Patient and Practice Management Issues in Vision Therapy
Throughout this text, we have emphasized the importance of considering a variety of treatment options in a sequential manner for all accommodative, ocular motor, and binocular vision disorders. Once the diagnosis has been determined and the specific treatment selected, the other critical aspects of the care we provide are communicating this information to the patient and implementing the treatment options. This is true irrespective of whether the diagnosis and treatment are simple, such as accommodative insufficiency and reading glasses, or more complicated, such as intermittent esotropia requiring prism and a bifocal, or convergence insufficiency needing vision therapy. This chapter reviews the information and skills necessary for successful communication of the various diagnostic and treatment alternatives, as well as practice management issues related to vision therapy.
Successful communication and implementation of treatment for accommodative, ocular motor, and binocular vision disorders depend on a number of factors, including the clinician’s ability to do the following:
Communicate the nature and extent of the disorder
Communicate the nature of the proposed treatment to the patient or parents of the patient
Communicate with other professionals verbally and in writing about the diagnosis and proposed treatment
Deal with the practice management aspects of vision therapy
Case Presentation
The clinician’s ability to communicate his/her thoughts about diagnosis and treatment to the patient is critical to the success of any treatment plan. In all cases of accommodative, ocular motor, and binocular vision disorders, this presentation will require more time and effort than required in more routine-type vision care.
Most people have little to no knowledge of these vision problems and have not had any personal experience with them. It is therefore necessary to educate the patient or parents about the nature of these conditions. It is best to speak to both parents at the case conference. If this is not possible, then, after the parents receive your report, the parent who was unable to attend the conference should be encouraged to call with any questions.
Given the ease of recording a presentation with any smartphone and forwarding such a recording electronically, it makes sense to record your case presentations. Even if both parents cannot attend the case presentation, they will have a full recording of the presentation. The parents can also share this recording with other professionals and school personnel.
We have organized the case presentation into a number of phases (Table 25.1). Each phase of the presentation has a specific objective.
SAMPLE CASE PRESENTATION FOR A CHILD REQUIRING VISION THERAPY
The following is an example of a presentation to the parents of a 10-year-old child (fifth grade) with convergence insufficiency.
Table 25.1 CASE PRESENTATION SEQUENCE | |
|---|---|
|
Phase 1: Review the Symptoms and Reasons for the Visit
Beginning the presentation with a review of why the patient was brought in to see you is an important starting point and allows you to build a relationship between the visual complaints and the diagnostic findings.
I am going to begin by first reviewing the various problems and complaints that Jimmy has been reporting. As you remember, he has been complaining of eyestrain, blurred vision, and words moving on the page after reading for about 5 to 10 minutes. When he is tired or tries to read at the end of the day, he occasionally experiences double vision. Although Jimmy complained about these problems last year, he definitely feels that they are getting worse. You also mentioned that Jimmy is doing much more reading and homework this year.
When he complained last year, you took Jimmy to a different eye doctor, who said he couldn’t really find a problem. He did prescribe weak reading glasses, which Jimmy felt made things worse. Does that seem like a reasonable summary of why you brought Jimmy to see me?
You should give the parents an opportunity to add any additional information or to agree that the key elements of the problem have been reviewed.
Phase 2: Explain the Nature of the Vision Problem
I want to spend a little more time than usual reviewing my findings, because Jimmy has a type of vision problem with which many people are not familiar. Most people are aware of vision problems such as nearsightedness or farsightedness, which affect our ability to see clearly. You know that we treat these conditions using eyeglasses. In Jimmy’s case, he sees clearly. In fact, he has perfect 20/20 vision in both eyes, his eyes are healthy, and he is neither nearsighted nor farsighted.
However, I want to stress that good vision is more than being able to see 20/20. It is possible to have excellent vision in each eye and still have a significant vision problem. For example, focusing, eye teaming, and tracking problems can all be present, even if an individual has 20/20 vision. People who have problems like these often see clearly, but they have uncomfortable vision, eyestrain, headaches, double vision, and similar symptoms when reading.
In Jimmy’s case, he has an eye teaming problem. I am sure that you have seen children with severe eye teaming problems in which an eye actually turns in or out. Jimmy does not have a severe problem like this. However, when he reads or does any close work, his eyes have a very strong tendency to drift out and his ability to compensate for this is inadequate.
With a convergence insufficiency patient, we usually demonstrate the receded near point of convergence to the parent at this time.
If Jimmy’s eyes actually turned out, he would experience double vision. Therefore, whenever he reads, he has to use excessive muscular effort to prevent his eyes from drifting out. This constant need to use excessive muscular effort can lead to the types of symptoms described by Jimmy. Patients with eye teaming disorders complain of a variety of problems, including eyestrain, headaches, blurred vision, double vision, sleepiness, difficulty concentrating on reading material, loss of comprehension over time, a pulling sensation around the eyes, and movement of the print.
Do you have questions about Jimmy’s vision problem? You may stop at this point to give the parents or patient an opportunity to ask any questions about the nature of the problem and how it may cause symptoms. It is a good idea to ask the parents to summarize what they feel the problem is, after hearing your presentation.
Phase 3: Explain the Proposed Treatment Plan
I have been stressing that Jimmy’s vision problem is different from the usual vision problems that are treated with eyeglasses. Jimmy does not have an optical problem such as nearsightedness or farsightedness. As a result, standard optical treatment, using eyeglasses alone, would not be successful. Rather, I am recommending that we treat Jimmy using an approach called “vision therapy.”
Vision therapy is a treatment approach involving a series of office visits in which we use a variety of instruments and procedures to teach Jimmy how to overcome this eye teaming problem. I am sure you have heard of children receiving therapy or tutoring for speech, reading, or math. You know that, with an effective therapist or tutor, these skills can be improved.
The good news is that vision therapy has also been shown to work very well and will almost always lead to improved eye teaming, focusing, and tracking skills. In fact, we are successful in about nine out of ten patients. The key to success is motivation and a commitment to attending the therapy sessions and performing the recommended home therapy techniques. Treatment for the type of vision problem that Jimmy has generally requires about 3 months of vision therapy. We will need to see Jimmy two times each week, and each visit will last 45 minutes. I will give you a packet of information about vision therapy as you leave today.
Once vision therapy is complete, we ask all of our patients to work on their own at home with several procedures. For example, for the first 3 months following the completion of vision therapy, we ask the patient to work three times a week, 5 minutes each time. We reevaluate the patient at this time and, if everything seems fine, we ask the patient to work once a week for 5 minutes for the next 6 months. If, at this 6-month reevaluation, the patient is still comfortable and the vision findings are normal, we ask the patient to check his eyes once a month, using one very simple procedure.
Do you have any questions about my recommendations?
You may stop and give the parents an opportunity to clear their doubts about vision therapy. If you are not sure whether the parent has understood, it is useful to ask the parent to summarize the treatment plan.
Phase 4: Discuss the Time and Financial Commitment
If vision therapy has been recommended, it is particularly important for the optometrist to spend time discussing the time and financial commitment that will be necessary.
The treatment approach that I am recommending is going to require both a time and a financial commitment on your part. To successfully treat Jimmy’s eye teaming problem, we will need to work with him for about 3 to 4 months. As a general rule, we need to see the child twice a week over this period of time, and each visit lasts 45 minutes. Vision therapy visits are scheduled Monday through Thursday, late afternoon and early evening.
The fee for each therapy visit is $100. In some cases, medical insurance may cover part of the cost of vision therapy. However, please be aware that we do not participate in any health insurance plans. This means that you will have to pay for the therapy and then seek reimbursement from your insurance company. My staff will be happy to assist you in finding out whether your insurance company will cover Jimmy’s therapy.
One important idea to keep in mind, when discussing this with your insurance company, is that the treatment we have recommended is not considered vision care. Rather, Jimmy has a medical condition and we have recommended medical treatment called vision therapy or orthoptics. This distinction is important because most medical insurances will only cover one vision examination once a year or every 2 years and some do not cover routine vision care at all. Vision therapy, however, is not routine vision care and, for insurance purposes, it is considered a form of medical treatment. It is very important that you use the correct terminology when you communicate with your insurance company. In my correspondence to you, I will include a letter with a full explanation of the diagnosis and treatment plan, which you can forward to your insurance company for a predetermination of benefits.
Do you have any questions about scheduling or the cost of vision therapy or insurance? (Appendix I provides sample correspondence.)
Phase 5: Open Questions and Discussion
This last phase is designed to allow the parents one more opportunity to ask you questions about any issues discussed in the case presentation. It is also your opportunity to summarize the presentation and determine whether the parents would like you to send a report to the school or other professionals. This is an excellent public relations opportunity, and you should try to communicate with as many individuals as possible after each evaluation.
At this time, we tell the parents that we will send a report summarizing the evaluation, diagnosis, and recommended treatment. If vision therapy has been recommended, we also send a letter of predetermination of benefits to the insurance company.
SAMPLE CASE PRESENTATION FOR CONDITIONS NOT REQUIRING VISION THERAPY
Regardless of the diagnosis and treatment, we follow the case presentation sequence described in Table 25.1 for all accommodative, ocular motor, and binocular vision disorders. If added lenses in a bifocal format or prism are recommended, the explanation of the proposed treatment and prognosis for improvement will require additional time. Most people have no personal experience with the use of prism, and bifocals are almost universally associated with the vision problems of middle-aged and older people. It is necessary, therefore, to educate the patient or parents about the use of these treatment options.
The presentation is significantly shorter and less complex when vision therapy is not necessary. However, even if the only treatment necessary is a single vision prescription for reading, time should be spent in each of the five phases outlined.
Sample Explanation of Proposed Treatment Using Prism
Phases 1 and 2, reviewing symptoms and reasons for the visit and explaining the vision disorder, are similar to those in the previous sample presentation.
Phase 3: Proposed Treatment and Prognosis for Improvement
I have been stressing that Billy’s vision problem is different from the usual vision problems that are treated with traditional eyeglasses. Billy does not have an optical problem such as nearsightedness or farsightedness. As a result, standard optical treatment alone, with regular eyeglasses, would not be successful. Rather, I am recommending that we treat Billy using eyeglasses that contain a special lens called prism.
Prism is used when an individual has a particular type of eye teaming problem. As we discussed earlier, Billy has a problem, which is, his eyes have a strong tendency to drift in. To control this tendency, he has to use excessive amounts of muscular effort. A prism is a special type of lens that decreases the amount of effort that an individual must use to control an eye teaming problem. The glasses will not look very different from regular glasses, although, if you look closely, you will see that one edge will be thicker than the other. It is important for you to realize that although prism will help Billy when he wears the glasses, the underlying problem will still be present. Prism does not correct the eye teaming problem. Rather, it will allow Billy to function more comfortably, in spite of the eye teaming problem.
Sample Explanation of Proposed Treatment Using a Bifocal
Phases 1 and 2, reviewing symptoms and reasons for the visit, and explaining the vision disorder, are similar to those in the previous sample presentation for the patient requiring vision therapy.
Phase 3: Proposed Treatment and Prognosis for Improvement
I have been stressing that Paul’s vision problem is different from the usual vision problems that are treated with traditional eyeglasses. Paul does not have an optical problem such as nearsightedness or farsightedness. As a result, standard optical treatment alone would not be successful. Rather, I am recommending that we treat Paul using glasses with a special lens called bifocals.
We often prescribe bifocals for people who have focusing or eye teaming problems. Bifocals are used when the power of the lens necessary for reading is different from the power of the lens needed for looking at a distance. Bifocals are useful for focusing problems because they decrease the amount of focusing effort the patient must use. They are also helpful for some eye teaming problems. In Paul’s case, for example, his eyes have a tendency to drift in and his ability to compensate is inadequate. He must therefore use muscular effort to control the eye teaming problem. The bifocals I am prescribing will reduce the amount of muscular effort that Paul must use. It is important for you to realize that although the bifocal lens will help Paul while he wears the glasses, the underlying problem will still be present. Bifocals do not correct the eye teaming problem. Rather, they will allow Paul to function more comfortably in spite of the eye teaming problem.
Communicating Your Findings to Other Professionals
Communication with other professionals is important for two reasons. First, communication can help develop your reputation in the community. Sending reports allows you to let other professionals know that your practice is different and unique. Your reports will inform them that you practice full-scope optometric care, including the use of vision therapy when appropriate. Appendix I includes several sample reports to psychologists, school personnel, physicians, and parents.
Communication is also important because of some of the misconceptions that persist about vision therapy. In spite of the extensive scientific support for the efficacy of vision therapy for the conditions described in this text, some professionals persist in their opposition to vision therapy. Parents often rely on the judgment of such professionals when decision-making about health issues is necessary.
It is therefore essential that you use handouts, reports, and copies of articles to provide as much educational information as possible at the time of your presentation to the patient or parents to prepare them for the negative advice they may receive. Appendices II and III include sources for brochures and articles that can be provided to your patients.
COMMUNICATING THROUGH WRITTEN CORRESPONDENCE
Because most people have little or no knowledge of accommodative, ocular motility, and binocular vision problems or vision therapy, it is important to follow up your case presentation with a written report. After each evaluation, we write a report that summarizes the symptoms, diagnosis, and proposed treatment plan. From a public relations point of view, if the patient is a child, it is also helpful to send a copy of this report to other professionals who are dealing with the child. We often send reports to teachers, reading specialists, school
psychologists, and pediatricians. If you practice in a small- to medium-sized community, after a short amount of time, these professionals will soon understand that your practice is unique, and they may begin to refer patients to your office when they encounter children with similar problems. Appendix I includes examples of this type of correspondence.
psychologists, and pediatricians. If you practice in a small- to medium-sized community, after a short amount of time, these professionals will soon understand that your practice is unique, and they may begin to refer patients to your office when they encounter children with similar problems. Appendix I includes examples of this type of correspondence.
Practice Management Aspects of Vision Therapy
Throughout this text, we have tried to establish the clinical basis for the importance of vision therapy as one of the treatment considerations for accommodative, ocular motility, and binocular vision disorders. We have emphasized that vision therapy is necessary to meet the needs of patients. At least 10% to 15% of patient problems cannot be treated with lenses, added lenses, or prisms alone, and vision therapy is required. We have also stressed that vision therapy has been proven to be an effective treatment approach. Studies of the efficacy of vision therapy for accommodative, ocular motility, and binocular vision disorders have revealed success rates between 85% and 95% (Chapters 3, 9, 10, 11, 12, 13).
From a practice management perspective, it is also important to realize that offering vision therapy as a service often makes a practice unique in a community. With many practices looking for a niche to make their practice special and to find new sources of revenue, vision therapy is an excellent service to offer.
Like any other optometric service we offer in our practices, however, vision therapy must be delivered in a cost-effective manner. Each practitioner must make a personal decision about the amount of income that is necessary from a particular service to make it financially viable. If vision therapy, or any other service, fails to meet this criterion, then, regardless of how much the treatment is needed or how effective it may be, it becomes impossible to offer such a service.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
