How to Incorporate
Vision Into Your Practice
DAVID G. KIRSCHEN, O.D., Ph.D., Brea, Calif., AND DANIEL M. LABY, M.D., Boston
Part 2 of our two-part series explains how
to add this specialty to your practice, as well as how to correct and enhance
we reviewed in Part I, the vision capabilities of athletes far exceeded those of
the general population. Therefore, phrases like "that's close enough," or your vision
is "pretty good," are not applicable to the sports vision world. The key word in
all sports vision correction is optimization.
1: Don't just help the
players see well; optimize their visual system.
The basis for all vision tasks is acuity. Therefore, for any part
of the visual system to work optimally, the patient's refraction must be exact (not
close, but exact). Your refracting technique should continue until each athlete's
vision is optimally corrected. Small corrections for astigmatism (both power and
axis) are critically important to athletes. Corrections like +0.25D, -0.50D x 117
are not uncommon and when you demonstrate the Rx to the athlete in a trial frame,
it can noticeably improve their vision.
Binocular balance is another critical aspect of the refraction.
The goal of refraction is not to optimize the visual acuity in each eye separately;
rather it is to equalize the accommodative effort in each eye so the two eyes work
better together. We will deal with optimizing binocularity in the next section,
but as a precursor, the patient must be wearing a balanced prescription. There are
many good techniques to binocularly balance a prescription (i.e., Turville or R/G
dissociation). Use the one that works best for you, but do use one.
alluded earlier to demonstrating the new prescription to the patient in a trial
frame. This is also an important step for optical and psychological reasons. Optically,
it gives you another opportunity to refine the spherical component of the refraction
when the patient is looking in free-space rather than behind the phoropter. Binocularly
adding +/-0.25D with flipper lenses gives the patient another chance to refine the
distance prescription. Psychologically, this is important for the patient. Many
athletes think their eyes are "perfect." By demonstrating that a correction (notice
we didn't say glasses) can improve their vision, they will be more willing to accept
your recommendation that a correction is necessary for optimal sports performance.
The patient's specific needs and your diagnosis will determine whether contact lens
or spectacle correction is best.
2: There are many parts
of the visual system that can be improved, pay attention to them all!
Distance stereopsis is the second major component related to sports
performance; this visual function must be optimized as well. The Smart System Pro-Sports
Screening system measures both contour and random dot stereo thresholds. Sub-optimal
performance usually occurs due to a lack of familiarity with the distance stereo
tests or central suppression. Prescribe vision training for any athlete who does
not perform well on distance stereo measures.
Most of the training techniques to enhance stereopsis and reduce
central suppression are done at near. Most stereo training done at near transfers
to distance viewing, but vectograms mounted on an overhead projector provide a good
distance target to train stereopsis. You can use classic vision therapy equipment,
as well as computerized vision training programs. Re-test to monitor progress. If
an optical correction is necessary, be sure that the patient wears the correction
during all exercise sessions.
Enhancement of contrast is still an area of intense study. There
have been numerous anecdotal reports that wearing yellow filters may improve contrast
for baseball players (e.g., Mark McGuire) and target shooters. The reports continue
even today with the introduction of Bausch & Lomb's new Maxsight contact lenses,
advertised to enhance contrast.
We are awaiting scientific published data to substantiate this
claim. We have measured the change in contrast with yellow filters for white targets
on a blue background and found a significant increase in contrast sensitivity for
about 33% of players tested. On the other hand, about 33% of players had a decrease
in their contrast sensitivity with the yellow filter, so use care when prescribing
a filter to enhance contrast.
3: Contrast sensitivity
can be enhanced with colored filters or contact lenses.
There is currently a study underway to determine whether on-field
performance changes with the filters. If you wish to understand the importance of
filters on contrast sensitivity for a particular athlete, test the player's contrast
sensitivity with and without the filters to see if there is a demonstrable difference.
On-field testing is also appropriate before prescribing.
There are other, more general exercises that involve hand-eye
coordination or visual reaction time that could enhance a player's visual performance
and help the on-field performance. However, these techniques have been difficult
One technique that has worked well for our players is the use
of a hoop and specially-designed balls. Ask a player to grab a specific ball as
it rotates toward him on the circular hoop. For the laymen this is a very difficult
task. For the average baseball player, this is a doable challenge; for the elite
hitter, the task is quickly mastered.
Although specific studies on the relationship between hand and
eye coordination are still ongoing, this technique appears to hold some promise
for the future.
your new specialty
4: It's not only about
the eyes, the eye-brain interaction is also critical.
Marketing the sports vision component of your practice does not
require an MBA in marketing, expensive consultants or a large budget. We find that
internal marketing is the most effective and efficient way to promote your sports
vision practice. Your patient history questionnaire should include questions about
sports the patient might participate in. Your case history should have direct questions
about patients' involvement in sports. Such questions and, more importantly, their
answers, provide you with an opportunity to have a sports vision discussion with
your patients. They will be amazed to learn that vision plays such a vital role
in sports. There are lots of topics to discuss such as sports vision needs, optical
options, vision training and eye protection.
The theme of sports vision can be carried throughout the office
with sports-oriented magazines in the reception area, posters on the walls and a
separate sports vision optical section of your dispensary. All of these components
make it easy to have a sports vision discussion with your patient.
Consider external marketing through lectures to service clubs,
PTAs, health clubs and parents of traveling sports teams in your city. These kinds
of groups are always looking for quality speakers, especially for free. We have
had good success in presenting to coaches at the local high school and community
or state college. This information is useful to them and keeps your name in the
forefront when they have a sports-related eye question.
to do a screening to develop your sports vision reputation. If you are new to public
speaking, all of the information you need to develop your presentation is available
from published research on sports vision on the Internet and the AOA Sports Vision
THE WIN: New techniques
can improve vision and hopefully on-field performance.
Our goal in this series was to give you a glimpse into the world
of sports vision. This has always been a challenging field within optometry because
there were only anecdotal reports and very little standardization in the field.
With the advent of new technologies and the experience we have gained over the last
15 years working with professional athletes, it is now possible to measure an athlete's
visual capabilities and compare them to a very large database. The results of this
analysis can be used directly to council the athlete on whether further testing
is necessary to more precisely define the vision problem. They can also suggest
what techniques may be available to enhance vision and hopefully improve on-field
received his O.D. and Ph.D. degrees from the University of California at Berkeley.
He is currently the Chief of Binocular Vision and Orthoptic Services at the Jules
Stein Eye Institute at the David Geffen School of Medicine, UCLA. He also serves
as Full Professor of Basic and Visual Science and Optometry at SCCO.
Dr. Laby received his medical degree
from the George Washington University School of Medicine. He serves as Assistant
Clinical Professor of Ophthalmology at Harvard Medical School and has served as
staff ophthalmologist for several professional sports teams including the LA Dodgers,
Boston Red Sox, NY Mets and LA Kings, among others. He is the co-author of Dictionary
Optometric Management, Issue: June 2006