Behavioral Optometry - a continuing controversy

There is a growing body of optometrists, and other eyecare practitioners (e.g., orthoptists) who have specialised in assessing and managing visual factors that are sometimes associated with specific learning difficulties (e.g., dyslexia). Most of these practitioners concentrate on activities that have been supported by rigorous research and would not describe themselves as behavioral optometrists.1

Behavioral optometry (BO) is a sub-discipline of optometry which has been popular in the USA and has some followers in the UK. The term covers a very broad range of activities and the simplest interpretation of BO is that optometrists should take account of the whole person and his/her environment. This is unquestionably sound advice which is likely to be followed by all good eye care practitioners. Some behavioral optometrists, like other optometrists specialising in vision and learning, concentrate on a very thorough investigation of orthoptic function and visual stress, and the treatment of anomalies detected in this way is not controversial. However, many behavioral optometrists additionally carry out unconventional tests. These practitioners often prescribe exercises and/or glasses to the majority of children they examine, even when these patients would not be thought to be abnormal following a thorough eye examination by a conventional optometrist or ophthalmologist. For example, many BOs regularly treat saccadic or pursuit eye movements in dyslexia, although these types of eye movement dysfunction have not been clearly established as a strong correlate of dyslexia, let alone a cause. Another area that BO concentrates on is perceptuo-motor function and exercises which are reminiscent of the "patterning treatment" of Dolman and Delacato.2

In recent years the healthcare sciences have been strongly influenced by the "evidence-based approach". This advocates a questioning approach to received wisdom and new ideas alike, until they have been validated by objective research. In view of the controversy surrounding BO, the UK College of Optometrists commissioned two reviews of BO.3;4 Both these reviews were critical of the lack of evidence-based support for most of the interventions recommended by BOs. It seems likely that at least some of the successes in improving reading that have been claimed by BOs are simply manifestations of the placebo effect. These cases may have benefited more if the resources had been spent on conventional management, such as extra teaching tailored to the child's individual needs.

The protocol for eyecare of people with specific learning difficulties that is used at the Institute of Optometry, and taught on courses that the Institute runs for eyecare practitioners, continually evolves in line with research findings. There are some tests that were popularised by BOs and that have been supported by compelling research findings (e.g., MEM retinoscopy) and these methods are used at the Institute of Optometry. But other methods that have been popular in BO and yet have been shown by research to be invalid (e.g., measuring saccadic eye movements with the DEM test) are not used at the Institute of Optometry.


1Allen PM, Evans BJW, Wilkins AJ. Vision and Reading Difficulties. London: Ten Alps; 2010.
2Silver LB. Review: Controversial approaches to treating learning disabilities and attention deficit disorder. Am J Diseases Childhood 1986; 140:1045-1052.
3Jennings A. Behavioural optometry: a critical review. Optometry in Practice 2000; 1:67-78.
4Barrett BT. A Critical Evaluation of the Evidence Supporting the Practice of Behavioural Vision Therapy. Ophthal Physiol Opt 2008; 29:4-25.