“I went to the eye doctor and they said my eyes were fine.” As the saying goes, If I had a nickel for every time I heard this. I do hear this a lot, almost weekly, while doing concussion rehab in my practice. So when the patient says my insurance company will only allow vision exams by such and such a doctor, I warn them of this potential outcome before they even go. Yet after the exam, I continue to hear in the clinic, “My vision is blurry; I get a headache from the screen; I can only read for 5 minutes before I get nauseous or a headache”. So now what?!
As an OT, my main concern is that these people can’t function because of their symptoms or perform their occupational roles- student, worker, driver, athlete, child, or mother. Over the years, I also got frustrated for these patients who kept getting steered in the wrong direction, so I sought out courses that were taught specifically by eye care specialists and even went back for my clinical doctorate, specializing in vision remediation. This is what I learned:
OT’s are the experts in activity and occupational performance:
Occupational therapy distinguishes itself from any other field by analyzing occupations and activities. We look at the person, the occupation, the environment and the performance in order for our clients to be independent. When a child can’t play, we assess why not and address it. When an adult can’t work, we assess why not and address it. We look at the skills needed for that task and compensate for, adapt or restore that missing piece. That is what we do and we are good at it!
Many times, the performance skill that is lacking or impaired is related to vision. Adult patients may say, “I get pressure in my temples when I read or think too hard”. With children, they may not be able to verbalize a headache during play, but they may bring an object closer or farther or maybe even not attend to the object at all. This behavior can also indicate a vision problem.
Occupational therapists are fortunate because physicians refer to us when there is a problem with activities of daily living, play and fine motor or returning to learn. We are the client’s first line of defense when they can no longer participate in life. That being said, we need to acknowledge that there may be a visual inefficiency causing their problem based on what is seen in our sessions and reported by family feedback. We need to be the referral source to eye care specialists for these patients that we see weekly, BUT we must know who to refer to.
OD’s are the experts in vision:
To differentiate, an ophthalmologist is a Medical Doctor that specializes in eye care, including the diagnosis, management, and surgery of ocular diseases and disorders (American Academy of Ophthalmology, 2018). The main emphasis is on surgery and prescribing medications for eye disease. However, they spend limited time in their education on the areas of visual efficiency and visual information processing and focus on a single component model of vision that only incorporates the category of visual integrity problems.
Optometrists are trained to use the 3-component model of visual integrity, efficiency and information processing (Ciuffreda, Ludlam & Yadav, 2015; Scheiman, 2011). They have a more complete understanding of the use of lenses, prisms, and vision rehabilitation to remediate ocular function, in turn, improving visual and occupational performance. It is important to note that while all optometrists receive this training, only a small percentage practice in this way.
I equate these two professions’ relationship to the OT and PT relationship. Let’s take an orthopedic condition, like a hip fracture. A physical therapist may look at the structure of the hip, including the strength and ROM of the hip, pelvis, and back so that the person can get back to walking. They may issue a cane or a walker so that they can move around. Occupational therapists, in turn, will look at the function of the entire person- can they dress themselves with or without adaptive equipment, can they get to the bathroom, can they stand and cook a meal, can they perform leisure pursuits?
The same is true for these two eye care professions. Ophthalmologists will look at the structure of the eye including the retina, the optic nerve, while checking for such things as glaucoma or cataracts. They may issue glasses so that the client can see. Optometrists, in turn, will look at the function of the eye- are the eyes converging and working together, are they communicating to the brain to perceive their environment appropriately, are they getting headaches after reading for 5 minutes due to an eye inefficiency? Each profession has a role in serving the client, but they are also specific, resulting in different treatment.
In terms of concussion rehabilitation or pediatric therapy, occupational therapists should be referring to those who perform a comprehensive eye exam and acknowledge the dysfunction occupational therapists see during treatment. This means referrals should be made to optometrists; but even within optometry, there is a lack of consensus and uniformity in the way eye examinations are performed. The eye-care professional that occupational therapists chose to refer to should perform the examination using a 3-component model of vision that includes the categories of visual integrity, visual efficiency and visual perceptual deficits that can impact occupational performance.
Visual integrity includes the areas of visual acuity, refraction (optics of the eye), and eye health. This area is always examined by both optometrists and ophthalmologists. The visual efficiency category includes accommodation, binocular vision, and eye movements, while visual information processing includes visual spatial, visual analysis and visual motor integration skills (Scheiman, 2011). Whether an eye examination includes all three of these components or just an assessment of visual integrity plays a major role in determining the outcome of the examination and, subsequently, the care provided to the client.
These two organizations are a great starting place to find a local expert:
The Neuro-Optometric Rehabilitation Association, International (NORA) is an inter-disciplinary group of professionals dedicated to providing patients who have physical or cognitive disabilities as a result of an acquired brain injury with a complete ocular health evaluation and optimum visual rehabilitation education and services to improve their quality of life.
The College of Optometrists in Vision Development (COVD) is a non-profit, international membership association of eye care professionals including optometrists, optometry students, and vision therapists. Established in 1971, COVD provides board certification for optometrists and vision therapists who are prepared to offer state-of-the-art services in: Behavioral and developmental vision care, Vision therapy and Neuro-optometric rehabilitation.
These specialized vision care services develop and enhance visual abilities and correct many vision problems in infants, children, and adults. Vision care provided by all COVD members is based on the principle that vision can be developed and changed.
A collaborative effort means the client wins
So what does this relationship look like? It has the potential to take many forms. Ideally, it may look like this:
The fields of optometry and occupational therapy are truly kindred spirits. Both professions look at function when serving clients. Both are experts in their own right, but share the ultimate goal of improved occupational performance, symptom free. Both need each other’s expertise to achieve that goal. And ultimately who wins? The client.
American Academy of Ophthalmology. (2018). The eye care team. Retrieved from: https://www.aao.org/about/eye-care-team
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68 (Suppl 1), S1-S48. doi: 10.5014/ajot.2014.682006
American Occupational Therapy Association. (2014). Scope of practice. American Journal of Occupational Therapy, 68 (Suppl 3), S34-S40. doi: 10.5014/ajot.2014.686S04
Ciuffreda, K. J., Ludlam, D. P., & Yadav, N. K. (2015). Conceptual model pyramid of optometric care in mild traumatic brain injury (mTBI): A perspective. Vision Development and Rehabilitation, 2, 105-108.
Scheiman, M. (2011). Understanding and managing vision deficits: A guide for occupational therapists (3rd ed.). Thorofare NJ: Slack, Inc.