LETTERS TO THE EDITOR
pants’ word regarding the topography of
The Journal of the American Osteopathic Association
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letters that discuss recently published original research.
Effect of Osteopathic
Cranial Manipulative
Medicine on Visual
Function
To the Editor:
We read with interest the research article
by Sandhouse et al titled “Effect of
Osteopathic Cranial
Medicine on Visual Function.”
authors conducted this study to deter-
mine the effect of osteopathic cranial
manipulative medicine (OCMM) on mul-
tiple functional visual parameters both
before and after management of spheno-
basilar synchondrosis (SBS) dysfunction.
Few studies have been conducted in this
area, especially with a blinded rando-
mized prospective design, which is a
strength of this study. However, we have
concerns regarding the methods.
The authors list several testing proce-
dures. The first measurement was “best-
corrected distance visual
Participants were asked to read the Early
Treatment of Diabetic Retinopathy
Study chart, the criterion standard for
checking visual acuity (VA) in research
studies, either uncorrected or using their
current corrective lenses. However, best-
corrected VA is normally measured after
a manifest refraction using a phoropter
to ensure that the participants’ actual
best potential vision is recorded. Some
The Journal of the American Osteopathic Association
(JAOA) encourages osteopathic physicians,
faculty members and students at colleges of
osteopathic medicine, and others within the
health care professions to submit comments
related to articles published in the JAOA and
the mission of the osteopathic medical profession.
The JAOA’s editors are particularly interested in
participants may have had latent hyper-
opia or a small degree of myopia that,
with correction, could have been
refracted to achieve better VA. Likewise,
they would have performed differently in
all of the measurements tested in the
study. This point is extremely important,
as not only do many people have small,
Manipulative or even large, degrees of uncorrected
1
The refractive error, but also the VAs of
these participants were measured weeks
apart, so any slight change in ocular
surface disease could have changed the
refractive error. Also, the only way to
definitively determine latent hyperopia,
especially in a young population, is
through a cycloplegic refraction, which
was not performed in this study.
Therefore, the measurements obtained in
the study cannot be considered “best-
corrected.” (Of note, there was a slight,
but not statistically significant, increase
in VA more so in the control group than
acuity.” the treatment group.) Furthermore,
without a manifest refraction, partici-
pants may not have actually met the
inclusion criteria, as some may have had
additional refractive errors that would
have excluded them from the study.
1
In addition, the authors claim that all
of the included patients had no irregular
astigmatism, as deduced through a
patient questionnaire and noncycloplegic
retinoscopy. However, taking the partici-
November 2017 | Vol 117 | No. 11
their cornea is flawed. Also, in current
practice, irregular astigmatism is diag-
nosed based on topography of the
cornea using advanced diagnostic equip-
ment. Although performing cycloplegic
retinoscopy may identify larger degrees
of irregular astigmatism, it will not pick
up subtle changes. Such slight changes
in corneal curvature could have altered
many of the measurements that the
authors performed.
A proper eye examination consists of a
dilated slit lamp examination of both the
anterior and posterior segments of both
eyes. Using the slit lamp, the ocular and
periocular tissues are examined with 5×
to 24× magnification, which is standard
in diagnosing almost all ocular diseases.
However, this part of the examination
was not performed in the study.1 As
most eye care professionals will attest,
many patients have undiagnosed or
undertreated ocular surface disease,
which has a major effect on refractive
error and VA. If the participants in this
study had undiagnosed ocular disease, it
would have affected many of the visual
measurements taken by the authors.
The other visual measurements that
achieved statistical significance were the
near point of convergence (NPC),
Donder pushup, and stereoacuity. Most
eye care professionals do not test for
stereoacuity that is better than 40
seconds of arc, which is what almost all
participants had in this study, nor is
there a differentiation made clinically
between intervals of 10 seconds of arc.
The change in stereoacuity noted in the
study is of no clinical significance in the
day-to-day practice of eye care.
Regarding vergence, Lee and Galetta2
commented on a study that assessed foot-
ball players’ change in visual function
681
 LETTERS TO THE EDITOR
after head trauma. They discussed that
the full testing of vergence—including
peak velocity, fusional amplitude, and
divergence—was not performed, which
is similar to the study by Sandhouse
et al.1 They also stated that the difference
in NPC was small, which is also similar
to the study by Sandhouse et al,1 as the
average NPC was within normal limits
throughout each group. Lee and Galetta2
also discussed the confounder of fatigue
relative to poor sleep, excessive near
work, and drug and alcohol intake that
were not assessed before each visit, all
of which can affect vergence measure-
ments. These confounding factors,
which were also not specifically assessed
1 1. Sandhouse ME, Shechtman D, Fecho G, Timoshkin
by Sandhouse et al, limit the reliability
of the measurements taken by the
authors. Additionally, without a cyclo-
plegic refraction, it is impossible to
perform any of these tests because they
must all be performed with the patients’
full refractive correction.
The final visual measurement dis-
cussed was pupil size. The most com-
monly used method of measuring pupils
for research purposes is by using a pupil-
ometer, which is a proven, standardized
method that will give the most objective
1
result. Sandhouse et al measured pupil
diameter by putting a ruler close to the
participants’ eyes. The pupillary sphinc-
ter and dilator muscles are extremely
dynamic. Any stimulation, whether a
sympathetic reaction due to fear of a
ruler coming close to the eye, accommo-
dation (either spasm or momentary), a
slight change in the luminance of the
bulb, or a flicker in the bulb lasting
under a second while the measurement
is being taken, can change the size of
the pupil. Thus, the change in pupil
size of less than 0.3 mm reported by
Sandhouse et al1 is of no clinical signifi-
682
cance, especially in young, healthy
participants, and we believe it is
likely not statistically significant.
In addition, it is unclear how long after
the intervention that the reassessment of
vision occurred. With the application of
osteopathic manipulative treatment, it is
important to measure the effects multiple
times after manipulation. In the study by
Sandhouse et al,1 multiple measurements
would be needed to elucidate whether
there was any immediate change in the
visual system resulting from OCMM,
how long it lasted, and at what rate the
changes regressed without further
treatment.
We also question the choice of
OCMM as the intervention. The visual
system involves numerous neurons and
pathways that span the majority of the
central nervous system and parts of the
peripheral nervous system. Thus,
OCMM can have tremendous effects on
different parts of the visual system. The
authors stated, both in this study1 as
3
well as in their pilot study, that they
attempted to show that treatment of the
SBS will affect the visual system, but
they did not state why they chose
OCMM. Having an understanding of the
effect on the inner workings of the
cranium and central nervous system and
how OCMM specifically will affect
visual function is necessary for the
understanding of the successes and fail-
ures of studies, as well as assisting in
the construction of new studies.
With the numerous limitations that the
authors discussed, including some of
those we have mentioned, we question
the validity of this study’s results.1
Well-constructed studies are needed to
determine OCMM’s full potential on the
visual system. There is great potential
for future studies of OCMM on the
The Journal of the American Osteopathic Association
visual pathway as it is connected to the
majority of the central nervous system
and portions of the peripheral nervous
system. In this era of evidence-based
medicine, all studies must be conducted
by adhering to the highest standards of
rigor and understanding. (doi:10.7556
/jaoa.2017.131)
Austin Bach, DO, MPH
Bascom Palmer Eye Institute, Miami, Florida
Miriam Bach, OD
Lake Erie College of Osteopathic Medicine, Bradenton,
Florida
Stephanie Frankel, OD
Elgut Eye Care, Fort Lauderdale, Florida
References
EM. Effect of osteopathic cranial manipulative
medicine on visual function. J Am Osteopath Assoc.
2016;116(11):706-714. doi:10.7556/jaoa.2016.141.
2. Lee AG, Galetta SL. Subconcussive head trauma
and near point of convergence. JAMA Ophthalmol.
2016;134(7):770-771. doi:10.1001
/jamaophthalmol.2016.1360.
3. Sandhouse ME, Shechtman D, Sorkin R, et al.
Effect of osteopathy in the cranial field on visual
function—a pilot study. J Am Osteopath Assoc.
2010;110(4):239-243.
© 2017 American Osteopathic Association
Editor’s Note: The authors were shown this
letter and declined to comment.
Correction
The author regrets an error that appeared
in the following article:
Casapulla SL. Self-efficacy of
osteopathic medical students in a
rural-urban underserved pathway
program. J Am Osteopath Assoc.
2017;117(9):577-585. doi:10.7556/
jaoa.2017.112
On page 582, column 1, lines 8 and 9,
the parenthetical data do not apply to the
statement and therefore should have been
removed. (doi:10.7556/jaoa.2017.132)
November 2017 | Vol 117 | No. 11