Article

HOW TO IDENTIFY VISION THERAPY PATIENTS

Use checklists as the first step in establishing and treating with vision therapy

Early in our professional training, we learn the eye is like a camera; later, we learn our “camera-eye” is full of aberrations (spherical, chromatic, coma, etc.), and our brain, when working properly, can filter the distortions and allows us to make sense of our world. Yet, while VA 20/20 is the gold standard of ocular and visual health, many of the patients I see still have visually related complaints. As such, it’s crucial to identify the areas of concern for these patients, which is achieved at my practice via tailored checklists.

Beyond the VA of each eye, the two eyes must aim and focus together to allow for a clear and single image; the eyes must be able to follow a moving target, track along a page of symbols and guide the hands and the body. Industry-tested and experience-driven checklists help you identify these patients, who may need help in processing visual information, and subsequently guide your clinical treatment plan.

This octogenarian was referred to Dr. Sapossnek by his ophthalmologist due to his double vision as a result of an auto accident he had 20 years prior. Dr. Sapossnek partially corrected his diplopia with prism and gave him some basic eye movement exercises to do. His double vision resolved with these basic steps in place after only a few weeks, she says.
Photo courtesy of Dr. Robin Sapossnek

ASK THE RIGHT QUESTIONS

Also featured in August:

If you think you’re not seeing patients who could use functional care, you’re probably not asking the right questions. What are the right questions? The COVD has developed a “Quality of Life Questionnaire,” which is often used as a baseline by practices that provide vision therapy (VT) care and repeat it as care progresses. This allows the doctor to assess change during and after VT. (View the checklist at bit.ly/COVDcheck .) Also useful is the Convergence Insufficiency Symptom Survey. (View the survey at bit.ly/ConISSurvey .)

In my specialty practice, I developed the following questionnaires over the years as a result of the needs of myself and my colleagues. The patient, or the patient’s parent, fills out one of three screening checklists, Adult Visual Efficiency Checklist, Child Visual Efficiency Checklist and Neuro-related Visual Efficiency Checklist, depending on history. Filling out the questionnaire causes patients to think about their visual symptoms prior to the examination and then provides a therapeutic roadmap for the doctor.

Adult Visual Efficiency Checklist. We ask an adult patient to grade the following questions on a scale of 1 (never) to 5 (always).

  • Do you get tired or fall asleep while reading or using the computer?
  • Does your vision seem worse at the end of the day?
  • Do you often close one eye when reading?
  • Do you experience double vision?
  • Does prolonged reading or close work give you headaches or eyestrain?
  • Is reading in a moving vehicle difficult?
  • When reading, do you skip or repeat lines?
  • When you look up from reading, do objects appear blurred?
  • Do you lose your place when moving from copy to a screen?

Each of the indicators in the questionnaire is designed to tease out a functional vision problem. For example: An adult may indicate on his questionnaire that he tends to close one eye when reading, and not realize he does so to avoid double vision, which he therefore doesn’t report. By having his information, the doctor will be alerted to: 1. Rule out an organic etiology and 2. Initiate testing, including an in-depth binocular evaluation, cover testing at all distances, phorias and fusion ranges, Maddox rod testing, Worth Four Dot testing and, in the case of monocular diplopia, a detailed ocular lens assessment, use retinal OCT and/or topography.

Child Visual Efficiency Checklist. A pediatric questionnaire would ask the parent whether these signs are apparent in their child.

Does your child:

  • Complain of headaches, sore eyes?
  • Experience a comprehension reduction as reading continues?
  • Experience better comprehension when he is read to?
  • Hold reading material too closely or hold his/her face close to the desk surface?
  • Lose his/her place during reading?
  • Use a finger to keep his/her place while reading?
  • Omit or insert small words when reading?
  • Reverse letters or words in writing and copying?
  • Write crookedly, poorly spaced or outside ruled lines?
  • Fail to complete smart board work on time?

A positive response to the questionnaire has a logically diagnostic or treatment follow-up step, guiding the initial visit. For example: A parent may indicate that her child has better comprehension when her child is read to, and that her child loses his place while reading and experiences headaches after reading. This information will then guide the doctor to test for accommodative, binocular or tracking inefficiencies. When comprehensive vision testing does not reveal any abnormalities, the child should be probed further in the realm of ocular motor development testing. (A referral to a doctor who specializes in vision function is in order if such testing is not available at your office.)

Neuro-related Visual Efficiency Checklist. A neuro-related questionnaire should include at least some of these questions:

  • Is normal indoor or outdoor lighting uncomfortable?
  • Are you clumsy or do you misjudge where items really are?
  • Do you drift to the right or left when walking?
  • Do you experience dizziness or balance problems?
  • Do you get visually annoyed or distracted in a very busy visual environment (like the mall)?
  • Do you have poor reading comprehension?
  • Do you skip lines or lose your place when reading?
  • Do you have side vision loss?
  • Do you have double vision when viewing at a distance or at near?
  • Do you experience headaches over the course of the day?

A patient who has neurological problems may indicate that he is bothered by fluorescent lighting. This information will then guide the doctor to explore specific blue-blocking lenses that best fit the patient’s lifestyle.

(I added a neurologically related vision questionnaire to treat referred patients who have issues, such as head trauma, stroke, multiple sclerosis and Parkinson’s disease.)

It’s worth noting the excellent resources for learning more about treating your patients via vision therapy on the COVD website and American Academy of Optometry’s pediatrics/binocular vision section.

TREAT THE WHOLE PERSON

Patients are not merely optical systems working independently of their neurology, and the eye is not independent of the whole body. Behavior and visual skills are contingent on a person’s development, physical and emotional health, day-to-day stresses, fatigue level and activities of daily living. Optometric education involves the fields of optics, medicine and behavior, and our ability to use lenses, prisms and filters and enhance patients’ abilities through VT makes us uniquely qualified to enrich the lives of those who seek our counsel. It is a privilege to help people on a deep and often profound level as is often the case in practicing a functionally based model of optometry. OM

Vision Therapy Checklists

ADULT VISUAL EFFICIENCY

ON A SCALE OF 1 (NEVER) TO 5 (ALWAYS) GRADE THE FREQUENCY OF THE FOLLOWING:

  • Do you get tired or fall asleep while reading or using the computer?
  • Does your vision seem worse at the end of the day?
  • Do you often close one eye when reading?
  • Do you experience double vision?
  • Does prolonged reading or close work give you headaches or eyestrain?
  • Is reading in a moving vehicle difficult?
  • When reading, do you skip or repeat lines?
  • When you look up from reading, do objects appear blurred?
  • Do you lose your place when moving from copy to a screen?

CHILD VISUAL EFFICIENCY

DOES YOUR CHILD:

  • Complain of headaches, sore eyes?
  • Experience a comprehension reduction as reading continues?
  • Experience better comprehension when he is read to?
  • Hold reading material too closely or hold his/her face close to the desk surface?
  • Lose his/her place during reading?
  • Use a finger to keep his/her place while reading?
  • Omit or insert small words when reading?
  • Reverse letters or words in writing and copying?
  • Write crookedly, poorly spaced or outside ruled lines?
  • Fail to complete board work on time?

NEURO-RELATED VISUAL EFFICIENCY

  • Is normal indoor or outdoor lighting uncomfortable?
  • Are you clumsy or do you misjudge where items really are?
  • Do you drift to the right or left when walking?
  • Do you experience dizziness or balance problems?
  • Do you get visually annoyed or distracted in a very busy visual environment (like the mall)?
  • Do you have poor reading comprehension?
  • Do you skip lines or lose your place when reading?
  • Do you have side vision loss?
  • Do you have double vision when viewing at a distance or at near?
  • Do you experience headaches over the course of the day?