Vision Therapy Needs: Is Optometry Adequately Addressing This Niche?

Patients rarely consider, or make inquiries into, vision therapy during a comprehensive eye exam. Optometrists may not expect patients to fully understand the benefits this treatment offers compared with the ease of wearing glasses or contact lenses, but even many clinicians overlook vision therapy’s potential. Often, patients and optometrists are content with simply achieving a visual acuity of 20/20 on the Snellen chart. But optometrists should understand that their patients’ visual acuity is just the tip of the iceberg when it comes to assessing visual function and performance. Knowing what a patient can see is an important piece of the puzzle, but it does not give clinicians data on how they are seeing, their vision quality, or how they are processing that information.

As a result, many patients with mild to moderate binocular, accommodative, oculomotor, and perceptual dysfunction may be missed in the primary care optometric setting. Optometrists will likely detect a constant strabismus, but may fail to observe small vertical heterophorias, convergence insufficiencies, accommodative dysfunctions, intermittent strabismus, and visual sequelae resulting from a concussion or mild traumatic brain injury.¹ 

Recognize The Unmet Need

Research shows that 32.3% of university students show some general binocular dysfunction — almost 11% have an accommodative issue alone and between 6% and 7% of students have a convergence insufficiency with an associate accommodative issue.² As smartphones, tablets, and computers become increasingly popular, the prevalence of digital eye strain has increased, soaring to 50% in digital device users.³ While studies show a link between digital eye strain and glare, dry eye, and posture, the condition may also be exacerbated by binocular or accommodative stress — both conditions that may be treated with vision therapy.⁴ Clinicians practicing in primary care will easily see 100 patients per week. According to the above-referenced studies, at least half of these individuals may experience eye strain, and between 5 and 10 are likely have a binocular vision issues. So how are optometrists handling these patients?

Formal research may not confirm exactly how many patients’ vision therapy needs are being overlooked, but my personal interactions with patients reveal hundreds (if not thousands) of incidents where binocular vision and accommodative issues are missed. These individuals bounce from doctor to doctor with the same complaint of intermittent double vision, an inability to read for longer than a few minutes without experiencing eye strain, or a failure to maintain place while reading. Clinicians frequently fail to provide solutions or may dismiss these concerns due to good presenting visual acuity.

While optometrists should be in tune with the needs of these individuals, my personal experience has shown that neurologists and concussion specialists are most likely to refer these patients for vision therapy, not necessarily primary eye care physicians.    

Make The Time 

Optometrists may decide against referring to vision therapy for a variety of reasons. Busy optometry offices may not provide time for full visual testing. Clinicians may have only limited exposure to visual function testing and may lack the confidence needed to perform it. Other clinicians may feel as though they are losing their patient to another optometrist (spoiler alert: vision therapy doctors will always send referrals back to their original doctor) or believe that offering lens options, such as added plus power or prism, will alleviate symptoms without the need for additional vision therapy. Optometrists have a duty to do their best to provide clear, comfortable vision and ensure ocular health in their patients, but they must also provide patients with the tools needed to achieve top visual function and performance. 

So how can clinicians ensure that patients with vision therapy needs receive the treatments they require? Optometrists must start by taking time to listen to their patients, perform extra diagnostic testing, and treat or refer for treatment. While adding a couple of extra steps may seem stressful, especially in an age of busy schedules and overbooking, these extra minutes may significantly improve patients’ quality of life and boost a clinician’s credibility. 

Obtain a Thorough Case History

Even before initiating pretesting, clinicians can begin the process of identifying vision therapy needs by taking the time to obtain a good case history.⁵ Optometrists are the gatekeepers of their patients’ visual systems — if they do not ask questions, patients are unlikely to say that anything is bothering them. In addition to asking standard intake questions — which should address flashes of light, floaters, itchiness, and dryness symptoms — clinicians must ask their patients if they experience intermittent double vision at distance or near or blurred vision while reading. Positive responses should elicit probing questions regarding onset and frequency. Adding the Convergence Insufficiency Symptom Survey may prove to be a good practice, as the instrument demonstrates validity and reliability in identifying convergence insufficiency.⁶ 

Eye strain, headaches, and intermittent blurred vision, are the most common symptoms of underlying binocular, accommodative and oculomotor issues. These may not be life- or vision-threatening concerns, but they have the potential to affect a patient’s quality of life, academic performance, and professional career.

Intake questions should also assess how many hours patients spend per day using digital devices and how they feel after using them. Understanding symptomatology following digital device use can be a great springboard for a discussion on reasons to perform additional testing.  

If a technician is performing the intake, they must be trained to ask the appropriate questions and highlight responses that elicit a follow-up response from the optometrist.   

Use Dependable Clinical Testing

Patient responses that indicate potential vision therapy needs may warrant additional clinical tests. Assessments should include a cover test at distance and near, and examinations of near point of convergence (NPC), saccades and pursuits, positive and negative relative accommodation (PRA and NRA, respectively), accommodative amplitudes, and positive and negative fusional ranges at both distance and near.⁵ These tests consume minimal chair time and yield an incredible amount of information.⁵ Patients can always return to complete these additional tests if time does not allow their completion within the allotted appointment slot. 

At a minimum, optometrists should perform a cover test and NPC (I recommend repeating this 2 to 3 times to catch any regression with fatigue) as part of their regular entrance testing. These high-yield tests have the potential to identify binocular and accommodative dysfunctions that may be treated with vision therapy. 

Decide to Treat or Refer 

Once a clinician has identified a vision therapy need, they must either create a treatment plan, which may include glasses and vision therapy, or refer the patient to a clinician who specializes in vision therapy. Initiating treatment does not involve fancy or expensive equipment and can be performed with limited tools. Starting with a basic vision therapy case, such as convergence insufficiency, is a great place to build confidence and see how much vision therapy can affect patients. Clinicians who offer this treatment can witness the benefits their patients experience firsthand and appreciate the need optometry has for this service.  

Optometrists who feel unprepared to personally treat their patients’ vision therapy needs, however, should not be discouraged. A good doctor is not necessarily a jack of all trades, but a master of 1 (or maybe 2 or 3). Just about every medical specialty has clinicians who excel at subspecialties within it, and optometry is no different. A clinician with proven expertise in treating dry eye and anterior segment disorders may not necessarily provide the same expert level of care for vision therapy. If a clinician does not feel that vision therapy is their niche, referral to a vision therapy specialist may be the best option. Patients who receive these referrals will appreciate a clinician’s honesty and effort to help them find an appropriate solution. Optometrists can find a vision therapy specialist with the doctor locator function at the College of Optometrists in Vision Development website.  

Vision Therapy Works 

While some clinicians may argue that many mild accommodative and binocular issues can be managed with lenses and prisms, this strategy acts as a bandage and does not get to the root of the underlying issue. A small amount of base-in prism will certainly help, say, a teenager with convergence insufficiency, but what will happen when they go to college and experience a workload increase leading to a decline in fusional ranges and accommodative ability? Those symptoms of headaches, intermittent double vision, and difficulty maintaining visual attention at near come back, and often with a vengeance. When it comes to convergence insufficiency, research has shown the benefits of in-office vision therapy.⁷ 

Vision is a learned process that develops from before birth and continues throughout life.⁸ Since 80% of learning is visual, addressing accommodative and binocular dysfunction will not only help to improve visual functioning, but may help patients learn and carry on their daily functioning with greater ease.⁹ By incorporating basic, high-yield testing into optometric examinations, clinicians can identify patients with vision therapy needs and improve their quality of life through referral or treatment.