The question I get asked the most about starting up a vision therapy practice is, “Where do I find the patients?”
To be honest, this is the easiest part! Your vision therapy patients are right there in front of you! The key is to know what questions to ask and which screening tests to do!
Even if you aren’t planning on doing therapy in your office, this list is also a great way to spot a potential vision therapy case. Making the right referral for a patient can change their life and in return, you will have gained a whole family worth of patients.
Here are 4 easy ways to identify your ‘at-risk’ patients:
This is by far the easiest addition to your workup, with the highest rate of return. Give out this questionnaire to your patients as part of their entrance paperwork. It takes the patient a few extra minutes, but gives you a wealth of knowledge about your patient.
My favorite vision skills screening questionnaire is the COVD - Quality of Life Survey.
This survey has been tested and re-tested with good repeatability and reliability for accurately identifying 'at-risk' patients. The cut-off score for the 'at-risk' patient is anything over 20.
Of all of the literature written on this survey, this paper, written by W.C. Maples, describes the most frequent and severe symptoms reported in the pediatric population. A must read!
You can give this survey to every patient that walks through the door (my recommendation), or only to those patients that are 18 years and younger. Whatever you choose to do, train your staff to highlight and inform you of the patients whose scores are high on the survey before you enter the exam room. This allows you to ask follow-up questions and perform additional tests to determine if a vision therapy evaluation or referral is warranted!
2. Cover Tests:
This might seem like an obvious thing to do, but I can't assume that every doctor is doing an accurate cover test at both distance and near on every patient. This test takes maybe an extra minute to perform, and gives you a wealth of information on how your patient functions.
For those that do not remember how to perform an accurate cover test (both unilateral and then alternating). Remember the keys to performing an accurate cover test are good fixation, proper occlusion, and patience.
I find that many patients have a moderate sized exophoria at near, that will easily break down into an intermittent exotropia. If you see something like this, you can start asking your patient follow-up questions to determine if they are symptomatic. You will be surprised at how many people see intermittent double vision at near and think it is normal!
3. Near Point of Convergence (NPC):
Near point of convergence can give you so much information about a patient's convergence ability, visual stamina, and recovery ability.
If I had to choose one test to perform to determine potential vision therapy patients, NPC would be that test.
With your fixation target in place for the cover test, you can then flow right into measuring near point of convergence. In case you need a reminder, I wrote an article a very long time ago, detailing how to perform NPC. The key here is to repeat the test more than once, and not to rush through it.
Author’s Tip: There are a multitude of targets you can use to test NPC, but my two favorites are a pen tip (my accommodative target) and a penlight (my non-accommodative target)!
4. Accommodative Amplitudes:
With the visual demands of today, our accommodative system is constantly and consistently being utilized. Many people experience intermittent blurred vision, and think it is normal because their eyes are "tired." We know this is not the case, and understand the true underlying cause of this.
Although some might argue that NRA/PRA gives you more information, I like to isolate the accommodative system from the binocular system in this instance. Performing a quick minus lens amplitude after you do some near testing can highlight a patient suffering from accommodative insufficiency.
To perform this test, make sure your patient is fully corrected, and use an accommodative target at 40cm (16 inches) with good lighting. Occlude one eye and slowly start introducing minus, making sure to ask your patient to occasionally re-read a line on your target to ensure they are fully clearing the line. Push the patient to their limit of blur and then calculate the amplitude (don't forget to account for the 2.5D of accommodation already instated with the target). Repeat for the other eye.
Figuring out the status of your patient's accommodative system may affect the way you prescribe glasses, and also opens up the conversation about vision therapy.
Disclaimer: Every patient you flag may not need or want to do therapy. You have to use your clinical judgement on when to make the internal or external referral for a full vision therapy work-up. I often compare the clinical findings with the symptoms survey and follow-up questions, and then determine the patient’s motivation for change.
Just remember the key to success in vision therapy is awareness: your awareness of patients at risk, and their awareness of the services you provide!