The History of Vision Therapy: Orthoptics to VR

Parents often assume vision therapy is new, or that it appeared alongside computers and headsets. It is much older than that. The techniques we use in our Coconut Creek, Boynton Beach and West Palm Beach offices sit at the end of a century-long chain. Eye training began inside hospital ophthalmology, was widened by optometry, and has since been put through a generation of clinical trials that both supported it and set limits on it.

That history is worth knowing, because it explains why you can read one professional body saying vision therapy works and another saying it does not.

Key takeaways

• Modern vision therapy grew out of orthoptics, the eye-training discipline that took shape in ophthalmology clinics in the first half of the twentieth century (Helveston, 2005).
• Optometry expanded the scope, applying visual training well beyond binocular function to uncomfortable vision, reading and academic performance (Helveston, 2005). That expansion is where the professional disagreement begins.
• Frederick Brock applied stereopsis to the diagnosis and treatment of binocular dysfunction (Wittenberg, 1981). The string that carries his name is still in use in our therapy rooms.
• The turning point for our field came in 2008, with the Convergence Insufficiency Treatment Trial (CITT Study Group, 2008); its 2019 follow-up delivered results in both directions (CITT-ART, 2019).
• Digital and virtual reality tools are promising, not proven replacements for established treatment (Pineles et al., 2020).

The nineteenth century made the eye examinable

Before anyone could train binocular vision, they had to be able to see inside the eye and measure how it worked. Helmholtz introduced the ophthalmoscope in 1851, which for the first time let a clinician observe light reflected back from the retina (Berendschot et al., 2003). Instruments for measuring eye alignment, fusion and depth perception followed.

Helmholtz’s ophthalmoscope, 1851

Some form of visual training has been used for centuries, but the organized, professional version of it is much younger: it took shape in the first half of the twentieth century (Helveston, 2005).

Orthoptics: eye training becomes a profession

The first organized discipline was orthoptics. In the first half of the twentieth century, orthoptists introduced a wide range of training techniques aimed mainly at improving binocular function (Helveston, 2005). Mary Maddox, daughter of the ophthalmologist Ernest Maddox, is generally credited with establishing orthoptics as a distinct healthcare discipline, and founded the first orthoptic clinic at the Royal Westminster Ophthalmic Hospital in London in 1928 (British and Irish Orthoptic Society).

Orthoptics was hospital-based, worked under ophthalmologists, and concentrated on strabismus and fusion. Much of what a therapy room still contains — instruments that show each eye a different image, targets that force the two eyes to work as a pair — descends directly from that era.

One correction is worth making here, because it appears in a lot of online summaries. You will sometimes read that vision therapy began with William H. Bates. We do not tell the story that way, and none of the histories we cite here support it: the procedures in a modern optometric program come from clinical orthoptics and from the optometry of the second half of the twentieth century (Helveston, 2005).

Optometry widens the scope

The other half of the story starts in the same year as Mary Maddox’s clinic. The Optometric Extension Program Foundation says it was founded in 1928 by A.M. Skeffington — whom it calls the father of behavioral optometry — and E.B. Alexander (OEPF).

A.M. Skeffington

Over the following decades, optometrists and other practitioners took visual training well beyond binocular dysfunction and applied it to a much wider range of conditions (Helveston, 2005). By 2002, a review could describe optometric vision therapy as an established treatment for non-strabismic accommodative and vergence disorders “for nearly 75 years,” argued largely from objective recordings of eye movement and focusing (Ciuffreda, 2002). That review was written by a proponent of the field, and it is fair to read it as an argument rather than a neutral audit.

This is the fork in the road. Ophthalmology largely stayed with the narrow orthoptic use; optometry built a broader discipline. The disagreement you can still read today dates from this period, not from anything recent. If you want the plain-English version of what a program actually involves, start with what vision therapy is.

Brock, and his string

Frederick Brock is one of the few individual clinicians whose name survives in everyday practice. His contribution was to apply stereopsis — depth perception built from two slightly different images — to the diagnosis and treatment of binocular dysfunction (Wittenberg, 1981).

A Brock string

The Brock string is deliberately low-tech. A cord, a few beads, and immediate feedback: when both eyes point at the same bead, the patient sees two strings crossing at it. It is also still being tested. A 2025 randomized trial in 50 patients aged 11 to 30 found that home Brock string exercises after concussion improved near point of convergence by 8.9 cm compared with 3.8 cm under usual care (Trbovich et al., 2025). That trial was small, single-blind, short, and measured the clinical sign rather than symptoms or return to school — but it is a real controlled test of one of the simplest tools in the room. More on the man and the method in who is Brock and why does he string.

The trial era, 2008 onward

The modern chapter of this history is not a device. It is a set of randomized controlled trials.

The Convergence Insufficiency Treatment Trial changed the conversation in 2008. In 221 children aged 9 to 17 with symptomatic convergence insufficiency, 73% were successful or improved after 12 weeks of office-based vergence and accommodative therapy, against 35% with office-based placebo therapy, 43% with pencil push-ups and 33% with home computer therapy (CITT Study Group, 2008). A Cochrane network meta-analysis of 12 trials and 1,289 participants later confirmed the advantage over placebo in children (Scheiman et al., 2020).

Vectogram work, a standard office-based eye-teaming activity

The follow-up trial is the part that honest histories have to include. CITT-ART, reported in 2019, found that clinical signs improved more with therapy than with placebo — near point of convergence 10.4 versus 6.2 cm, fusional vergence 23.2 versus 8.8 prism diopters — but symptom scores improved about the same in both groups (CITT-ART, 2019). A companion paper found reading comprehension improved 3.7 points with therapy and 3.8 points with placebo, meaning the therapy was no better than placebo for reading (CITT-ART, 2019).

Amblyopia followed a parallel path through the Pediatric Eye Disease Investigator Group, and that work still shapes the amblyopia and strabismus care we plan today. Its 2002 trial in 419 children showed patching and atropine performing similarly, at 3.16 versus 2.84 lines of improvement, and established both as appropriate first-line treatments (PEDIG, 2002). We summarize the whole picture in does vision therapy work: an honest evidence summary and go trial by trial in what the CITT and CITT-ART trials actually found.

The critics, and what they got right

Two positions have run alongside each other for decades, and both belong in this history.

Pediatrics and ophthalmology hold that dyslexia is a language-based disorder, that vision problems can interfere with learning but do not cause it, and that eye exercises, behavioral vision therapy and tinted lenses are not supported for treating learning disabilities (AAP/AAO/AAPOS/AACO, 2009), a position reaffirmed in 2014. Writing in 2005, Helveston concluded that apart from near point of convergence exercises, visual training lacked documented evidence of effectiveness for ophthalmologists (Helveston, 2005).

Optometry’s position, stated jointly in 1997, is that vision problems can and often do interfere with learning, and that optometric care aims to improve visual function as one part of a multidisciplinary approach (AAO/AOA, 1997).

A 2009 review took the middle route and is, in our view, the fairest summary of where things stood. It found reasonable evidence for treating convergence insufficiency, for yoked prisms in neurological patients and for vision rehabilitation after brain injury. Most other behavioral approaches were not evidence-based, largely because the controlled trials had not been done (Barrett, 2009).

Our clinical perspective at Vision & Learning Center is that the critics were right about the claims that outran the data, and that the correct response was the one the field took after 2008: run the trials. Vision therapy is not a treatment for dyslexia or ADHD. In our hands it is aimed at measurable problems with eye teaming and focusing — the two areas where the controlled evidence is strongest (CITT Study Group, 2008; Scheiman et al., 2020) — some of which make reading uncomfortable.

Screens, games and headsets

The newest chapter is digital, and its results are genuinely mixed.

A large trial in children aged 5 to 12 found a binocular iPad game less effective than part-time patching, with only 22% of the game group completing more than three-quarters of the prescribed play (Holmes et al., 2016). A companion trial in 13- to 16-year-olds found the game no better than patching, and possibly worse, with adherence of 13% (Manh et al., 2018). The BRAVO trial found an active binocular game no better than a placebo game (Gao et al., 2018). Reviewing 20 studies, the American Academy of Ophthalmology concluded there was no level I evidence for binocular treatment as a substitute for patching or glasses (Pineles et al., 2020).

Virtual reality dichoptic training

Then the picture improved. A 2022 pivotal trial of a dichoptic digital therapeutic in 105 children aged 4 to 7 showed 1.8 lines of improvement versus 0.8 lines with glasses alone — although the comparator was glasses, not patching (Xiao et al., 2022). In adults, a small uncontrolled study of VR dichoptic training with a headset reported improvements in acuity and stereoacuity after eight sessions, and the authors called for controlled trials (Ziak et al., 2017).

That is the honest state of the art: a promising delivery system, not a replacement for established treatment. We use these tools inside a program, alongside lenses, prisms and hands-on procedures. More on how we use them in the virtual reality revolution in vision therapy.

What a century of history suggests

The pattern is consistent. Techniques were invented in clinic, spread faster than the evidence, and were then narrowed and confirmed by trials. The parts that survived testing — office-based therapy for symptomatic convergence insufficiency, established amblyopia treatment, targeted work after brain injury — are the parts we lean on hardest, and we try to be as clear about the limits as about the results.

If reading, focus or eye strain is a problem for someone in your family, the useful next step is measurement, not history. A full evaluation is what tells us whether vision therapy is the right tool, and which parts of it. Schedule an evaluation or read what a comprehensive and developmental eye examination involves, and we will tell you what we find.