Leonard J. Press, O.D., FCOVD, FAAO
The need for vision therapy services continues to increase, while the number of doctors delivering vision therapy (VT) services has decreased. According to Optometric Clinical Practice Guidelines published by the American Optometric Association, the prevalence of visual efficiency problems ranges between 15 to 20 percent of the population. At least 20 percent of children with learning disabilities have problems in visual processing. If we add in the number of adults who benefit from VT, including patients who experience head injury or stroke, the numbers of potential VT patients are staggering.
It may be surprising to hear, but I don’t necessarily consider the decrease in the number of doctors who say they provide VT services to be a problem. After all, the provision of these services has become increasingly challenging. Comprehensive vision therapy services require a considerable amount of resources in doctor and staff time, as well as specialized training and continuing education. Basic procedures can be done with lenses and prisms, but specific equipment and activities beyond lenses and prisms are often required.
Our profession has grown to the point now where VT is a specialized service. It’s hard to dabble in it and provide successful results. Practices such as ours do not participate in third party plan coverage for therapy, but we are strong advocates for patients getting the reimbursement to which they’re entitled. How then do we meet the need for the increasing numbers of patients requiring vision therapy services?
We have adopted a “co-management model” in which we work closely with other optometrists in helping them to feel comfortable about identifying and referring patients in need of VT services.
Although most of us learned the normative clinical data against which to compare findings during our optometric education, and there are now many fine textbooks to brush up, a wonderful resource that you should access are the Clinical Practice Guidelines (CPGs) from the AOA. Go to www.aoa.org, and you will find the CPGs under the section on Clinical Care. The CPGs most pertinent to our discussion are:
- Pediatric Eye and Vision Examination
- Care of the Patient with Learning Related Vision Problems
- Care of the Patient with Strabismus: Esotropia and Exotropia
- Care of the Patient with Accommodative and Vergence Dysfunction
- What follows are a few clinical tips to supplement the information in the CPGs.
The best way to determine if a patient may be in need of VT is by taking a relevant case history. There are many possible questions that you can ask about visual performance, but the most pertinent are the following:
- Is school performance up to expected levels?
- Does extended use of the computer or reading cause eyestrain?
- Do you have difficulty keeping your place or concentrating when reading?
- Do you comprehend much better when listening as compared to reading the same material?
- Is there fluctuation in vision, where objects or print are sometimes clear, yet blurry at other times?
Clinical Findings: Visual Efficiency
Findings from your primary care optometric examination should address most of these issues. You can pick up obvious problems with convergence when a patient has trouble staying on the target as you move it inward. If the response is variable, repeat it once or twice. When doing a cover test, particularly at near, look at the patient’s ability to maintain fixation on the target. If you have an assistant doing preliminary testing with a stereopscope such as the Titmus or Keystone, note the stability of responses. Likewise, when doing vergence ranges, note how stable the patient’s hold on binocular vision is. Take the same approach when probing ocular motilities, and when testing accommodative skills. Sometimes it’s not as much the quantity as it is the quality of the responses. Eventually you’ll get a feel for “funny looking efficiency findings” as much as you’ve gotten a feel for “funny looking fundi”.
Clinical Findings: Visual Processing
It is unrealistic to expect most primary care practitioners to conduct tests of visual processing or perception. However, reversing letters or transposing the order of letters in words is suggestive of something beyond a visual efficiency problem. Common reversals such as “b” for “d” and “p” for “q”, should drop out by age 7. Transpositions such as “was” for “saw”, and trouble sequencing words in the proper order, are suggestive of visual dyslexia. Think of the brief history you’re taking about normal early development, or academic performance to expected levels, as a quality of life inventory for patients.
Observations during the examination can provide the intuitive need for referral. For a child who is above age 7, uncertainty about which eye it is when you ask her to cover her left eye while taking acuities may signal directional confusion. When you sense that a child has difficulty understanding simple instructions during the examination, inquire again about academic performance. Parents tend to gloss over academic performance when bringing their child for an examination because it doesn’t occur to them that vision beyond eyesight has anything to do with learning. Educating parents and patients about options is a critical role of the primary eyecare provider.
Consultation and Referral
We encourage colleagues to call if they have questions about signs, symptoms or findings. Optometric physicians in our area receive a folder from us that includes a referral/consultation form. The folder also includes patient education literature about a variety of conditions, in language easily understood by the patient. Topics included are:
- Questions and Answers About Strabismus
- It’s Never Too Late to Treat a Lazy Eye: Amblyopia
- Answers to Your Questions About Eye Coordination
- Bifocals for Children
- Vision in the Classroom
Once the decision has been made to refer a patient for a VT evaluation, the referring O.D. should expect our office staff to be highly knowledgable in assisting the patient. We are therefore well-prepared to answer any questions from patients on their initial telephone call to our office such as:
- Why the doctor referred me for further testing
- What will you be doing that is different from Dr. X?
- What are the doctor’s credentials?
- If I need vision therapy, what is involved?
- Does insurance cover vision therapy services?
We handle the intake of information in whichever manner the referring doctor is comfortable. Some doctors like to speak with us by phone, and others prefer a letter summarizing our findings and recommendations. Patients referred to our office by an O.D. have visibly different files with a red border, and are affectionately known as “RODs” (Referred by O.D.). This helps our staff identify patients who need updated reports, and who are due to return to the referring doctor’s office for primary care needs including eye health or prescriptive needs.
Referral Protocol – Ethics
When I first introduced myself to optometric colleagues in the area, three issues of concern surfaced about their prior experiences. O.D.s had experienced problems in getting timely reports about patients. They were also uncertain about endpoints of VT, and concerned about when patients would return to their care.
The College of Optometrists in Vision Development (www.covd.org) produces white papers and fact sheets, one of which is entitled: “Referral Protocol – Ethics”. The opening paragraph reads: “Your primary care optometrist or ophthalmologist has referred you or a member of your family to a COVD optometrist. Your doctor respects the expertise of the COVD optometrist and together they will provide the best care available for your particular visual needs”.
Our office distributes this information, in the form of a brochure, to all referring doctors and to their patients. We are fortunate to have a wonderful working relationship with many ODs in our area. I believe our sincerity shines through when we tell the patient how fortunate they are that their referring O.D. detected the need for further evaluation. Particularly at the conclusion of VT services in our office, we remind the patient how important it is for them to maintain their ongoing primary care appointments with their referring doctor.
Patient Centered Co-Management
The clinical model for intraprofessional referral in Optometry is thriving in many areas. Our local OMNI Eye Services sets the tone for collaboration, and their pediatric ophthalmologist is supportive of vision therapy. A recent publication from the AOA on Optometric Co-Management of Vision Therapy1 highlights the benefits to patients when the primary care optometrist and the consulting optometrist establish protocols and guidelines to assist in co-management. In select cases, the recommendations of other specialists such as a neurologist, pediatric ophthalmologist, occupational therapist, or learning specialist may be involved, based on communication between the primary care O.D. and the consulting O.D.
To facilitate communication with referring O.D.s, our practice produces a bimonthly newsletter, “Press Clippings”, that is mailed to colleagues in our area. It is a double-sided, one page sheet which features case presentations on VT (“The Press Box”) with permission from the referring O.D. and the patient. Reading about actual cases referred by a colleague helps the practitioner to identify with the variety of signs, symptoms, and findings that point toward vision therapy consultation.
Examples of patients we have recently co-managed with optometrists include:
- A teenager with esophoria who could not comfortably focus at near with her contact lenses.
- An adult with intermittent esotropia at distance who had difficulty with spatial judgements and fatigue while driving.
- A child who had difficulty with reading, and did not respond to “pencil push-up” exercises.
- A child whose amblyopia was not detected by vision screening, and who resisted patching by his primary care O.D.
- An adult with amblyopia who had previously been told that he was too old to benefit from vision therapy.
- A patient who was in a car accident and two years after rehab still experienced visual confusion in crowded places and was unable to drive.