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care.

I, too, would like to summarize the statement that has been prepared as the formal statement for the committee.

Mr. ROGERS of Florida. Without objection that will be permissible, and your formal statement will be made a part of the record at this point.

(Dr. Ewalt's statement in full along with additional literature follows:)

STATEMENT OF H. WARD EWALT, JR., O.D. Mr. Chairman and members of the committee, I am Dr. H. Ward Ewalt, immediate past president of the American Optometric Association and a practicing optometrist in Pittsburgh, Pa. I am optometric consultant to the Surgeon General of the U.S. Army, a fellow of the American Academy of Optometry and the American Association for the Advancement of Science. I am also a member of the National Education Association and the International Reading Association.

It is indeed a privilege for me to appear before you today in support of H.R. 8546 and to answer some of your questions about the importance of optometry and the vision care provided our Nation.

Optometry is the profession specifically licensed in all the 50 States and the District of Columbia to care for vision, just as dentistry is the profession specifically, licensed for dental care. Every year more than 30 million Americans obtain vision care; and the chances are 3-to-1 that you or a member of your immediate family will have a professional vision examination within the next 12 months.

The informed American-particularly you who are our representatives in Congress-should have available all the basic facts about vision and optometric

In very brief fashion today I will attempt to inform you on such questions as—why is the need for vision care growing ?-what is the education of the optometrist?—what is optometry's unique service?

The need for vision care grows as modern civilization becomes more complex. Nature made man's eyes for distant seeing—for stalking game or for looking off to the horizon. Today, in an age of science and technology, most critical seeing tasks are within arm's length. Everyone must read and study more than was true for any previous generation Technical jobs require more accurate near-point vision.

About a hundred years ago, instruments for measuring vision were developed. Some opticians, who ground and sold lenses, began using these instruments, and soon they became known as "refracting opticians" or "examining opticians." In 1898 these specialists organized what has become the American Optometric Association, and the development of optometry as the vision-care profession had begun.

The background of optometry is comparable to the evolution of other health professions. There was a time when teeth were pulled by blacksmiths, because the blacksmith's tongs served this purpose better than anything else readily available. The barber-surgeon was once common, because only the barber had the sharp instruments best suited to bloodletting, boil-lancing, and similar "operations."

Just as the other health professions have evolved so, too, the optometrist of 1898 bears only an ancestral resemblance to the modern professional practitioner. Many sciences have contributed to a better understanding of vision and its improvement. Not only is the examination of vision and the prescription of glasses a highly developed science and art, but the optometrist has pioneered and added many innovations—visual training, contact lenses, special aids for the partially blind, and other types of specialized lenses—to solve problems for which there were formerly no solutions.

Modern optometry performs a unique and distinct vision service. It is based on the concept of functional vision in contrast to the traditional concept of the eye as a static optical instrument. This means that the optometrist's objective is to enable the patient to see clearly, comfortably, and efficiently for each specific task, regardless of demand or distance. He concerns himself with visual development in the growing child and the prevention, as well as correction, of vision problems.

Competence in optometry is gained by formal education as well as by example, precept, demonstration, and extensive clinical experience under competent teachers at institutions of higher learning and by continuous programs of postgraduate education.

With its education in physiological, psychological, mechanical, physical, and geometric optics, in addition to a broad foundation in other sciences such as physiology, anatomy, and pathology, optometry provides its practitioners with a complete and thoroughly rounded preparation for the vision care of mankind. This fundamental training with emphasis on psychophysiology of vision, underlies modern optometry's concept and practice of functional vision

care.

The treatment of pathological conditions and eye surgery is acknowledged by optometry to be in the field of medicine. However, for the protection of the public, about one-fourth of the optometrist's education is devoted to study of the body, eye diseases, and symptoms of other diseases revealed in the eyes.

Thus the optometrist is well trained in the detection of ocular signs of pathology so that he can refer patients for whatever other professional care they may require from other practitioners and specialists.

Because the optometrist performs 65 to 70 percent of the refracting work in this country, 75 percent of the work in contact lenses, and 80 percent of the work in orthoptics and visual training and thus first sees approximately threefourths of all patients seeking vision care, the optometric profession is our country's first line of defense against blindness.

Dr. Galen F. Kintner, in an article in the American Journal of Public Health, which I am appending to this statement, put it this way: "The visual system is a generous window to a number of the patient's health problems. While the optometrist's area of service includes refraction and coordination problems (with lenses, orthoptics, subnormal visual aids and the like), his field of investigation includes much more in determining the state of health of the patient and his visual system. Conditions requiring medical or surgical treatment of the eyes are referred to an ophthalmologist. In general, referrals can be divided into two groups: the desirable but elective, and the more formal or specific referrals. Even though the public is becoming more sophisticated in: its self-diagnosis, and hence its choice of health specialists, the fact is that a great number of people with vague symptoms first come to the optometrist.”

As consultant to the Surgeon General of the Army, I have intimate knowledge that in our armed services optometrists take care of the vision requirements of 85 percent of our fighting men. The following table illustrates the number and distribution of the optometrists and ophthalmologists in the Armed Forces. Ophthalmologists are the eye physicians and surgeons to whom optometrists refer most of their patients who are found to have pathological or other conditions requiring medical treatment. Optometrists in the M.S.C. :

Army: 184 (authorized ratio of 1 to 7,500 soldiers, but most training

centers have approximately 1 to 5,000). Navy:59 (no set ratio).

Air Force : 162 (no set ratio).
Ophthalmologists in the M.S.C.:

Army: 71 (16 board certified).
Navy: 67 (23 board certified).
Air Force: 45 (9 board certified, 30 eligible, and 2 with 1 year training

ophthalmology). Relative distribution of optometrists and medical eye specialists, who are in civilian practice across our country, is shown in a table I am appending to this statement for the record.

Optometry has become the profession that it is because it provides a complete vision care service. As noted, there is need in our modern complex civilization for functional vision care, principally for near-point seeing tasks. It is this need which optometry fills and which accounts for the development of optometry as an independent coordinate profession, separate from medicine.

Since its early beginnings, optometry has placed emphasis on meaningful seeing. No one has "perfect vision” for all purposes—a woman at her housework, a man operating a crane, a child reading a primer in school-each of these persons should have the best possible and most efficient vision for the task to be done and it is on this that the optometrist concentrates.

i The ratio figures do not include military dependents.

Optometry discovered many years ago that a person could read a Snellen letter chart at 20 feet and still have vision problems that make adequate achievement impossible. A person may be able to see perfectly well at 20 feet and lack good binocular (two-eyed) coordination at near, thereby finding reading difficult or impossible.

A person with good sight can see the chart at 20 feet and still have vision difficulties; so let me make clear now the difference between sight and vision. Sight is acuity-the ability to see forms; vision is the ability to give meaning to those forms.

Vision is a learned skill, not something solely dependent on the shape of the eye as tradition held for many generations. Skills that are learned can be taught. This is the basis of scientific visual training in which optometry has pioneered. Anatomical completion or growth leads only to minimum performance, Visual training results in the enhancement of visual performance skills.

Visual training (orthoptics) has long been recognized as an effective method of correcting some types of squint or strabismus (crossed eyes). The child who has difficulty in making the two eyes work together may turn one out of the way and use only the other. Visual training, or orthoptics, can in many instances restore the binocular skill. When the eye straightens, the child sees with both eyes.

Just as visual training may restore the skill in the crosseyed, it may also restore binocularity where the lack of it is not so obvious. There are many children, and adults as well, who suspend vision in one eye, without turning it out of the way. Intermittently, or continuously, they have only one-eyed vision. Just as visual training may restore the skill in the crosseyed, it may also restore binocular efficiency where the lack of it is not so obvious.

By the use of visual training, in combination with lenses or without lenses, optometrists solve not only these problems, but many others as well. Through visual training one can learn to see several words at once, instead of only a few letters or syllables, and to perceive more quickly, all of which is of great value in reading. It can teach accuracy and speed in seeing.

As the very able chairman of the subcommittee, Congressman Roberts, knows from his special wartime training in the field of “recognition” at Purdue University, visual training was found to be the only successful method of training airmen to quickly distinguish enemy from friendly aircraft during World War II. As practiced by optometrists today, visual training has many uses, particularly for those schoolchildren who for some reason have failed to develop necessary vision skills.

The concept of vision as a learned skill is probably best described by Dr. Arnold Gesell in “Vision-Its Development in Infant and Child," a copy of which I am leaving with the committee in case you should desire further information on this subject.

A proper vision examination takes into account all areas of visual performance. It must ask and answer such questions as: Can the patient focus and point his eyes together as a team? How accurate is his vision when he looks from one object to another? Can he sustain his visual performance comfortably and efficiently and over a protracted period of time when he is reading? What is his speed of visual perception? Does he have a full field of vision ? And so on.

Vision problems are not the same eye problems. Classically, eye problems are focus problems and are commonly known as farsightedness, nearsightedness, and astigmatism.

Low visual performance is a major contributor to reading problems. Helen G. Robinson in “Clinical Studies in Reading, Part II,” Educational Monograph No. 77, University of Chicago Press, says, "The only visual test that consistently differentiated high achievers from low achievers were tests involving measures of binocular ability.”

Dr. Lois B. Bing, then chairman of the American Optometric Association's Committee on Visual Problems of Children and Youth, in the committee's report to the 1960 White House Conference on Children and Youth, said, “Vision problems at the college level require far more concern than has been given them up to this time. As college populations have expanded, and as the number of students taking advanced work has increased, more and more students are finding they cannot adjust satisfactorily to the reading demands made upon them.

"A recent study at Bradley University in Peoria, Ill., reveals that nearly two-thirds of all of the freshmen (61.9 percent) had (corrected or uncorrected) vision problems on entering college, and more than a third of these (23.9 percent of all freshmen) had unsuspected vision problems *** The optometric profession has been increasingly concerned over the expanding need for visual care for the students of college level.”

These problems should be met before they reach the college level. Lois Bing says, “Optometry feels that adequate preventive eye care programs drafted by optometry for children of all ages should go a long way, if widely adopted and properly supported, to establish and maintain good visual habits among the elementary and secondary school children which will carry over with these children into the college level and thus avoid the vision difficulties now so common on our national campuses."

Ideally, a program of developmental vision should begin at birth. As Lois Bing says, “when the nascent reflex patterns of eyes, hand, touch, balance, hearing, taste, and smell are beginning to organize within themselves and in relation to each other. Actually, vision development has already gone through many stages before birth. Thus, shortly after birth, specific vision activities may be set up for the baby, and the child will welcome and respond to appropriate visual stimulation."

Henry W. Hofstetter, a member of the board of trustees of AOA and director of the Division of Optometry at Indiana University, makes a similar point in a chapter called “Optometry and Children's Vision,” contained in a book titled “Vision of Children," a copy of which I would like to give to this committee.

In Dr. Hofstetter's words, “That optometrists, as well as other professional groups are becoming vitally concerned with developmental aspects of childhood is apparent in many phases of activity. Current optometric educational programs frequently include such topics as visual readiness for reading, vision and reading, achievement, management of myopia, asthetic aspects of children's eyewear, visual screening in schools *** optometric device to the child's parents, vision of infants, visual aspects of classroom design * *

Optometrists believe in preventive vision care. Dr. Bing has described for us how an infant learns to see in Baby Post magazine: “There can be endless fascination in watching a child progress from one stage to another as he learns to see and get meaning out of the information that his eyes so avidly gather. At first he checks everything with his mouth, as if he didn't trust his eyes. What an achievement it is when he developes hand-eye coordination, when his eye can guide his hand or mouth.

"You can watch your child build his space world. As you would expect, he is the center of it. At first he has little awareness of anything beyond arm's length, Slowly he expands this little space world about him, literally learning what and where the objects are that his eyes see. This is a developmental process involving not only, his eyes, but his whole being.

"You will notice what the Gesell research has pointed out, that he develops the two sides of his body alternately. For a few days or weeks he will explore this expanding world with his right hand, right foot, and right eye. Then, in turn, will come a period of concentration on the left hand, left foot, and left eye. Soon the cycle is repeated and growth and development take place."

How well your baby sees may determine how well he will grow and develop. Vision may affect a child's posture. It will surely affect his personality.

When a child does not see properly with the two eyes together, he may tilt his head or continually squirm into an unnatural posture as he avoids using one eye while looking at his toy or his book. Then he grows that way with a head tilt, shoulder slump, or curved spine. There are thousands of examples. If he is too nearsighted, he may have no interest in games with other children, and later in sports. If he is too farsighted, he may avoid near activity and have trouble with his lessons when he gets to school. It is easy to see how frustrations like these can affect a child's personality.

Vision, then, is very important in your child's growth and development. It is your baby's most precious sense. He will gather more information of the world about him through his eyes than all the rest of his body. A child should progress to sustained two-eyed vision; unless he does, he should have care as soon as possible.

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Preventive vision care includes a thorough examination at the age of 3 to foresee future trouble. By that time it is possible to determine whether there is a tendency toward cross-eyedness, nearsightedness, or farsightedness, and whether the many visual skills that the child will need are beginning to develop as they should. Another benefit of that early examination is that it provides a record with which to compare later developments. With this accurate history, the optometrist can make a better evaluation of any symptoms that appear as the child grows older.

As he grows up, the child's vision may be "perfect"-according to the antiquated classical theory of 20/20 vision (visual acuity). Yet something is obviously wrong, and what possibly is wrong is that there is interference in visual perception. The child may not have learned skillful visual performance.

The optometrist must take into account the intricate and complex learned skills whereby the eyes do work together as a team-and perhaps he (the child) has developed distortions in various areas of performance. Visual training (orthoptics) can often restore his binocular skill and raise the level of his visual performance.

The Snellen chart and its emphasis on 20/20 sight will not bring out such problems. Lois Bing, whom I quoted earlier, makes this important point. She says, “In the field of vision screening in the schools, optometry has found that the multiprofessional approach, in which optometrists, ophthalmologists, school administrators, public health officials, teachers, and parents cooperate in the development of a program, provides the best hope of achieving a successful and effective and practical result. In practical operation, such an approach is being used with encouraging success in Euclid, Ohio, schools, where children are tested not only by Snellen chart for visual acuity at 20 feet, but by additional tests which reveal difficulties in using the eyes together with ease and efficiency for boardwork, deskwork, and reading.”

When his eyes work together as a team, the child will learn faster, and retain more information. "Vision,” Dr. Arnold Gesell has aptly put it, “is the key to the child's whole individuality * * * To understand the child, we must know the nature of his vision."

Because the child can see small letters clearly at 20 feet and there are no obvious errors in the optical systems of either eye, the diagnosis is often that the child has healthy eyes and there is nothing wrong with his vision. The mistake here lies in the confusion between an eye problem and a visual problem. There are many children with 20/20 sight who have vision problems: They do not have vision for reading. For comfortable, easy seeing, the images must merge into one in the brain. If this does not happen, he may reverse letters or entire words, may see only one letter or one syllable of a word at a time, instead of seeing the entire word at one time. He may lose his place easily and have to follow his finger. He may see the chalkboard clearly, but focuses at a reading distance with difficulty.

When he has such vision difficulties, he is likely to be classed as a reading problem, or he may be considered lazy or disinterested. Teachers may reprimand him, parents castigate him, schoolmates tease him. And the child comes to feel that he is unjustly punished, and in time is likely to develop severe behavioral problems.

Repeating what I said earlier: The ideal time to start working for efficient vision is when the child is very young. Optometrists use a battery of develop mental vision tests when working with a child only 16 weeks old. Modern optometry has a major role to play in aiding children in the development of adequate vision skills. Good vision skills developed early prevent such problems as I have just indicated. Such developmental investigation can chart the child's visual behavior and does, for example, uncover deviations from normal vision behavior—such as the child using only one eye, inadequate oculomotor patterns, poor form perception.

If the child does not evidence any visual difficulties, the time for the first important examination is at age 3 or just prior to his starting kindergarten. If any vision defect is uncovered at that point, the optometrist with the parents' cooperation can often lay out a training program to encourage normal, efficient vision development in the growing youngster.

As stated previously, modern optometry is based on the concept of functional vision, which takes into account not only the shape of the eyeball-the mechanistic-physical aspect of eye care-but the entire visual process, both physiological and psychological. It is important to know how well the child's

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