Dear Editor, I read with great interest the recent case report by Roy et al. entitled “Impact of Early Vision Therapy Intervention on an Infant with Retinopathy of Prematurity” (TNOA J Ophthalmic Sci Res 2025; 63:331–4).1 The authors are to be commended for their systematic documentation and multidisciplinary approach highlighting the potential benefits of early vision therapy in infants with regressed retinopathy of prematurity (ROP). Nevertheless, on careful appraisal, several methodological and interpretative points merit consideration to strengthen the report’s scientific value. FEASIBILITY OF THE COVER TEST IN A NON-FIXATING INFANT Table 1 reports cover test results despite the infant being described as having poor fixation and limited tracking. As reliable cover testing presupposes stable fixation, such readings may be difficult to interpret. In infants with poor visual attention or nystagmus, simpler objective assessments such as the Hirschberg or Krimsky tests are generally more dependable, as they offer better reproducibility and validity when fixation is inconsistent.2Table 1: Orthoptic assessment (before therapy)REFRACTIVE STATUS, OCULAR ALIGNMENT AND ACCOMMODATION The child demonstrated esotropia (R > L) with mild anisometropic astigmatism (OD plano/−0.75@180; OS plano/−1.50@180). However, the report does not specify whether full cycloplegic correction was prescribed prior to therapy. Considering the presence of gross atrophic changes and probable cortical involvement, accommodative ability may have been compromised. In such cases, providing full optical correction is crucial to optimise image clarity and binocular alignment, and to minimise accommodative effort that could exacerbate esodeviation. The lack of information on cycloplegic correction limits confidence in attributing improvements solely to therapy, as uncorrected refractive error can substantially influence fixation and ocular posture in premature infants.3,4 CHARACTERISATION OF NYSTAGMUS The description of “congenital jerk nystagmus (horizontal and upbeat)” would benefit from further objective substantiation. Quantitative nystagmography or pre-/post-therapy video analysis could better validate the reported reduction in nystagmus amplitude and frequency noted in Table 2.Table 2: Visual and developmental progress (post-vision therapy)DATA INTERPRETATION AND PRESENTATION While the progressive improvements in fixation and alignment are encouraging, distinguishing therapy-related gains from normal neurodevelopmental maturation remains challenging. Inclusion of validated visual assessment tools such as Teller acuity cards or the cortical visual impairment range could strengthen objectivity in future reports. Additionally, clarification of the notation “PDBO” (prism dioptres base out) is warranted, as this term typically denotes the direction of base placement rather than measured deviation. CONCLUSION AND FUTURE DIRECTIONS Despite these observations, this case contributes meaningfully to the understanding of early neuro-optometric rehabilitation in infants with ROP sequelae.5 Future case reports would benefit from addressing these methodological points to further strengthen the evidence base for vision therapy in infants affected by ROP. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Samir Sutar (Thu,) studied this question.