The need for vision therapy (VT) services is widespread. The prevalence of visual efficiency problems ranges from 15 to 20% of the population.1 At least 20% of children with learning disabilities have problems with visual processing. If we add the number of adults who benefit from VT, including patients who experienced head injury or stroke, the number of potential VT patients is staggering.

Though the need for VT services continues to increase, the number of doctors who offer VT has decreased. The provision of these services has become increasingly challenging. Our profession has grown to the point at which VT is a specialized service. Its hard to dabble in it and provide successful results. How then do we meet the need for the increasing numbers of patients who require VT services?

Here, Ill explain how you can identify when a patient needs a VT evaluation, how to refer a patient to an appropriate VT specialist for patient-centered comanagement, and how you can be sure to retain that patient in the process.

A child does a pegboard rotator activity, aiming to insert a peg accurately into a specific spot. When used with red/green fliters, the colors aid binocular vision.

Identify Patients
During our optometric education, most of us learned the normative clinical data against which to compare findings, and many textbooks for brushing up that knowledge now exist. But for a really handy resource, access the Clinical Practice Guidelines (CPGs) from the AOA. Go to, and you will find the CPGs under the section on Clinical Care.These will start you off on the right foot. But to supplement the information in the CPGs, consider the following clinical tips:

Take a good case history. The best way to determine if a patient may require VT is to take a relevant case history. There are many possible questions that you can ask about visual performance, but the most pertinent include:

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 compared to reading the same material?

Is there fluctuation in vision, in which objects or print are sometimes clear, yet blurry at other times?

Evaluate visual efficiency. 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 performing a cover test, particularly at near, look at the patients ability to maintain fixation on the target. If an assistant performs preliminary testing with a stereoscope, such as the Titmus or Keystone, note the stability of responses.

Likewise, when doing vergence ranges, note how stable the patients hold on binocular vision is. Take the same approach when probing ocular motilities and testing accommodative skills. Sometimes its not as much the quantity as it is the quality of the responses. Eventually youll get a feel for funny looking efficiency findings as much as youve gotten a feel for funny looking fundi.

Take note of visual processing. It is unrealistic to expect most primary-care practitioners to conduct visual processing or perception tests. However, reversing 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 not occur after 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 youre 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 older than 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 they dont often realize that vision beyond eyesight has anything to do with learning. Educating parents and patients about options is a critical role of the primary eye care 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, written in language that can be understood by patients or their caretakers. These sheets cover a variety of conditions, such as strabismus, amblyopia, eye coordination and vision in the classroom.

Once the decision has been made to refer a patient for a VT evaluation, the referring O.D. should expect the VT specialists employees to be highly knowledgeable in assisting the patient. When patients call the VT specialists office, VT staff should be well prepared to answer questions, such as:

Why is the doctor referring me for further testing?

What will you do that is different from the primary-care O.D.?

What are the doctors credentials?

If I need vision therapy, what is involved?

Does insurance cover vision therapy services?

In our practice, we handle the intake of information in whichever manner the referring doctor is comfortable. Some doctors like to speak with us by phone, while 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 are due to return to the referring doctors office for primary-care needs.

Recent Evidence That VT Really Works

Interest in VT has been heightened by many recent publications. Here are three important papers with which you should be familiar.

1. Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in nonstrabismic accommodative and vergence disorders. Optometry 2002 Dec;73(12):735-62. This article summarizes models of the accommodative and vergence systems, as well as cure rates of vision therapy for problems with accommodation and vergence. The studies cited are very valuable, but the gem of this paper is a section on how models of the accommodative and vergence systems can be helpful to the clinician.

2. Solan HA. Learning-related vision problems: How visual processing affects reading efficiency. Learning Disabilities: A Multidisciplinary Journal 2004;13:25-32. This article offers a concise summary of research on refractive errors, binocular visual deficiencies, visual processing disorders, eye movements, visual attention and vision therapy regarding children identified as reading and learning disabled. The multidisciplinary nature of this journal makes it a useful, up-to-date reference for pediatricians and learning specialists, as well as primary-care optometrists.

3. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol 2005 Jan;123(1):14-24. This new study is the gold standard research in vision therapy that the medical community has been waiting for. Results of in-office vision therapy are demonstrated to be far superior to either pencil push-ups or placebo therapy for convergence insufficiency. The randomized, multicenter clinical trial involved six colleges of optometry and was funded by the National Eye Institute. The results were so impressive that the NEI has granted $6.1 million to this research group to fund a larger study involving more patients, followed for longer periods of time, and at nine centers.

Although each of these articles provides direct support for the types of cases you will encounter in clinical practice, they are also exciting to read because they present scientific evidence that vision therapy works. L.J.P.

Referral Protocol and Ethics

When I first introduced myself to colleagues in my area, three concerns about their prior experiences surfaced: O.D.s had experienced problems in getting timely reports about patients; they were uncertain about endpoints of VT; and they were concerned about when patients would return to their care.

The College of Optometrists in Vision Development ( produces white papers and fact sheets, including Referral ProtocolEthics. 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 their patients. I sincerely tell patients how fortunate they are that their referring O.D. detected the need for further evaluation. At the conclusion of VT services in our office, we remind patients how important it is that they maintain their ongoing primary-care appointments with their referring doctor.

Patient-Based Comanagement
The clinical model for intraprofessional referral in optometry is thriving in many areas. Our local optometric referral center, OMNI Eye Services, sets the tone for collaboration, and their pediatric ophthalmologist is supportive of vision therapy.

A recent publication from the AOA, Optometric Co-Management of Vision Therapy, highlights the benefits for patients when the primary-care optometrist and the consulting optometrist establish protocols and guidelines to assist in comanagement.2 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 that we mail to colleagues in our area. The newsletter features case presentations on VT (with permission from the referring O.D. and the patient). By reading about actual cases in which an optometrist referred a patient to a VT specialist the practitioner can identify the variety of signs, symptoms and findings that point toward VT consultation. Examples of patients we have recently comanaged 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 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.

You may not be inclined to offer VT services in your practice, but your patients trust you to identify all their vision problems. If those problems require VT, be sure to consider appropriate referral and comanagement. Your patients will appreciate and benefit from it.

Dr. Press is a fellow of the College of Optometrists in Vision Development, and a diplomate of the American Academy of Optometry. His vision therapy practice is located in Fair Lawn, N.J.

1. Cooper JS, Burns CR, Cotter SA, et al. Optometric Clinical Practice Guideline: Care of the Patient with Accommodative and Vergence Dysfunction. St. Louis: American Optometric Association, 1998: 14-16.
2. Williams GJ, Kitchener G, Press LJ, Steele GT. Optometric co-management of vision therapy. Optometry 2004 Nov; 75(11):719. Also available at:

Vol. No: 142:2Issue: 2/15/05