/Number 2/Page 38 Journal of Behavioral Optometry

lished in the Journal of the American ticle, Is vision therapy quackery?, from firsthand experience devel-
Optometric Association on the efficacy of speaks for itself. oped considerable skepticism about
optometric vision therapy, including over Permit me to illustrate the sensational- the scientific base of many things
200 references.8 More recently, a Joint ism of this approach with an analogous ti- done by physicians. Several years
Policy Statement was issued by the Amer- tle for a prospective article: Is ago which means things should
ican Academy of Optometry and the Strabismus Surgery A Hoax? In such an have improved in the meantime I
American Optometric Association, pin- article I might point out that strabismus served as an expert witness in a
pointing flaws in the criticisms of Oph- surgery was accepted as a legitimate ap- hearing involving the scientific va-
thalmology and Pediatrics against proach in medicine without the benefit of lidity of optometrists use of vision
optometric vision therapy.9 controlled scientific studies, and that its training to correct strabismus (mis-
In one of the more candid discussions outcome as other than a cosmetic cure re- alignment of the eyes). Ophthalmol-
to appear in print on this subject, several lies principally on anecdotal evidence. ogi s t s had char ged t h a t t h e
pediatric ophthalmologists revealed their Even if I were to present an even-handed optometric research on vision train-
concern about the collective insouciance analysis I have successfully cast asper- ing did not prove that vision training
of their profession. Their remarks can be sions by virtue of how the question of its worked. They were right; some
found in a paper by Mazow et al on ac- efficacy was couched. optometric literature on the subject
commodative and convergence insuffi- The shallow intentions of the Quack- was scientifically flawed. However,
ciency, and its relationship to learning, ery article, and its willful or unintended I also evaluated the research that
published in the Transactions of the ignorance of studies that should have been ophthalmologists used to defend
American Ophthalmological Society.10 evaluated, were exposed by one of the their surgical approach to correct-
Consider the following (Dr. Leonard Apt, foremost optometric researchers in ac- ing strabismus. The literature on
p.171): commodation and convergence, Dr. surgical correction was no more sci-
My impression is that many ophthal- Jeffrey Cooper.15 However, as has been entifically valid than the compara-
mologists handle this disorder our experience in Optometry, no matter ble studies on vision training.
poorly. Too often they consider most how thoughtful and scholarly our re- Physicians who live in glass houses
cases of asthenopia in young per- sponses are to the Ophthalmologic asper- should not throw stones.
sons as instances of uncomplicated sions cast on vision therapy, the negative How does the public view the conflict-
convergence insufficiency and treat campaign continues. ing opinions of organized optometry and
these patients with simple push-up Fallacies inherent in ophthalmology? Theyre likely reminded
exercises. This unsophisticated ap- ophthalmologic critiques of vision of the classic New Yorker cartoon that
proach ofttimes is not helpful and the therapy borrows a line from Gore Vidal. In the
patient leaves dissatisfied. Many The picture painted thus far does not cartoon, two dogs wearing suit and tie are
ophthalmologists do not fully appre- seem to bode well for bridging the gap be- seated at a bar sipping martinis. One looks
ciate the role and function of the pro- tween ophthalmologic and optometric at the other and declares: Its not enough
c e ss of accom modation and viewpoints about vision therapy. How- that we succeed. Cats must also fail.
convergence, their interrelation- ever, several observations may serve oph- Public savvy was the impetus leading to a
ship, and how to study their thalmologists and pediatricians well in resolution by the National PTA, issued at
dysfunctions. Thus proper treatment their efforts to serve as informed patient its national meeting in Oregon in 1999,
is not given. Many of these patients advocates. There is a common flaw that is urging educators, other professionals and
end up under the care of optome- shared by the joint organizational policy the public to become more conversant
trists. statements of Ophthalmology and Pediat- with the role that vision plays in the learn-
But Optometry has clearly demon- rics, Kollers quackery article, and the ing process. Public savvy is a strong rea-
strated its body of knowledge in this area, opinions of local ophthalmologists in- son why The White House has issued a
with notable works that summarize its clined to discredit optometric vision ther- statement every year, for the past decade,
clinical relevance and validity.11-13 Oph- apy and its practitioners. It is counter- honoring August as Vision and Learning
thalmology has not undertaken Dr. Apts intuitive that material taught in every Col- Month.
challenge to develop a more sophisticated lege of Optometry in the country, and for All this begs an obvious question: If vi-
clinical approach to vision problems that which there are definitive clinical practice sion therapy is unsubstantiated and mis-
contribute to learning difficulties. Rather guidelines issued by a national profes- guided, how does it survive in the
than objectively evaluate ongoing sional organization in existence for over marketplace? Consider the following: Op-
optometric contributions to this field, 100 years, 16 has no basis. This was tometrists are rarely, if ever, the first pro-
ophthalmology collectively continues to brought to the surface by Jeffrey Bauer, a fessionals consulted when parents find
take a simpler and less responsible ap- Ph.D., Fulbright Scholar, and Kellogg their children struggling to learn. Optom-
proach. The quintessential low road was Foundation National Fellow, who noted:17 etrists who practice vision therapy are
taken in an article published in the Review Regarding the related insinuation therefore seeing a skewed population,
of Ophthalmology several years ago.14 that optometrists simply do not know typically of children who are not perform-
Dripping with innuendo, the title of the ar- as much as ophthalmologists, I have ing to levels of realistic expectation in

Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 39

school. More than likely, they have been QUESTION 1: Academy of Optometry (AAO) has a
through a number of assessments and in- Where is the scientific basis for diplomate program in binocular vision
terventions prior to coming to our offices. Optometric Vision Therapy? and perception as well as in pediatric
Physicians harbor the notion, evident in ANSWER 1: optometry.
the language of organizational policy As mentioned, Dr. Coopers scholarly QUESTION 5:
statements, that a proposed course of vi- article provides references that clearly Why is vision therapy so expensive?
sion therapy when indicated somehow de- substantiate the scientific basis of vi- ANSWER 5:
ters unsuspecting parents from pursuing sion therapy. Clinical Practice Guide- It is intriguing that physicians dont ask
lines are available from the American the same questions regarding the ex-
necessary and proven courses of action.
Optometric Association on the Care of pense, scientific underpinnings, and
On the contrary, this fallacy is actually the
the Patient with Learning Related Vi- pertinence to learning of occupational
basis for success of many patients in
sion Problems, Accommodative and therapy, which they endorse far less
optometric vision therapy. Vergence Dysfunction, Amblyopia, critically, despite the obvious parallels
In many instances, optometric vision and Strabismus. Each of these has ref- between the two fields.19 To answer
therapy is successful in helping patients erences incorporating scientific the question directly, the fees for vision
precisely because they have had other in- method. The research presented is therapy services are commensurate
terventions which have ignored pertinent commensurate with clinical research with other therapy procedures involv-
visual abilities. In other instances visual in fields such as occupational therapy, ing similar bodies of knowledge and
problems trivialized by other profession- and is equal to or better than research time expended. Aside from the doc-
als, or the effective sensory integration of traditionally presented for clinical tors time in evaluating the patient,
visual abilities to facilitate motor planning methods in pediatric ophthalmology. there are often prior reports to read that
and multi-tasking, is lacking. If QUESTION 2: are pertinent to decisions about
optometric vision therapy were princi- How do optometrists know which pa- optometric intervention, time spent
pally tender, loving care,or a Haw- tients might benefit from vision ther- programming and sequencing activi-
thorne effect, then the prior interventions apy? ties to strike an effective balance be-
the child had would have already supplied ANSWER 2: tween office and home therapy, and
that effect. Why would vision therapy The Four Clinical Practice Guidelines time spent with therapists to discuss on-
supply more of a Hawthorne effect than from the AOA mentioned above pro- going progress.
occupational therapy, or remedial reading, vide clear guidelines for differential di- QUESTION 6:
agnoses. Textbooks referenced in this Why does vision therapy work when it
or music lessons, or the myriad activities
article, in addition to others available, does? Eye problems shouldnt have
in which todays parents engage their chil-
provide this as well. anything to do with LD or ADD since
dren? It is more likely that vision therapy
QUESTION 3: these are CNS or brain problems.
is helping the patient develop abilities that Is it true that vision therapy patients are ANSWER 6:
were a legitimate missing link in the learn- in for life? The retina is brain tissue. Dissociating
ing process. In acquiring improved visual ANSWER 3: the role of the eye in visual processing
processing abilities, the patient is in a Nothing could be further from the truth. from brain function is an artificial dis-
better position to benefit from traditional The clinical practice guidelines above, tinction. With regard to learning and
educational interventions. in addition to guidelines issued by the attention systems, principles of cogni-
Improving the interface to better College of Optometrists in Vision De- tive neuroscience substantiate that in-
serve the public velopment (COVD)18 based on ICD terventions directed toward sensory
Answers to the questions posed to me codes for various conditions, are proof and motor eye functions have a salutary
during the panel discussion of Why that this is not the case. and pervasive effect on central pro-
Cant EYE Learn? will not immediately QUESTION 4: cesses of the brain.
bridge the chasm between ophthal- How might I judge if a patient is in need
References
mologic and optometric points of view, of vision therapy, or if a person I am re- 1. Romano P. Report of the meeting of the Amer-
but are important steps in the right direc- ferring the patient to is a credible pro- ican Academy of Pediatrics Section on
vider? Ophthalmology Why Cant EYE Learn?
tion. Close inspection of these answers Bin Vis & Strab Quart 2001;18:217-21.
may influence ophthalmology and pediat- ANSWER 4: 2. Press LJ. The evolution of vision therapy. In:
rics to channel its efforts in patient advo- All optometrists receive graduate edu- LJ Press, ed. Applied Concepts in Vision
cation in and are licensed to practice vi- Therapy. St. Louis: Mosby, 1997:208.
cacy toward interventions that truly 3. Kramer ME. Clinical Orthoptics: Diagnosis
sion t her apy. T he O pt om et r i c and Treatment. St. Louis: C.V. Mosby, 1949.
warrant skepticism. Optometric vision 4. Gesell A, Ilg FL, Bullis GE. Vision: Its Devel-
Extension Program (OEP) provides
therapy has stood the test of time and the opment in Infant and Child. New York:
post-graduate education in the areas Harper and Row, 1949.
metric of clinical science to the point encompassing vision therapy. The Col- 5. Flax N. The eye and learning disabilites. J Am
where the practice of deterring patients lege of Optometrists in Vision Devel- Optom Assoc 1972;43:612-17.
from seeking this service becomes ques- 6. Flax N, Mozlin R, Solan HA. Discrediting the
opment (COVD) provides a board basis of the AAO policy: Learning disabilities,
tionable. certification process, and has a national dyslexia and vision. J Am Optom Assoc
directory of providers. The American 1984;55:399-403.

Volume 13/2002/Number 2/Page 40 Journal of Behavioral Optometry

 APPENDIX 1 APPENDIX 2
PRIMARY DIAGNOSTIC CONDITIONS SAMPLE METHODS FOR OPTOMETRIC VISION THERAPY
AMENABLE TO AMBLYOPIA
OPTOMETRIC VISION THERAPY* Sequence: 1. Appropriate Rx
2. Occlusion therapy
Diagnostic Condition ICD-9-CM 3. Eye-hand coordination
CODE 4. Ocular motor accuracy
Accommodative excess 367.53 5. Accommodative therapy
Accommodative 367.50 6. Fusion enhancement
insufficiency Methodology: For 1) and 2) standard approaches
Accommodative infacility 367.50 For 3) letter tracking sheets; pointer-in-straw
Amblyopia 368.01 For 4) Haidinger Brush device (foveal fixation)
Convergence excess 378.84 For 5) loose lens accommodative rock
Convergence insufficiency 378.83 For 6) Polaroid vectrograms
Divergence excess (DE) 378.24 ACCOMMODATION
Divergence 378.85 Sequence 1. Appropriate Rx
insufficiency (DI) 2. Monocular accommodative stimulation
Esotropia 378.35 3. Monocular accommodative relaxation
Exotropia 378.15 4. Binocular accommodative stimulation
Intermittent exotropia 378.23 5. Binocular accommodative relaxation
(DE or basic) Methodology For 1) standard approach including multifocal if indicated
Intermittent esotropia 378.21 For 2) through 5) loose lens and lens flippers
(DI or basic) For 2) through 5) letter charts of various sizes utilized at
Vertical deviations 378.43 appropriate dioptric demand distances
Visual processing deficit(s) 315.90 VERGENCE
Sequence 1. Appropriate Rx
*The clinical practice guidelines delin- 2. Monocular accommodative and ocular motor activities if
eating these diagnoses can be found in evidence of inequality OD vs. OS
the following monographs published by 3. Bi-ocular phase of 2) if suppression evident
the American Optometric Association 4. Physiological diplopia therapy if spatial localization deficient
(St. Louis): 5. Expansion of fusional vergence ranges
1. Care of the Patient with Strabismus: 6. Integration of accommodative and fusional vergence ranges
Esotropia and Exotropia (1995) Methodology For 1) standard approach using prism if indicated
2. Care of the Patient with Accommoda- For 2) amblyopia and accommodation above
tive and Vergence Dysfunction (1998) For 3) septum or prism dissociation
3. Care of the Patient with Learning Re- For 4) Brock string (beads)
lated Vision Problems (2000) For 5) Computerized random dot stereograms/adapted stereoscopes
For 6) Stereoscopes; orthopic and chiascopic fusion/lens flippers
STRABISMUS
7 American Academy of Pediatrics (Committee Sequence 1. Appropriate Rx
on Children with Disabilities American Acad-
emy of Pediatrics and American Academy of 2. Monocular accommodative and ocular motor phase
Ophthalmology, American Association for 3. Monocular activities in a binocular field
Pediatric Ophthalmology and Strabismus). 4. Anti-surppresion; bi-ocularity
Pediatrics 1998.102:1217-19.
8. Special report: The efficacy of optometric vi- 5. First, second, third degree fusion (select free space or
s io n t h e r a p y. J Am O p to m A sso c instrument stimuli based on correspondence and depth
1988;59:95-105.
9. American Academy of Optometry, American of suppression)
Optometric Association. Vision, learning and 6. Integration of fusion with vestibular-motor feedback
dyslexia: A joint organizational policy state- 7. Integrate sensorimotor functions including accommodation
ment. J Am Optom Assoc 1997;68:284-86.
10.Mazow ML, France, TD, Finkelman S, et al. (including AC/A and CA/C effects)
Acute accommodative and convergence insuf- Methodology For 1) standard approach using multifocals and prism if indicated
ficiency. Tr Am Ophth Soc 1989;87:158-173. For 2) anaglyphic or polaroid targets
11.Rosner J. Helping Children Overcome
Learning Difficulties. 3rd ed. New York: For 4) anaglyphic, septum, or prismatic dissociation targets
Walker and Company, 1993. For 5) major amblyoscope; adapted mirror sterescopes;
12.Scheiman MM, Rouse MW. Optometric Man- computerized vergence stimuli
agement of Learning-Related Vision Prob-
lems. St. Louis: Mosby, 1994. For 6) egocentric/oculocentric balance activities (may preceed
13.Griffin JR, Christenson GN, Wesson MD. anti-suppression when indicated by clinical assessment)
Optometric Management of Reading Dys-
function. Boston: Butterworth-Heinemann, For 7) orthopic and chiascopic free space fusion stimuli with lens
1997. flippers and variable viewing distances and angles
14.Koller HP. Is vision therapy quackery? Re-
view of Ophthalmology 1998;3:38-49.

Journal of Behavioral Optometry Volume 13/2002/Number 2/Page 41

15.Cooper J. Deflating the rubber duck. J Behav
Optom 1998;9:115-19.
16.Optometric clinical practice guideline: Care
of the patient with learning related vision
problems. St. Louis: American Optometric
Association, 2000.
17.Bauer JC. Not What The Doctor Ordered. 2nd
ed. Columbus, OH: McGraw-Hill, 1998.
18.College of Optometrists in Vision Develop-
ment. , www.covd.org or 1-888-268-3770
19.Scheiman M. Understanding and Managing
Vision Deficits: A Guide for Occupational
Therapists. Thorofare, NJ: Slack, 1997.

Corresponding author:
Leonard J. Press, O.D., FCOVD, FAAO
Optometric Director
The Vision and Learning Center
Fair Lawn, NJ 07410

Journal of Behavioral Optometry

published by:
Optometric Extension Program Founda-
tion, Inc.
1921 East Carnegie Ave., Suite 3-L
Santa Ana, CA 92705
949-250-8070
www.oep.org

Volume 13/2002/Number 2/Page 42 Journal of Behavioral Optometry