New opportunities in vision therapy

Article Outline

 

A critically acclaimed new book explains how patients, young and old, can benefit when primary eye care practitioners diagnose oculomotor problems and ensure patients receive proper treatment. The National Institutes of Health's (NIH) Convergence Insufficiency Symptoms Survey (CISS) form gives practitioners a quick, efficient way to spot such problems.

Two relatively recent publications are providing important new insight into the diagnosis and treatment of oculomotor problems, effectively offering new hope that patients with such conditions will receive the care they need. The Convergence Insufficiency Treatment Trial (CITT), reported last October in Archives of Ophthalmology, found that although the majority of eye care professionals treat children with convergence insufficiency (CI) using some form of home-based therapy, office-based treatment by a trained therapist along with at-home reinforcement is more effective. Funded by the National Eye Institute (NEI), part of the National Institutes of Health (NIH), the results of this study provide incontrovertible proof of the efficacy of vision therapy (VT) for CI. Moreover, the Convergence Insufficiency Symptoms Survey (CISS), used to compile data for the 12-week survey, effectively showed that binocular vision problems can interfere with visual function in school, work, and play. Most important, the survey found that these problems can be easily detected.

This past spring, another publication, Fixing My Gaze, by Susan R. Barry (New York, Basic) demonstrated, for both general and scientific audiences, the importance of VT for certain adults with strabismus. The author, dubbed “Stereo Sue” by researchers and reviewers for her advocacy of good stereoscopic vision, is a neuroscientist at Mount Holyoke College who explains in the book how vision problems can have a much greater impact on the quality of life than many who have those problems may have ever imagined. She also documents, through published research, the plasticity of the visual system. The ability of the visual system to change is, of course, the basis for vision therapy. Barry's interest in the subject is more than academic. She suffered the effects of esotropia despite 3 childhood surgeries, until presbyopia prompted her to visit her optometrist, and she was referred for a consultation with a vision therapy provider. As a result, Barry is uniquely able to provide meaningful insight on VT and strabismus from the perspectives of both a patient and a scientist. (For a review of the book, see the October edition of Optometry: Journal of the American Optometric Association.)

As a practicing optometrist, I have found that many people have oculomotor visual problems that interfere with one aspect or another of daily life. Often such patients may not even realize that their problems are visual, and, if they do, they may not be aware that their problems can be corrected. In all too many cases, even if they go to an eye doctor, their oculomotor problems will not be diagnosed or treated. Most eye care practitioners have been under the impression that there is no practical, reliable way to detect such problems in the course of a routine office visit. And should oculomotor problems be diagnosed, only 1 in 8 (13.2%) optometric practices is prepared to offer the vision therapy necessary, according to the 2008 American Optometric Association (AOA) Scope of Practice Survey. And many practices that do not offer vision therapy may not know of a nearby practice to which they can readily refer patients for the necessary care. This situation clearly suggests missed opportunities for both patients and optometrists.

Fortunately, the CITT has now shown a strong correlation between symptoms and binocular dysfunctions. That means detection can be accomplished through a questionnaire such as the CISS (see Figure 1) that queries patients on 15 issues that can indicate oculomotor problems (i.e., “Do your eyes feel uncomfortable when reading or doing close work?” “Do you have trouble remembering what you have read?”). Patients are asked to indicate whether they experience such problems “never,” “infrequently,” “sometimes,” “fairly often,” or “always.” Values of “0” through “4” are then assigned, based on the answers. The CITT determined a total score of 16 or higher to be a clinically significant indicator of convergence insufficiency. A practitioner could easily include such a survey as a routine part of pretesting or add it to the services provided as part of an extended evaluation. Administration of the survey could be delegated to a technician. AOA members can obtain a CISS survey form, on a sturdy laminated card appropriate for daily use in the practice, from the AOA Pediatrics & Binocular Vision Committee (AOA-PBVC).

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1 

  The Convergence Insufficiency Symptoms Survey (CISS) form.

However, such dysfunctions could also be detected through a few quick questions on a patient history form or by a few problem-focused questions posed verbally. A few examples are:


•Do you experience discomfort or fatigue while reading or doing close work?


•How long can you read or work easily?


•Do you lose your place when reading or copying?


•Is it hard to concentrate when reading?


•Is homework a struggle?



Should questioning reveal possible oculomotor disorders, the practitioner can then perform appropriate tests. (To assist, the AOA-PBVC has prepared a limited number of oculomotor test kits, which are available to AOA members while supplies last.)

Either way, once a problem is detected, it will generally take a practitioner just a few minutes to explain the condition to the patient. Practitioners may find it worthwhile to read Fixing My Gaze, just for some of Barry's insights on explaining the nature of oculomotor conditions—in particular on the advantages of explaining the benefits of 3-dimensional vision to those who have never personally experienced it. The book has been widely praised in reviews and features from Discover Magazine to National Public Radio to peer-reviewed scientific publications. More helpful suggestions on explaining oculomotor problems can be found in the AOA Vision Therapy White Paper, which can be accessed on the AOA Web site's Pediatrics & Binocular Vision page (www.aoa.org/x5411.xml). Practitioners may also find the book and white paper useful in countering documents that call into question some aspects of vision therapy, such as the American Academy of Pediatrics' newly revised policy statement on “Learning, Disabilities, Dyslexia and Vision” (www.pediatrics.org/cgi/content/full/124/12/837).

Optometrists who wish to refer patients to a vision therapy provider can use the AOA Web site's Doctor Locator feature, by logging onto the Web site at www.aoa.org, and selecting “Find an Optometrist” at the top of the Web site's homepage, or by visiting www.aoadrlocator.com. Once on the Doctor Locator search page (www.aoa.org/x5428.xml), enter the ZIP code, city, or state in which a vision therapy provider is being sought and select “Vision Therapy and Rehabilitation” from the drop-down menu for the “Practice Emphasis” window. About 418 AOA members are listed on the Web site as VT and rehabilitation providers. Additional VT providers may be found through the Aurora, Ohio-based College of Optometrists in Vision Development (COVD), a nonprofit, international membership association of eye care professionals, established in 1971 to provide board certification for practitioners who are prepared to offer state-of-the-art services in behavioral and developmental vision care, vision therapy, and visual rehabilitation. The COVD also offers a Doctor Locator feature on its Web site (www.covd.org). VT practitioners may also be identified through the Santa Ana, California–based Optometric Extension Program Foundation (www.oepf.org). As with most types of referrals, practitioners may wish to research the availability of VT providers in their area, have referral information ready for patients, and understand what patient information the VT practitioners may need. (The author's practice makes a faxable referral form available to area eye care practices, see Figure 2). For additional information, see the AOA Web site's Optometric Co-management of Vision Therapy page (www.aoa.org/x5414.xml).

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2 

  Vision therapy referral form.

Once an optometrist has incorporated detection of visual system problems into the practice protocols, it may become advantageous to bring a vision therapy practitioner into the practice. In addition to enhancing the quality of eye care provided in a practice, vision therapy can offer a new revenue stream. Tips on establishing and maintaining a vision therapy practice from 3 practitioners who provide VT exclusively are offered on the AOA Web site Vision Therapy Only page (www.aoa.org/x5736.xml).

However, even when practices do not provide vision therapy in-house, the diagnosis of visual system disorders can reap practice management benefits in terms of both improved patient satisfaction and an enhanced practice reputation. When optometrists successfully diagnose and manage patients' visual system problems, whether care is provided in the practice or an outside consultation is required, they build confidence in the optometric practice as an entry point for eye and vision care. Patients will be more inclined to readily refer friends and relatives who are encountering vision problems to the practice. As the practice's reputation grows, other health care professionals and institutions, such as schools, will begin referring more patients for consultations. In such cases, communication with schools and other professionals should make it clear that the primary care eye doctor has detected this condition and has the primary responsibility for this patient. The patient is helped and everyone benefits.

What happens when a patient is directed to an office for a suspected learning-related vision problem? Instead of disappointment and continuing frustration on the part of the family, detecting and managing the problem can create an enthusiastically satisfied patient, parent, and referral source.

There is a pool of potential patients and their families to be helped. The challenge is to detect and manage these problems efficiently. Although optometrists have become increasingly diligent in diagnosing critical eye and systemic health problems, it is also important that practitioners address the oculomotor problems for which many patients will seek care.