One of the best things an optometrist can do for their patients is make a referral to another optometrist for specialty care. I (Dr. Taub) was referred from my primary OD to a vision therapy specialist when I was in second grade, and I genuinely believe that the referral and vision therapy program altered my life path.
Even though referring when appropriate seems like common sense and should be the standard of care, too many optometrists struggle with this line of thinking. Referrals, of course, are not limited to our optometric colleagues and also include primary care and specialty care physicians. The following case highlights several off-the-beaten-path referral sources that optometrists need to consider.
A 15-year-old patient presented for an annual exam at Southern College of Optometry for the first time. He had worn glasses for distance vision in the past but lost them, and he was unsure when his previous exam had been completed. He was reading on grade level but did not like to read. He was underperforming in school and receiving Fs. He had been diagnosed with ADHD five years prior and took an unknown medication that made little impact. He had tried several other medications without success. He was hard of hearing and had been wearing hearing aids in both ears for many years. In school, he and several other hard-of-hearing children had an aide to help them work through their hearing disabilities, but no other services were provided.
The examination was very straightforward. The patient entered seeing 20/20 OD, OS and OU at distance and near. Binocular vision testing showed a normal near point of convergence at “to the nose,” stereopsis was 25 seconds of arc and cover testing was ortho at distance and four exophoria at near. Accommodative testing showed low but balanced negative and positive relative accommodations at +1.50 and -1.50, respectively, and his amplitudes met the minimum age norms at 13D OD and OS. Retinoscopy was plano OD and -0.25 OS; no prescription was given. The anterior and posterior segments were unremarkable.
Based on the examination data, our work here should have been done, but in our opinion, we would have failed in our duties if we had simply scheduled the next annual examination and sent him on his way. Instead, we made three referrals.
This doctor is concerned with exploring the relationship between a patient’s brain and their behavior. We consider this member of the team the quarterback. They not only can assess cognition, behavior and legal, social and emotional factors, but they can also offer diagnoses and recommend treatments. They work with children and teens and routinely see adults who are suffering from a brain injury or a neurological condition such as multiple sclerosis or Parkinson’s disease. Referral for testing from other professionals, including ADHD specialists, speech/language therapists, occupational therapists and cognitive therapists, are common recommendations.
For our patient, we hoped the evaluation would reveal potential deficiencies that might be contributing to his poor school performance. With that knowledge, his school would better understand his abilities and recommendations could be incorporated into an Individualized Education Plan. As the name implies, this plan offers ways in which a child’s educational program can be enhanced through accommodations such as receiving extra time on tests, taking tests verbally and taking tests in a quiet setting.
A doctor of audiology is an expert in hearing and works with individuals with audiological processing deficiencies. Hearing is analogous to seeing, so audiological processing is akin to visual processing. We are more conditioned to recognize pure hearing issues, but if the brain is not processing what is physically heard, the input will not be clean, leading to poor comprehension of what is heard. The output, in the form of speech, may also be impacted. As with the visual system, wherein we ensure the clearest images, in audiology, an attempt is made to encourage the cleanest sounds. That may include hearing aids and assistive technology. When an issue with audiological processing is identified, a program of audiological rehabilitation can be provided.
For our patient, there was a previously identified hearing issue, for which he was using hearing aids in both ears. No further treatment had been offered in the form of rehabilitation, and the patient had not been seen recently to evaluate whether the current aids were still appropriate and providing the best foundation for processing. Even though the patient was under the care of one center, we referred him to another since the first did not seem to be offering all available resources.
Traditionally, the pediatrician is the first line in diagnosing and treating ADD and ADHD. Apart from the history, this diagnosis is made through parent and teacher surveys. When treatment begins, the medication chosen is up to the doctor, and often, it takes several attempts to find an appropriate option. For many patients, this is a good place to start, but for others, this shotgun approach turns out to be fruitless and wastes precious time. We prefer to refer to a neurobehavioral specialist, as this type of pediatrician takes a different approach: they do genetic testing to determine which class of medication will best suit the patient. These specialists don’t just use surveys to aid in making a diagnosis, often employing age-normed testing as well.
For our patient, his pediatrician had tried several different medications without success. Starting over with the specialist to confirm the diagnosis, testing for the most appropriate starting medication and offering suggestions for school accommodations was desperately needed. As an aside, processing difficulties can muddy the waters when making a diagnosis related to attention deficits. In reality, ADHD may not be an accurate label to place on this child.
As you can see, we are just at the beginning of our journey with this patient. Even though we did not offer refractive correction or even diagnose a condition requiring vision therapy, our jobs were not done. The three referrals to the neuropsychologist, audiologist and neurobehavioral specialist will hopefully aid this child socially, emotionally and academically. The referrals will also provide the mother and the school with a better understanding of the child’s abilities and what they can do to effectively assist him. As optometrists, we must not stop short of helping our patients in any way we can; doing so is against our oath and fails our promise.
Dr. Taub is a professor, chief of the Vision Therapy and Rehabilitation service and co-supervisor of the Vision Therapy and Pediatrics residency at Southern College of Optometry (SCO) in Memphis. He specializes in vision therapy, pediatrics and brain injury. Dr. Schnell is an associate professor at SCO and teaches courses on ocular motility and vision therapy. She works in the pediatric and vision therapy clinics and is co-supervisor of the Vision Therapy and Pediatrics residency. Her clinical interests include infant and toddler eye care, vision therapy, visual development and the treatment and management of special populations. They have no financial interests to disclose.